Abstract: To validate the axillary approach as a safe and efficient option for the transcatheter aortic valve implantation in patients who have contraindication for femoral approach at three Spanish hospitals.
Abstract: Although drug-eluting stents have reduced the restenosis rate, some patients are not good candidates for prolonged double-antiplatelet therapy. Our goal was to learn the results of implanting cobalt-chromium stents in long lesions of large vessels.All consecutive patients with ≥1 lesion treated with a cobalt-chromium stent ≥28 mm in length and ≥3.5 mm in diameter during a 12-month period in 2 centers were monitored clinically and angiographically to determine the clinical status, restenosis rate, pattern of restenosis, and need for revascularization.The series comprised 78 patients with 81 lesions, mean age, 62.6 ± 15.2 yr; diabetes mellitus,19.2%; and primary or rescue intervention, 20.6%. Target vessels were the left anterior descending coronary artery, 12 (14.8%); left circumflex coronary artery, 12 (14.8%); and right coronary artery, 57 (70.4%). The mean lesion length was 35.18 ± 12.65 mm. The proximal reference diameter after percutaneous coronary intervention was 3.64 ± 0.54 mm; the distal, 3.2 ± 0.43 mm; and the mean, 3.42 ± 0.44 mm. The mean stent length was 38.05 ± 12.78 mm (range, 28-90 mm). The binary restenosis rate was 23% (15/64), with pattern IB in 2 cases, IC in 5, II in 7, and IV in 1. Revascularization was needed in 6 patients.In treating long lesions of large vessels, we found that cobalt-chromium stents achieved a moderate rate of target-vessel restenosis and a low rate of repeat revascularization. The pattern of restenosis was focal in almost half of the cases, and, in most remaining cases, restenosis affected short segments of the vessel.
Abstract: BACKGROUND: Left ventricle remodeling (LVR) is a relatively common and unfavourable event occurring after acute myocardial infarction. A link exists between inflammation and LVR. Neopterin, a marker of inflammation and macrophage activation, is a predictor of left ventricular dysfunction in patients with coronary artery disease. We therefore sought to assess whether both neopterin and brain natriuretic peptide (BNP), a marker of LV dysfunction and patient outcome, correlate with LVR in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We prospectively assessed 108 STEMI patients (age 64+/-11 years; 85% male) undergoing primary percutaneous coronary intervention (PCI) who were assessed echocardiographycally assessment was performed at 96+/-10h after the onset of symptoms and 12month after STEMI. LVR was defined as >20% increase in LV end-diastolic volume at 12months of follow-up compared to baseline. Neopterin and BNP serum concentrations were measured immediately before primary PCI. RESULTS: At 1 year, 21 patients (19%) showed LVR and 87 (81%) had no LVR. Patients with LVR had higher levels of neopterin at study entry (7.45+/-1.04 vs 5.19+/-1.39nmol/L; p<0.001). After adjustment for relevant confounders, neopterin levels were found to be an independent predictor of LVR (OR ranging from [3.10, CI 95% 1.928-4.990, p<0.001] to [3.32, CI 95% 1.999-5.532, p<0.001]). ROC analysis showed an area under the curve of 0.901 for neopterin (CI 95% 0.84-0.96, p<0.0001) compared to 0.579 for BNP (CI 95% 0.409-0.748) regarding LVR. CONCLUSIONS: In STEMI patients undergoing primary PCI, high neopterin levels - but not BNP - predict LVR at 1-year follow-up.
Abstract: INTRODUCTION AND OBJECTIVES: The aim of the study was to describe early experience and medium-term follow-up with the CoreValve self-expanding aortic prosthesis at three Spanish hospitals. METHODS: The study included patients with severe symptomatic aortic stenosis. Other inclusion criteria were: aortic valve area <1 cm(2) (<0.6 cm(2)/m(2)); aortic valve annulus diameter in the range 20-27 mm; diameter of the ascending aorta at the level of the sinotubular junction < or = 40 mm (small prosthesis) or < or = 43 mm (large prosthesis), and femoral artery diameter >6 mm. RESULTS: The study included 108 patients with a mean age of 78.6 + or - 6.7 years, a mean aortic valve area of 0.63 + or - 0.2 cm(2) and a mean logistic EuroSCORE of 16% + or - 13.9% (range, 2.27%-86.4%). After valve implantation, the maximum echocardiographic transaortic valve gradient decreased from 83.8 + or - 23 to 12.6 + or - 6 mmHg. No patient presented with greater than grade-2 residual aortic regurgitation on angiography. The procedural success rate was 98.1%. No patient died during the procedure. Definitive pacemaker implantation was carried out for atrioventricular block in 38 patients (35.2%). At 30 days, all-cause mortality and the rate of the combined endpoint of death, stroke, myocardial infarction or referral for surgery were 7.4% and 8.3%, respectively. The estimated 1-year survival rate calculated using the Kaplan-Meier method was 82.3% (for a median follow-up period of 7.6 months). CONCLUSIONS: Our early experience indicates that percutaneous aortic valve replacement is a safe and practical therapeutic option for patients with severe aortic stenosis who are at a high surgical risk.
Abstract: INTRODUCTION AND OBJECTIVES: The coexistence of heart and dental disease is common and antiplatelet therapy with aspirin and clopidogrel following a percutaneous intervention can interfere with dental practice. Our aim was to study dentists' knowledge of percutaneous coronary interventions and their approach to affected patients. METHODS: A questionnaire was used to evaluate the knowledge of 100 randomly selected dentists in Spain about coronary stents, antiplatelet therapy, and guidelines prepared by American medical societies, including the American Dental Association, and to determine how frequently they consulted a cardiologist. RESULTS: Data were collected from 100 dentists. Of these, 17 had no knowledge of coronary stents, but only one did not interrupt dual therapy: 12 consulted a cardiologist and the remaining four discontinued therapy themselves. Of the 83 who knew about stents, only 28 (34%) understood the difference between bare metal and drug-eluting stents. The drug clopidogrel's name was known by 21%, while 60% recognized one of the drug's commercial names and 45% recognized the other. Of the 83 aware of stents, 48 (58%) knew of the possibility of stent thrombosis, but only three knew about possible mortality. Cardiologists were consulted before dental procedures in 83% of cases. Only 36% knew about the existence of the guidelines. CONCLUSIONS: Although Spanish dentists' knowledge of coronary interventions was limited, in the majority of cases a cardiologist was consulted before a patient taking dual antiplatelet therapy was treated. Only a small percentage of those questioned knew of the existence of American medical society guidelines.
Abstract: We read with great interest the recent article by Alber et al., who assessed the relationship between the extent of coronary artery disease (CAD) and neopterin/CD4+CD28- lymphocytes in patients with chronic stable angina pectoris. The results of Alber et al. - in a small group of patients - contradict previous findings by our group in larger and well characterized groups of patients. Unfortunately, however, Alber et al. seem not to have been aware of our studies, as they are not cited or discussed in the context of their recent findings reported in the Journal. We have previously shown that increased neopterin levels, a marker of macrophage activation, predict adverse cardiovascular events during one year follow-up in patients with chronic stable angina. Our data indicate that patients in the highest neopterin tertile of neopterin concentration had a three fold increase in the risk of developing adverse cardiovascular events compared to those in the lowest tertile, a finding that was independent of the severity of CAD in these patients. In addition, other studies from our group have shown a correlation between neopterin levels and the presence of multiple complex (vulnerable) plaques in patients with unstable angina. We also showed that increased neopterin is a predictor of both worse outcome in hypertensive patients with non obstructive CAD and rapid CAD progression in patients with CAD undergoing revascularization.
Abstract: INTRODUCTION AND OBJECTIVES: Drug-eluting stents (DES) reduce the restenosis rate in native vessels. However, results in saphenous vein grafts (SVG) are less clear. The aim of this study was to compare DES and bare metal stents (BMS) in de novo stenosis in SVG. METHODS: The study included all percutaneous interventions involving a DES in SVG carried out at five centers up until July 2007. Findings were compared with those in a historical cohort that used conventional stents at two centers. The study analyzed in-hospital and long-term outcomes and predictors of survival and revascularization. RESULTS: The study included 107 stenoses treated with DESs in 98 patients and 130 stenoses treated with BMS in 113 patients. The DES group was older at baseline and had thrombus less often. There were also procedural differences: in the DES group, stents were longer, direct stenting was used less, and the stent diameter was smaller. The proportion of patients who experienced cardiac death by 12, 24 and 30 months was 95%+/-2%, 91%+/-3% and 89%+/-3%, respectively, in the DES group and 95%+/-2%, 90%+/-3% and 87%+/-3% in the BMS group (P=.66). The proportion without target vessel revascularization at 12, 24 and 30 months was 90%+/-3%, 86%+/-4% and 83%+/-4%, respectively, in the DES group and 94%+/-2%, 87%+/-3% and 87%+/-3% in the BMS group (P=.49). The only predictor of cardiac death was the ejection fraction. There was no predictor of revascularization. CONCLUSIONS: In our series, using DESs in SVGs was not associated with a reduction in mortality or target vessel revascularization. The only predictor of cardiac death was the ejection fraction. There was no predictor of revascularization.
Abstract: C-reactive protein (CRP) is a marker for cardiovascular risk but may also participate in the pathogenesis of atherosclerosis and myocardial injury. We sought to investigate the relationship among CRP, left ventricular ejection fraction (LVEF) and symptoms of congestive heart failure (CHF) in patients with chronic stable angina (CSA) pectoris. METHODS: We studied 841 patients (63+/-10 years, 72% men) with CSA undergoing coronary angiography. Symptoms of CHF were assessed using the New York Heart Association (NYHA) functional classification. CRP measurements were performed using a high sensitivity (hs-) immunoassay at the time of diagnostic coronary angiography. RESULTS: Baseline serum hs-CRP levels showed a significant correlation with LVEF (r=-0.11; P=0.004), and prevalence of moderate-to-severe CHF correlated with serum hs-CRP quartiles (P(trend)<0.0001). After adjustment, age (P=0.004), female gender (P=0.03), body mass index (P<0.0001) and hs-CRP (OR 2.2 [1.3-3.6] CI 95%; P=0.002) were independent predictors of NYHA functional classes III-IV irrespective of LVEF and angiographic severity of CAD. A CRP value of 3.2mg/L had a sensitivity of 72%, a specificity of 75%, and a negative predictive value of 96% for detecting an impaired functional class. INTERPRETATION: Hs-CRP serum concentrations showed an inverse correlation with LVEF and were an independent predictor of NYHA functional class in patients with CSA.
Abstract: INTRODUCTION: CD40 ligand has been suggested to play a pathogenic role in atherogenesis and coronary artery disease progression. Clinical studies suggest that intravenous (IV) abciximab administration attenuates the acute inflammatory response associated with percutaneous coronary intervention (PCI). The anti-inflammatory effects of intracoronary (IC) versus IV administration of abciximab have not been systematically investigated. We assessed changes in soluble CD40 ligand (sCD40L) concentrations in response to IC versus IV abciximab in patients with ST-elevation myocardial infarction (STEMI) undergoing thrombus-aspirating device during primary PCI. METHODS: Patients were randomized to receive IC (n=25) or IV (n=25) bolus abciximab followed in every case by a 12-h IV abciximab infusion. sCD40L was measured immediately before the administration of abciximab (baseline) and 60min post bolus administration. RESULTS: Clinical baseline and angiographic characteristics were similar in both patient groups. Similarly, there were no significant differences in baseline serum sCD40L levels in the IC group compared to IV group (116.6+/-42.13pg/mL vs 124.9+/-43.04pg/mL, P=0.49). At 60min post PCI, however, sCD40L levels decreased by 23% (P<0.001) in the IC group and by 11% (P<0.001) in the IV group. sCD40L levels 60min post PCI were significantly reduced, particularly in the IC group compared to the IV group (73.04+/-12.21pg/mL vs 99.92+/-25.89pg/mL, P<0.001). CONCLUSION: In STEMI patients undergoing primary PCI, IC bolus administration of abciximab was associated with a larger reduction in sCD40L levels compared to standard IV bolus. Whether this more powerful anti-inflammatory effect of IC abciximab translates into improved clinical outcomes deserves investigation.
Abstract: INTRODUCTION AND AIMS: Coronary occlusions resulting in acute events often occur at the site of non-severe stenoses. We sought to assess the prognostic value of non-obstructive coronary stenoses and C-reactive protein (CRP) levels in patients with chronic stable angina (CSA). METHODS: We studied 790 consecutive patients with CSA who underwent routine coronary arteriography. High sensitivity CRP and coronary angiograms were assessed at study entry. Angiographic coronary disease severity was graded using a "vessel score" (number of coronary arteries showing at least 50% reduction in lumen diameter) and extent of disease with an "extension score" (proportion of the coronary artery tree showing angiographically detectable atheroma). Patients were followed up for 1 year. RESULTS: Significant left main stem disease was present in 54 patients (6.8%). 368 patients (46.6%) underwent revascularization. 71 patients (9%) had at least one of the events comprised in the combined study end-point (unstable angina, myocardial infarction (AMI) and cardiac death). Patients who suffered cardiac adverse events had a significantly higher vessel score (n) (2.0 [2.0-3.0] vs. 2.0 [1.0-2.0], P<0.001), extension score (%) (23.5 [17-34.5] vs. 16.0 [6.0-27.0], P<0.001) and CRP levels (mg/L) (3.0 [1.8-7.2] vs. 2.3 [1.1-4.7], P=0.001) compared to patients without events. Age, previous history of AMI, vessel score, extension score and CRP levels were significantly associated with the study end-point. Multivariate analysis showed extension score (OR 5.3 [2.8-10.3] CI 95%; P<0.001), revascularization (OR 0.26 [0.14-0.48] CI 95%; P<0.001) and CRP levels (OR 1.9 [1.1-3.2] CI 95%; P=0.03), but not vessel score (P=0.1), to be independent predictors of the combined end-point. CONCLUSIONS: In patients with CSA, independently of revascularization, extension score and CRP levels predict cardiac adverse events, regardless of the presence or absence of flow limiting coronary lesions.
Abstract: AIM: Endothelin-1 (ET-1) promotes vasoconstriction and cell proliferation, and has been implicated in hypertension and coronary artery disease. Our aim was to analyse the role of the ET-1 gene (EDN1) in the risk for atherosclerosis/myocardial infarction (MI) in a population with smoking as the prevalent risk factor. METHODS: The study included 316 patients with early onset MI (<55 years old). All were male with at least one diseased coronary vessel. Denaturing high performance liquid chromatography (DHPLC), single-strand conformation analysis (SSCA), and direct sequencing were used to search for DNA variants in the five EDN1 exons and the promoter region. To determine the association of EDN1 polymorphisms with MI, we genotyped the patients and controls (n=350) and compared the allele and genotype frequencies between groups. RESULTS: We found six common nucleotide changes: -1394 (T/G) and -974 C/A (promoter), +120 ins/del A (exon 1, 5' UTR), 568 A/G (exon 3, E106E), 844 G/T (exon 5, K198N), and 1617 T/C (exon 5, 3' UTR). No rare EDN1-variants specific to the MIpatients were found. None of the EDN1 polymorphisms were significantly associated with early-onset MI in our population. The two promoter polymorphisms were in linkage disequilibrium with K198N, but no haplotype was associated with MI risk. CONCLUSIONS: In our population, the EDN1 variation did not contribute to early-onset MI.
Abstract: Neopterin is produced by human and primate monocyte/macrophages upon activation by pro-inflammatory stimuli like Th1-type cytokine interferon-gamma. Neopterin has pro-oxidative properties, which have been demonstrated in vitro in physicochemical and cell culture studies and also in in vivo experiments, e.g. the Langendorff perfusion model of rat hearts. In the past several years, the measurement of neopterin concentrations in body fluids including serum, urine and cerebrospinal fluid has revealed a potential role of this molecule in the prediction of long-term prognosis in both patients with cancer and those with systemic infections such as HIV-1 infection. Moreover, elevated neopterin concentrations have been reported in patients with coronary disease compared to controls and in recent years it has become apparent that increased neopterin concentrations are an independent marker for cardiovascular disease and a predictor of future cardiovascular events in patients with coronary artery disease. Current data suggest that the diagnostic performance of neopterin testing is comparable to that of well established biomarkers such as C-reactive protein and cholesterol plasma levels. The present article reviews the role of neopterin in the pathogenesis of cardiovascular disease and as a marker of coronary artery disease progression.
Abstract: AIMS: The beneficial effect of specific measures in patients with newly detected diabetes during percutaneous coronary intervention (PCI) has been poorly studied. Here, we determined the prevalence of newly detected diabetes in a cohort of patients who underwent PCI and analysed their clinical outcome. METHODS AND RESULTS: A prospective study included patients without previous diagnosis of diabetes that were referred for PCI between November 2005 and May 2006. Major cardiac events were registered after admission and during 12 months of follow-up, and oral glucose tolerance was tested at 15 days after hospital discharge. Six hundred and sixty-two consecutive patients were referred to our hospital for PCI. The distribution of the glycometabolic state of the entire population was (95% CI): known diabetes 28.8% (25.2-32.6), newly detected diabetes 16.2% (13.1-19.8), impaired glucose tolerance 24.5% (20.8-28.5), impaired fasting glucose 1% (0.4-2.4), and normal glucose regulation 29.5% (25.5-33.7). In a multivariable analysis, the presence of newly detected diabetes was not an independent predictor of cardiac events after 1 year of follow-up. CONCLUSION: The prevalence of diabetes in patients who underwent PCI was very high (45%), 35% of which was patients with newly detected diabetes. In our series newly detected diabetes was not an independent predictor of outcome at 12 months. Nevertheless, this finding requires independent confirmation in other series to draw general conclusions on the whole spectrum of percutaneous interventions.
Abstract: Saphenous veins remain a source of conduit for use in surgical coronary bypass graft revascularisation procedures. Saphenous vein grafts have a progressive closure rate estimated to be 12% to 20% at the end of the first year, and approximately 50% by 10 years. Regarding secondary revascularisation in these cases, reoperation carries substantially increased morbidity and mortality rates, making saphenous coronary intervention, in particular stent implantation, a more attractive means of revascularisation. However, this procedure carries a significant risk of major adverse clinical events, predominantly myocardial infarction or reduced antegrade flow (non-reflow phenomenon), mainly due to distal embolisation of atherothrombotic debris and distal microvascular occlusion. Embolic protection devices are used to reduce the risk of distal embolisation. There are two different designs: filter and occlusion-aspiration devices. In this article we present the different systems of embolic protection devices in saphenous percutaneous intervention and the previously published information is reviewed.
Abstract: OBJECTIVES: Inherited and acquired risk factors contribute to the development of the atherosclerotic lesion and its most common clinical manifestation, myocardial infarction (MI). Multiple studies have suggested a role for matrix metalloproteinases (MMPs) in atherosclerosis, and several functional polymorphisms in the MMP-1 gene have been linked to the risk of MI. The aim of this study was to evaluate the association between MMP-1 promoter polymorphisms and early MI in a Spanish cohort. METHODS: We carried out a case-control study with 261 unrelated patients who had suffered an MI before 55 years of age and 194 healthy controls, all male and smokers. The genotypes for the three MMP-1 promoter polymorphisms -1607 1G/2G, -519 A/G, and -340 T/C were determined through PCR-restriction fragment length polymorphism. Allelic, genotypic, and haplotypic frequencies were statistically compared between groups. RESULTS: Frequencies of the three polymorphisms did not differ between patients and controls. The -1607 1G/2G and -519 A/G variants were in linkage disequilibrium. Analysis of the haplotype frequencies showed significant associations of the 2G(-1607)-G(-519)-T(-340) (odds ratio = 2.40; 95% confidence interval = 1.27-4.55; P<0.006) and 1G(-1607)-G(-519)-T(-340) (odds ratio = 0.68; 95% confidence interval = 0.50-0.94; P<0.05) haplotypes with the risk of early MI. CONCLUSION: MMP-1 promoter polymorphisms are associated with the risk of early MI in a Spanish population of smoking males.
Abstract: Inflammation plays a major pathogenic role in atherosclerosis and its complications. Among the inflammatory cells that take part in this process, activated macrophages contribute significantly to atherosclerotic plaque progression, fibrous cap disruption and intracoronary thrombus formation. Neopterin, a pteridine derivative and a byproduct of the guanosine triphosphate-biopterin pathway, is mainly produced by activated macrophages. This article reviews the existing evidence suggesting an important role for neopterin as a marker for cardiovascular risk and also as a possible pathogenic factor in atherosclerosis.
Abstract: Coronary fistulas to cardiac chambers are an infrequent anomaly and usually are found casually. Although the majority of patients are asymptomatic, in rare cases it may cause coronary steal and cardiac ischemia. We present a patient with a left anterior descending coronary artery with multiple small fistulas to the left ventricle that suffered angina and an episode of ventricular fibrillation that required electrical cardioversion and an intracardiac defibrillator.
Abstract: INTRODUCTION AND OBJECTIVES: Recently we reported that prolongation of the corrected QT (CTc) interval is an independent risk factor in patients with unstable angina and acute ischemic changes. The aim of this study was to determine the prognostic value of this variable in patients with non-ST-segment elevation acute coronary syndrome who do not exhibit acute ischemic changes on admission ECG. METHODS: The study included 55 patients with this syndrome. On admission, a standard 12-lead ECG was recorded, the cardiac troponin-T was measured and a TIMI (Thrombolysis in Myocardial Infarction) risk score was calculated. The primary endpoint was the combination of nonfatal acute myocardial infarction, percutaneous or surgical revascularization, and cardiac death up to 30 days after discharge. Two independent investigators measured the QT interval manually and the corrected value was derived using Bazett's formula. In the statistical analysis, the following cut-off points were used: the median TIMI risk score, a cardiac troponin-T level of 0.04 ng/mL, and a QTc of 0.458 s. RESULTS: Of the 21 patients (38%) who reached the primary endpoint, 17 (81%) had QTc prolongation. Binary logistic regression analysis showed that QTc prolongation was an independent predictor of the combined endpoint. CONCLUSIONS: This study shows that QTc prolongation is an independent predictor of cardiovascular risk in patients with non-ST-segment elevation acute coronary syndrome but without acute ischemic changes on admission ECG.
Abstract: INTRODUCTION AND OBJECTIVES: Greater life-expectancy has led to an increase in the incidence of severe aortic stenosis, which accounts for a significant proportion of the workload of cardiology departments. With the imminent arrival of percutaneous aortic valve prostheses, it is important to know how effective surgery currently is in octogenarians. METHODS: The study included all patients aged >or=80 years with severe aortic stenosis who underwent cardiac catheterization prior to aortic valve replacement between May 1996 and May 2006. The percentage of patients who underwent surgery, outcomes at 30 days, long-term survival, and predictors of mortality were analyzed. RESULTS: Of the 137 patients evaluated, 104 (75.9%) underwent surgery, while 33 did not due to a low ejection fraction or severe chronic bronchitis, or because the patient's family did not give consent. The patients' mean age was 81.7 (1.5) years, 61.5% were female, 18.4% had diabetes, 7.8% had had a previous infarction, and 32.7% had coronary disease. Three patients (2.9%) had a perioperative myocardial infarction, six (5.8%) had a stroke, and six (5.8%) had a permanent pacemaker. Four patients (3.8%) died during the first 30 days. The survival rates at 1, 2, 3, 4, 5 and 6 years were 90 (2.9), 81 (4.2), 78 (4.8), 75 (5.3), 65 (7.2) and 60 (8.2)%, respectively. The following predictors of long-term mortality were identified: creatinine level, emergency surgery, and reintervention because of bleeding. Some 76.3% of patients remained in New York Heart Association functional class I-IV. CONCLUSIONS: Aortic valve replacement can be performed successfully in patients aged >or=80 years with severe aortic stenosis; the complication rate was low, and the survival rate and long-term results were good. Predictors of mortality in this series were the creatinine level, emergency surgery, and reintervention because of bleeding.
Abstract: Although medical treatment is the first-line therapy for myocardial bridges, in some cases revascularization may be required. Percutaneous intervention with bare metal stents is associated with a high restenosis rate. It has been speculated that drug eluting stents might be useful in this setting, although data are limited. We present a patient who suffered multifocal in-stent restenosis after a paclitaxel stent in a myocardial bridge.
Abstract: Bifurcated lesions are associated with higher complexity and restenosis. Sometimes implantation of two stents is necessary, requiring larger guiding catheters. We describe the implantation of two drug-eluting stents (DES) utilizing the balloon-crushing technique and 6 Fr catheters. METHODS: This was a prospective and observational study of a cohort of 15 consecutive patients with 1 bifurcated lesion treated with 2 DES through a 6 Fr catheter and the balloon-crushing technique between April and November 2005. The baseline characteristics of the patients, lesions and procedures were registered. Clinical follow up was obtained by telephone contact. RESULTS: Patient age ranged from 71.6+/- 9.4 years; 6 patients (40%) had diabetes; ejection fraction was 56 +/- 12%; radial access was used in 4 patients (26.6%). In 9 patients (60%) the target lesion was the left main artery; in 3 patients (20%) the target lesion was the LAD/diagonal and in the remaining 3 patients (20%), the target lesion was the circumflex/obtuse marginal. The median follow-up period was 316 days. There were 2 sudden deaths: 1 patient whose target lesion was the left main artery died 10 days following the procedure, and the other patient whose lesion was in the in LAD/diagonal died at day-187, 10 days following stent thrombosis. Both of them presented with severe ventricular dysfunction prior to the intervention. One patient required new percutaneous intervention due to in-segment restenosis in the left main artery. The composite major adverse cardiac events at follow up was 5 (33.3%, 2 deaths, 2 non-Q-wave myocardial infarctions and 1 revascularization). CONCLUSIONS: This technique permits the treatment of bifurcated lesions with 2 stents using 6 Fr guiding catheters, which could be very useful in radial access procedures. However, though the angiographic results were very satisfactory, the events observed in the follow-up period require a word of caution about its mid-term safety.
Abstract: Endovascular treatment of thoracic aortic pathology has become a valuable alternative therapeutic option to open surgery, however complications both during implantation and the postoperative period may occur. In this case report we present an intimal dehiscence during endovascular procedure. Diagnosis was made by transoesophageal echocardiography.
Abstract: INTRODUCTION: Intraaortic balloon counterpulsation (IABP) may be necessary during percutaneous intervention (PCI) and sometimes it would be useful to withdraw it at the end of procedure. We describe the utility of a closure suture device to retrieve the IABP in the cardiac catheterization laboratory immediately after the intervention. METHODS: Observational study of nine consecutive high-risk PCI where an 8.5 F IABP had been retrieved at the end of the procedure with a 6 F Perclose with the "preclosure" technique. The baseline clinical characteristics as well as the in-hospital and 90-days follow-up are described. RESULTS: The patients age was 67.4 +/- 14.9 years (mean 45-85; three patients were >80; 3 females (33.3%). Left main coronary artery was the target lesion in 8 (88.8%) and 4 (44.4%) patients, performed by radial access. Abciximab was used in 7 patients (77.7%). Successful hemostasis was achieved in all the cases without manual or mechanical compression. Only one patient was transferred to the Coronary Care Unit due to advanced age, left main coronary artery stenting, and severe ventricular dysfunction. Five patients (55.5%) were discharged 24 h after the PCI, three (33.3%) 48 h, and only one remained 72 h after the procedure. There were no events in the 90-days follow-up. CONCLUSIONS: The "preclosure" technique with the 6 F Perclose is an ingenious approach to achieve successful hemostasis after IABP removal. It may permit to transfer the patients to units without critical care facilities, shorten the admission and reduce vascular complications in patients with peripheral vascular disease who may need the counterpulsation only during the percutaneous intervention.
Abstract: Coronary artery obstruction during cardiac catheterization is rare. It is a serious complication and has been reported to occur in 0.15 to 0.5% of cases. Thromboembolism, air embolism and coronary dissection have been described as the most common causes of intraprocedural coronary occlusion. Aortic valve masses can also cause coronary obstruction. We report the case of a young woman with a complication and an incidental finding during angiographic procedure. A surgical treatment was needed.
Abstract: Restenosis after percutaneous intervention in the left main coronary artery may present as sudden cardiac death. Although drug-eluting stents have demonstrated promising results, there remains the question about appropriate length of the left main artery to be covered with the stent. We describe a patient who received two drug-eluting stents with the balloon crushing technique in the distal left main coronary artery. Three months later, this patient presented with a new lesion in the segment of the left main artery not covered with stent, but instead at the site where the balloon was inflated in the initial procedure.
Abstract: BACKGROUND: The role of inflammation in the pathogenesis of acute coronary syndrome (ACS) is established. Little is known however, regarding the use of inflammatory markers as predictors of future cardiovascular events in patients presenting to the emergency department (ED) with suspected ACS. HYPOTHESIS: To assess whether biomarkers that predict cardiovascular risk in apparently healthy individuals and coronary artery disease patients are useful predictors of future cardiovascular events in patients presenting to the ED with chest pain suggestive of ACS. METHODS: We compared the abilities of serum C-reactive protein (hs-CRP), albumin and leukocyte count to identify subjects with ACS and those who are at high risk of developing events during a 30-day follow-up. RESULTS: 144 patients (mean age 62+/-13 years, 45 female) presenting to the ED <3 h after the onset of symptoms suggestive of ACS were evaluated. Final hospital diagnoses were non-ischemic chest pain in 43 (30%) and ACS in 101 (70%) patients. Patients with ACS had significantly higher leukocyte count (p<0.0001) and hs-CRP levels (p<0.02) and lower albumin concentrations, compared to patients with NICP (p<0.0001). Lower albumin concentrations (p=0.03) and hs-CRP (p=0.049) were predictors of recurrent events at 30 days. On multivariate analysis, however, only leukocyte count was a predictor of ACS (OR 20.9; 95% CI: 3.7-19.5; p=0.01) and high hs-CRP levels were a predictor of clinical outcome (OR 2.8; 95% CI: 1.5-5.2; p=0.001). CONCLUSIONS: Leukocyte count is an independent predictor of ACS in patients presenting to the ED with chest pain suggestive of ACS and high hs-CRP levels are an independent predictor of clinical outcome in ACS patients.
Abstract: The use of stent grafts for treating diseases of the aorta has been assisted by the development of new percutaneous techniques for closing the access site. The purpose of this study is to describe our clinical experience and results obtained using percutaneous closure devices for femoral artery closure after the placement of stent grafts.
Abstract: AIMS: Serum levels of neopterin, an immune modulator secreted by activated macrophages, are elevated in patients with acute coronary syndromes compared with stable angina patients and control subjects. In unstable angina, serum neopterin levels correlate with the presence of vulnerable coronary stenosis, multiple complex coronary lesions, and patient outcome. The present study assessed the prognostic significance of raised serum neopterin concentrations in patients with stable angina pectoris. METHODS AND RESULTS: We carried out a 1-year follow-up prospective study in 297 patients with chronic stable chest pain undergoing diagnostic coronary angiography. The primary study endpoint was the composite of non-fatal myocardial infarction, unstable angina, and cardiac death. Fifty-one patients (17.2%) had adverse coronary events during follow-up. Mean serum neopterin levels were significantly higher in patients with events compared with those without (P=0.02). On multiple regression analysis, neopterin levels (P=0.021), severity of coronary artery disease (P=0.009), and a history of previous myocardial infarction (P=0.001) were independent predictors of adverse events. CONCLUSIONS: Serum neopterin is an independent predictor of major adverse coronary events in patients with chronic stable angina pectoris. This marker of macrophage activation may be useful for risk stratification in patients with chronic stable angina.
Abstract: Dobutamine stress echocardiography is widely used after myocardial infarction. This technique is safe and severe adverse reactions are uncommon. We report one case of cardiac rupture during contrast-enhanced dobutamine stress echocardiography.
Abstract: In the last decade, compelling evidence has evolved at both the basic science and clinical level for the implication of inflammation in the pathogenesis of atherosclerosis and its complications. The composition of the atherosclerotic plaque, rather than the degree of stenosis, is now recognized as a pivotal feature in determining plaque vulnerability and hence the risk of acute coronary ischaemic events. Current evidence supports a key role for inflammation in all phases of the atherosclerotic process, from plaque formation through to progression and, ultimately, the thrombotic complications of atherosclerosis. The growing appreciation of the role of inflammation in atherogenesis has focused attention on whether circulating levels of inflammatory biomarkers may help to identify those at risk of future cardiovascular events. In addition, the protective effects of a variety of interventions, such as statins, aspirin, and fibrates, are often associated with the evidence of reduced inflammation, further strengthening the notion that inflammation and the acute complications of atherosclerosis are causally related. The present review describes the pathophysiology of atheromatous plaque vulnerability and discusses the clinical use of inflammatory biomarkers for prognostic stratification of patients with acute coronary syndromes.
Abstract: Radial artery access improves the patient's well-being, permits earlier ambulation and diminishes vascular complications after cardiac catheterization. Using the same catheter to study the left and right coronary arteries may facilitate the technique. In a cohort of 100 patients we prospectively analyzed the possibility of studying both coronary arteries with a Judkins left 3.5 catheter. The variables studied were percentage of successful access, complications, and procedural time from insertion of the guiding catheter to the end of ventriculography. It was possible to catheterize both coronary arteries with the same catheter in 94 cases (94%) with a procedural time of 16.7 (6.8) min. In 6 patients a JR4 catheter was required, in one of them due to severe spasm of the right coronary artery ostium and due to impossibility to catheterize the ostium in the other 5. There were no cases of severe radial artery spasm.
Abstract: We present a 55 year old man that was admitted to our Institution because of anginal chest pain. Transthoracic echocardiogram was normal. Coronary angiography showed three vessels disease and an anomalous circumflex artery arising from right proximal coronary artery. By-pass surgery was successfully performed.
Abstract: Inflammation plays an important role in atherosclerosis and the genesis of acute coronary syndromes, i.e., atheromatous plaque disruption. Neutrophil count and C-reactive protein (CRP) levels are markers of ongoing inflammation and predictors of cardiovascular risk. We sought to assess whether these inflammatory markers are associated with the presence of multiple complex stenoses in patients with chronic stable angina. METHODS AND RESULTS: We assessed 150 patients with chronic stable angina, 121 with significant coronary artery stenosis (> or =50% diameter reduction) and 29 without. CRP levels and neutrophil count were assessed at study entry. Stenoses were classified as "complex" (irregular or scalloped borders, ulceration or filling defects) or "smooth" (absence of complex features). Eighty-eight percent of the complex lesions were of type C according to AHA/ACC classification whereas the rest were type B. Patients with > or =3 complex lesions were considered to have multiple complex stenoses. Extent of coronary artery disease was assessed using a validated score. Baseline neutrophil count (4.39 x 10(9) L (-1) +/- 28 versus 3.82 x 10(9) L (-1) +/- 0.77; P = 0.004) and CRP levels (2.15 mg/L (4.6-1) versus 0.39 mg/L (0.69-0.23); P < 0.0001) were higher in patients with significant stenoses compared to patients without. No association was found between disease extent and CRP levels or neutrophil count. Neutrophil count, however (but not CRP) correlated with stenosis complexity (r = 0.28; P = 0.002 ) and was also an independent predictor of the presence of multiple complex stenoses (OR: 4.05; CI 95% (1.9-10.4); P = 0.038). CONCLUSIONS: CRP levels and neutrophil count are higher in angina patients with coronary stenoses compared to those without. Neutrophil count, but not CRP levels, correlates with angiographic stenosis complexity.
Abstract: AIMS: We sought to assess (1) whether C-reactive protein (CRP) is an independent predictor of future cardiovascular events after adjustment for coronary artery disease (CAD) severity and (2) whether CRP levels correlate with number of angiographically complex coronary artery stenosis. METHODS AND RESULTS: We studied 825 consecutive angina patients (mean age 63+/-10 years, 74% men), 700 with chronic stable angina (CSA) and 125 with acute coronary syndromes without ST-segment elevation (ACS). The composite endpoint of non-fatal acute myocardial infarction, hospital admission with class IIIb unstable angina and cardiac death was assessed at one year follow-up. Hs-CRP level was higher in CSA patients with the combined end-point (P=0.03) after adjustment for number of diseased coronary arteries. Hs-CRP was also significantly higher in patients with ACS compared to CSA ( P=0.004) and correlated with number of complex angiographic stenoses (r=0.36, P=0.01). Hs-CRP was also increased in patients with NYHA functional class III or IV compared to those in class I or II (p<0.0001). CONCLUSIONS: CRP levels predict future cardiovascular events independently of CAD severity and correlate with number of angiographically complex coronary artery stenosis in patients with ACS. Thus, CRP levels are a marker of atheromatous plaque vulnerability and CAD activity.
Abstract: We sought to assess the relation between circulating levels of inflammation markers, such as neopterin and C-reactive protein, and the development of adverse cardiovascular events in patients with hypertension but without obstructive coronary artery disease. We observed that patients who developed adverse events during follow-up had significantly higher neopterin levels compared with patients without events.
Abstract: OBJECTIVE: To assess the relation between markers of inflammation and the presence of multiple vulnerable plaques in patients with non-ST segment elevation acute coronary syndromes. DESIGN: Prospective cohort study of 55 patients with non-ST segment elevation acute coronary syndromes and angiographically documented coronary disease. Blood samples were obtained at study entry for the assessment of high sensitivity C reactive protein (CRP), neopterin, and neutrophil count. Coronary stenoses were assessed by quantitative computerised angiography and classified as "complex" (irregular borders, ulceration, or filling defects) or "smooth" (absence of complex features). Extent of disease was also assessed by a validated angiographic score. RESULTS: Neutrophil count (r = 0.36, p = 0.007), CRP concentration (r = 0.33, p = 0.02), and neopterin concentration (r = 0.45, p < 0.001) correlated with the number of complex stenoses. Patients with multiple (three or more) complex stenoses, but not patients with multiple smooth lesions, had a higher neutrophil count (5.9 (1.4) x 10(9)/l v 4.8 (1.4) x 10(9)/l, p = 0.02), CRP concentration (log transformed) (1.08 (0.63) v 0.6 (0.6), p = 0.03), and neopterin concentration (log transformed) (0.94 (0.18) v 0.79 (0.15), p = 0.002). Multiple regression analysis showed that neopterin concentration (B = 4.8, 95% confidence interval (CI) 1.9 to 7.7, p = 0.002) and extent of coronary artery disease (B = 0.6, 95% CI 0.03 to 1.2, p = 0.04) were independently associated with the number of complex stenoses. CONCLUSIONS: Acute inflammatory markers such as high neutrophil count, CRP concentration, and neopterin concentration correlate with the presence of multiple angiographically complex coronary stenoses. Neopterin concentration was a stronger predictor of multiple complex plaques than were neutrophil count and CRP concentration. These findings suggest that a relation exists between inflammation and pancoronary plaque vulnerability.
Abstract: BACKGROUND: Ischemia-modified albumin (IMA) is a new marker of myocardial ischemia, there is concern that IMA concentrations may be affected by ischemia occurring in tissues other than the myocardium. METHODS: We assessed 23 consecutive patients (15 males; mean age, 67 years) with typical leg claudication and documented peripheral vascular disease (PVD). All patients underwent both treadmill-exercise stress testing to induce leg ischemia and dobutamine stress echocardiography 1 week apart for the assessment of myocardial ischemia. Blood samples for IMA measurements were obtained at baseline, immediately after peak exercise/stress, and 1 h after exercise/stress. Statistical analysis was performed with the ANOVA repeated-measures test. RESULTS: Compared with baseline, mean (SD) IMA was significantly lower after the induction of skeletal muscle ischemia and returned to baseline values at 1 h: baseline, 74.6 (15.6) kilounits/L; peak stress, 69.5 (14.0) kilounits/L (P <0.0001 vs baseline); 1 h after stress, 75.9 (15.7) kilounits/L (P <0.0001 vs peak stress; P = 0.3 vs baseline). Baseline, peak stress, and 1-h poststress IMA concentrations were inversely correlated with the ankle-brachial index after exercise (r = -0.4; P <0.05). None of the patients showed regional wall motion abnormalities during dobutamine stress echocardiography, and IMA concentrations remained unchanged from baseline. There were no differences in baseline [74.6 (15.6) vs 72.7 (11.5) kilounits/L; P = 0.6], peak stress, or poststress IMA concentrations when exercise testing and dobutamine stress echocardiography values were compared. CONCLUSIONS: The relationship between disease severity (of a noncardiac origin) and baseline IMA values is an important and novel finding. IMA is significantly lower immediately after exercise-induced leg ischemia in patients with PVD and is related to disease severity. IMA concentrations can therefore be affected by the development of skeletal muscle ischemia, and this may have implications regarding the ability of IMA to detect myocardial ischemia in PVD patients.
Abstract: BACKGROUND: Both endothelial cell activation and macrophage activation play a significant role in atherogenesis and atheromatous plaque vulnerability and may determine rapid coronary artery disease (CAD) progression. We sought to assess the association between serum inflammatory markers and rapid CAD progression in patients with chronic stable angina pectoris. METHODS AND RESULTS: We studied 124 chronic stable angina pectoris patients (84 men; mean age, 61+/-10 years) who were on a waiting list for coronary angioplasty for a mean time of 4.8+/-2.4 months. CAD progression was defined as > or =10% diameter reduction of a pre-existing stenosis > or =50%, > or =30% diameter reduction of a stenosis <50%, development of a new stenosis > or =30% in a previously normal segment, or progression of any stenosis to total occlusion. CAD progression occurred in 35 patients (28%). After adjustment with binary logistic regression, neopterin (P<0.001), high-sensitivity C-reactive protein (P=0.017), matrix metalloproteinase-9 (P=0.002), soluble intercellular adhesion molecule 1 (P<0.001), and previous history of unstable angina (P=0.01) were independent predictors of rapid CAD progression. The association between rapid disease progression and inflammatory markers remained significant even when presence of complex lesions was introduced into the multivariate model. CONCLUSIONS: Rapid CAD progression in patients with stable angina pectoris is associated with increased C-reactive protein levels and raised concentrations of biochemical markers of endothelial and macrophage activation.
Abstract: The CD14 receptor is a pattern recognition molecule in the innate immune response against microorganisms and other exogenous and endogenous stress factors. The most important CD14 signalling co-receptor is toll-like receptor 4 (TLR4), which activates, among others, the nuclear factor kappaB (NF-kappaB) inflammatory pathway. Besides its role in innate immunity and host defence, the proinflammatory cytokines expressed upon TLR4/NF-kappaB pathway activation exert proatherogenic effects. The CD14 C(-260)T promoter and TLR4 Asp299Gly functional polymorphisms have been recently implicated in the development of cardiovascular events, suggesting that the genetically determined inflammatory response against pathogens or their antigens may have a major role in atherogenesis and subsequent acute events. Is the association of these polymorphisms with cardiovascular disease more evidence for the implication of infection, especially by Gram negative bacteria, in the development of acute coronary events? This article reviews the molecular basis, biological functions, and clinical implications of the CD14/TLR4 polymorphisms in the development of cardiovascular events.
Abstract: BACKGROUND: The diagnosis of myocardial ischemia in patients with acute chest pain at rest but non-diagnostic electrocardiograms (ECG) is problematic. Ischemia Modified Albumin (IMA) is a new biochemical marker of ischemia, which may be useful to characterise acute coronary syndrome (ACS) patients. METHODS: We studied 131 patients (mean age 58.5 years; 95 male) presenting to the emergency department with symptoms suggestive of ACS but with normal or non-diagnostic ECGs. Cardiac troponin T (cTnT) and IMA were measured within 3 h of last chest pain episode. Based on hospital diagnostic test results, patients were classified as having ACS or non-ischemic chest pain (NICP), by two independent cardiologists unaware of IMA results. RESULTS: Mean IMA levels (U/ml) were higher in patients with ACS (98.3+/-11) compared to patients with NICP (85.5+/-15); p<0.0001. IMA levels >93.5 U/ml demonstrated a sensitivity and specificity of 75% for the diagnosis of ACS; area under the receiver operator characteristic curve 0.78 (95% CI: 0.70-0.85). If we applied the manufacturer cutoff point of 85 U/ml, the sensitivity of IMA increased to 90.6% with a specificity of 49.3% (negative predictive value=84.6%). In combination with cTnT (6-12 h) (>0.05 ng/ml), the sensitivity increased to 92.2%. After multivariate analysis, IMA levels >85 U/ml (odds ratio=14.6 [95% CI 4.4-48.4]; p<0.0001), age and prior myocardial infarction were independent predictors of ACS. CONCLUSION: IMA may be a useful biomarker for the identification of ACS in patients presenting with typical acute chest pain but normal or non-diagnostic ECGs.
Abstract: OBJECTIVES: The latest development in echocardiography is the hand-held ultrasound device. Previous studies have shown that portable ultrasound devices detect major cardiovascular pathology better than the physical examination, but their diagnostic accuracy is still not known. The purpose of this study was to compare the results of examinations made with portable devices to those obtained with higher-scale platforms. PATIENTS AND METHOD: 211 consecutive unselected patients were included in the study. Patients were randomly studied with a portable device and a standard platform (considered the gold standard for comparison) by cardiologists experienced in echocardiography. Parameters of cardiac morphology and function, and valvular regurgitation were compared and analyzed using the McNemar paired test. Differences of more than one grade were considered major differences. RESULTS: The subjective assessment of the studies made with the portable device was significantly worse. The correlation between estimates of left ventricular function (differences not statistically significant) was adequate, but significant differences were detected in the evaluation of left atrial enlargement, left ventricular hypertrophy, aortic root enlargement, and mitral and tricuspid regurgitation. CONCLUSIONS: Hand-held cardiac ultrasound devices do not satisfy criteria for a complete echocardiographic study. They provide accurate information about ventricular function but fail to adequately measure cardiac chambers or assess valve function.
Abstract: AIMS: Endothelial dysfunction and subangiographic atheroma have been reported in patients with cardiac syndrome X (CSX) but little is known regarding chronic inflammation and reduced arterial distensibility as pathogenic mechanisms. We assessed whether markers of inflammation and arterial distensibility differ in CSX patients compared to control subjects. METHODS AND RESULTS: We studied 30 consecutive CSX patients (mean age 57+/-6 years, 25 women) and 30 healthy controls (mean age 54+/-8 years, 25 women). High sensitivity C-reactive protein (hs-CRP) levels were significantly higher in patients with CSX compared to controls (2.6 [1.7-4.5] vs 1.5[0.7-2.7] mg/l, P=0.02). Hs-CRP levels correlated with carotid intima-media thickness (IMT) (Spearman's rho=0.51; P=0.013). CSX patients also had significantly increased mean IMT values than controls (P<0.0001). Arterial stiffness and elastic modulus were also significantly increased in CSX patients compared to control subjects (P=0.04 and P=0.04, respectively). Distensibility tended to be lower in CSX patients than controls although this difference did not reach statistical significance. CONCLUSIONS: This study showed for the first time that compared to control subjects, patients with CSX have higher hs-CRP serum levels, increased mean common carotid artery IMT and increased arterial stiffness. The role of these abnormalities in the pathogenesis of CSX deserves investigation.
Abstract: BACKGROUND: There is evidence that new portable echocardiographic devices are useful in evaluating heart anatomy and function, but a lack of Doppler modes has up to now been an important limitation in obtaining haemodynamic data. OBJECTIVES: To report the Doppler capabilities of a new hand held echocardiographic device. DESIGN: Blinded comparison of two types of echocardiography machine. SETTING: Tertiary care centre. PATIENTS: 98 consecutive patients were randomly imaged with the hand held device, with a standard platform as reference. OUTCOME MEASURES: Pulsed wave transmitral Doppler inflow tract velocities, deceleration time, and continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation peak velocities were recorded. RESULTS: There was excellent agreement between the hand held device and standard echocardiography for the evaluation of diastolic E and A waves, E/A ratio, and deceleration time with pulsed wave Doppler (intraclass correlation coefficients of 0.97, 0.93, 0.90, and 0.78, respectively). In addition, good agreement was found between continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation velocities (intraclass correlation coefficients of 0.96 and 0.80). However, there was a significant difference between patients with tricuspid regurgitation measured with the hand held device (25.5%) and by standard echocardiography (65.3%), resulting in misdiagnosis of eight patients with pronounced pulmonary hypertension. CONCLUSIONS: New hand held devices with Doppler capabilities overcome previous limitations in evaluating haemodynamic variables. With colour Doppler they are now suitable for the complete evaluation of valvar disease and diastolic function. However, important limitations remain in the evaluation of pulmonary pressures.
Abstract: The results in this study confirm and expand previous reports that ischemia-modified albumin (IMA) is an early marker of ischemia in the setting of percutaneous coronary intervention (PCI). We observed that IMA levels are related to the number of inflations, inflation pressure, and duration of inflations. It is therefore likely that IMA reflects the magnitude and duration of ischemia induced during PCI.
