Abstract: Endovascular methods have become more widespread symptomatic carotid artery pseudoaneurysm treated and offer an alternative to surgery, which is often diffi-using a stent graft. cult in case of a hostile neck resulting from radiotherapy. Carotid pseudoaneurysm after laryngectomy is a very uncommon complication. We report a case of symptomatic carotid artery pseudoaneurysm treated using a stent graft.
Abstract: Two cases of percutaneous closure of atrial septal defect and patent foramen ovale with intracardiac echo monitoring are described. Intracardiac echocardiography was compared to contemporary TOE with full data concordance. The inherent implications and limitations of this new method are discussed.
Abstract: The results of using the culotte bifurcation technique have not been promising with regard to bare metal stents; however, some possible advantages with regard to drug-eluting stents (DES) must be taken into account, such as the possibility to stent provisionally, to use lower French sizes, and to completely cover the coronary wall and the new carina with a single or double stent layer. The crush technique, which aims to reach a complete coverage of the coronary wall to allow antiproliferative drugs to homogeneously distribute into the coronary walls, has been introduced. The culotte technique seems to act more physiologically, allowing the creation of a new, homogeneously covered carina, without any crushed metal inside the coronary wall. We present the case of a coronary bifurcation treated with the use of the culotte technique and paclitaxel-eluting stent deployment, with good angiographic results after 10 months of follow-up. Further data are needed to evaluate the potential utility of the culotte technique in treating bifurcation coronary lesions in the area of DES.
Abstract: We report two cases of cardiac transplantation of donor hearts with left anterior descending (LAD) myocardial bridging (MB). In the first case, the diagnosis was done only days after transplant. In the second case, a pre-operative angiography showed evidence of LAD myocardial bridging and the organ was used for a marginal recipient. Both patients tolerated the procedure very well and did not have peri-operative cardiac complications. In this study, MB is discussed and its relationship to rejection of donor hearts is evaluated. In light of the growing demand for donated hearts, and in consideration of the relatively high and often undiagnosed occurrence of MB, a liberalized approach to acceptance of this anatomic variant could be adopted in the selection of donor hearts. Identification of MB in the prospective donor heart should not be an absolute contraindication for transplantation.
Abstract: A case of coronary dissection with large parietal hematoma, involving the proximal left anterior descending and the left main coronary arteries after systemic thrombolysis for acute anterior myocardial infarction is described. The peculiar intravascular ultrasound features, therapy options, complications after stenting and follow-up are described.
Abstract: BACKGROUND: The best treatment option for high-risk patients with unstable coronary syndrome is an early invasive strategy accompanied by intensive anti-platelet therapy. We tested the effect on clinical outcome of early coronary angioplasty using a high-dose bolus of tirofiban in patients with non-ST segment elevation acute coronary syndrome. METHODS: One hundred and forty consecutive patients with unstable coronary syndrome who underwent an immediate percutaneous coronary intervention with the administration of a high (25 microg/kg) dose bolus of tirofiban followed by an 18-h infusion of 0.15 microg kg(-1) min(-1) were compared with a matched control group of 162 patients treated with abciximab. The primary endpoint of the study was the 30-day incidence of major adverse cardiac events; the secondary endpoints were the incidence of major and minor bleeding. RESULTS: The time from admission to PCI was slightly shorter in the tirofiban group (3.9+/-4.8 vs. 4.5+/-4.4 h; P=0.26). The 30-day rate of major adverse cardiac events was similar in the two groups (6% with tirofiban and 8.6% with abciximab: OR=1.37, 95% CI=0.58-3.29, P=0.52). No major bleeding episodes were observed; the incidence of minor bleeding was 3.6% in the tirofiban group and 2.5% in the abciximab group (OR=0.68, 95% CI=0.18-2.59, P=0.74). CONCLUSIONS: In this preliminary study, the beneficial effect of the administration of a high-dose tirofiban bolus on 30-day clinical outcomes was similar to that of abciximab in high-risk patients with unstable angina undergoing immediate percutaneous coronary intervention. The results of this therapeutic strategy should be tested in a larger randomised study.
Abstract: BACKGROUND: The intrinsic thrombogeneity of stents was the historic limitation to their usage during the early phases of stenting. The risk of stent thrombosis has been minimized by the widespread use of platelet antiaggregation. Nowadays, the risk of subacute stent thrombosis is around 1%. Thrombotic risk depends on several factors, such as type of stent, complexity of lesion, and clinical picture. CASE REPORT: We present a case of recurrent acute in-stent thrombosis in a patient with mild antithrombin III (AT) deficiency despite the combined administration of clopidogrel and aspirin. CONCLUSION: In our patient, several factors, such as diabetes, AT deficiency, and the use of a paclitaxel-eluting stent, have contributed to the development of recurrent acute stent thrombosis. Although we were not able to identify the culprit factor, we should keep in mind that the deployment of a drug-eluting stent could be unsafe if it is not supported by a clear clinically oriented pathway that considers the overall condition of the patient since, in some cases, neither coronary lesions nor coronary stents are responsible for the negative outcome of patient therapy, which may be caused instead by incomplete or inadequate patient assessment.
Abstract: Upper extremity ischemia is a rare entity usually due to emboli of arterial origin. Such thromboemboli produce acute symptoms of sufficient severity as to necessitate early surgical intervention. We report the case of a patient with severe ischemia in his left hand, in whom the embolic source was a mural thrombus localized at the level of a saccular aneurysm of the subclavian artery. After having excluded the presence of a thoracic outlet syndrome, the lesion was successfully treated by means of percutaneous implantation of a stent graft with the exclusion of the aneurysm and the sealing of the thrombus.
Abstract: BACKGROUND: It has been shown that thrombin injection is a safe and effective technique for the treatment of iatrogenic femoral pseudoaneurysm. The aim of this study was to evaluate and compare the use of ultrasound-guided low-dose thrombin injections with ultrasonographically-guided compression repair in the treatment of iatrogenic femoral arterial pseudoaneurysm. METHODS: We compared two cohorts of patients treated for iatrogenic femoral pseudoaneurysm: the first included 38 patients who underwent ultrasonographically-guided compression repair as a first-step approach between January 1998 and November 2002; the second included 21 patients treated with ultrasound-guided low-dose thrombin injection between December 2002 and December 2003. RESULTS: Both groups had similar demographic characteristics and aneurysm sizes (p = 0.72). Compression was successful in 24/38 patients (63%); the 14 persistent aneurysms were surgically repaired (37%). The primary thrombin injection of a mean dose of 185+/-95 U/ml (range 100-400 U/ml) successfully obliterated all of the 21 pseudoaneurysms (success rate 100 vs 63% in the compression group, p = 0.004). Thrombosis occurred within an average of 12+/-15 s of thrombin injection. Sedation was used in 42% of the patients undergoing compression and in none of those receiving thrombin (p = 0.001). The duration of hospitalization was significantly longer in patients undergoing compression therapy (9.8+/-5.6 vs 5.6+/-1.4 days, p = 0.001). CONCLUSIONS: Ultrasound-guided low-dose thrombin injection appears to be more effective in reducing the need for surgical repair when used to treat iatrogenic femoral pseudoaneurysm, is better tolerated by the patients, and requires a shorter hospital stay.
Abstract: Forty-six patients were randomized to receive drug (group 1) or hypnotic sedation (group 2) during percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery. Intracoronary and standard electrocardiograms were continuously registered, and heart rate spectral variability was studied. Normalized units of low- and high-frequency components and the ratio of low to high frequency were measured during balloon inflations. The ST segment shifted at the first balloon inflation from 0.02 +/- 0.01 to 0.09 +/- 0.6 mm in group 1 and from 0.02 +/- 0.08 to 0.1 +/- 0.6 in group 2 mm (p <0.05). In group 1, the low-frequency band and the ratio of low to high frequency increased significantly during the first balloon inflation (from 59 +/- 10 to 75 +/- 10 normalized units and from 2.4 +/- 1.4 to 7.3 +/- 4.7, respectively; p <0.001). The increase of the ratio of low to high frequency was significantly related to ST shift (r = 0.706; p <0.01). In contrast, no significant variation of spectral parameters was found in group 2. The increase in cardiac sympathetic activity associated with balloon inflation and myocardial ischemia during percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery was selectively eliminated by hypnosis but not by drug sedation.
Abstract: To overcome the suboptimal platelet inhibition induced by tirofiban in the first hour after a percutaneous coronary intervention, a new regimen of 25 microg/kg bolus followed by an 18-hr infusion of 0.15 microg/kg/min has been proposed. The aim of this study was to compare the effects of this high bolus dose of tirofiban with those of abciximab on bleeding risk and 30-day clinical outcome in patients undergoing coronary stenting. We compared two cohorts of patients who underwent coronary stent placement between January 2000 and December 2002. In the first cohort, the only available IIb/IIIa receptor inhibitor was abciximab, which was given to 280 (34.9%) out of 802 stented patients; in the second cohort, tirofiban was administered to 274 (38.3%) out of 716 treated patients. The primary endpoints were the proportion of patients with major bleeding and the rate of site access complications; the 30-day incidence of major adverse cardiac events (MACE) was also assessed. After the procedure, the patients were given ticlopidine for 4 weeks and aspirin indefinitely. Major bleeding episodes were observed in four patients receiving abciximab and in none receiving tirofiban (1.4% vs. 0%; P = 0.12); the rates of site access complications were similar (3.6% vs. 3.3%; P = 0.96). The 30-day incidence of MACE was 7.1% in the abciximab group and 5.8% in the tirofiban group (P = 0.65). In patients undergoing coronary stenting, the high bolus dose of tirofiban is safe and not associated with an increased risk of major bleeding or site access complications in comparison with abciximab.
Abstract: In patients treated with primary coronary angioplasty, the use of abciximab improves microvascular perfusion and enhances the recovery of contractile function. This study compared the effects of the new dose regimen of tirofiban (25-microg/kg bolus followed by an 18-hour infusion at 0.15 microg/kg/min) on left ventricular function with those of abciximab in patients who underwent direct angioplasty. One hundred patients who underwent primary coronary angioplasty were randomized to receive a standard dose of abciximab or a large-dose bolus of tirofiban. The primary end point of the study was change in the infarct-zone wall motion score index between the initial and 30-day follow-up echocardiographic studies. The secondary end points were procedural evaluations before and after Thrombolysis In Myocardial Infarction (TIMI) grade flow, TIMI grade myocardial perfusion, and corrected TIMI frame count. Baseline global and regional ventricular functions were similar in the 2 treatment groups. After the procedure, a TIMI grade 3 flow was obtained in 86% of patients treated with abciximab and 88% of those receiving tirofiban (p = 1.0), whereas TIMI grade 3 myocardial perfusion was present in 70% and 76%, respectively (p = 0.65); corrected TIMI frame count was 22.5 +/- 1.9 and 22.1 +/- 2.5 (p = 0.37). After 30 days, we obtained 87 paired echocardiographic studies. The infarct-zone wall motion score index decreased from 2.20 +/- 0.3 to 1.99 +/- 0.2 in the abciximab group and from 2.18 +/- 0.3 to 1.95 +/- 0.3 in the tirofiban group (p = 0.67). Thus, in patients who had primary coronary angioplasty, abciximab, and the large-dose bolus of tirofiban showed similar effects on the initial angiographic results and 30-day recovery of left ventricular function.
Abstract: AIM: The aim of this study was to assess the influence of coronary arteriography with the use of a non-ionic low molecular monomer (iopromide) on left ventricular function. METHODS: Fifty consecutive patients with coronary artery disease (CAD) and normal left ventricular ejection fraction were studied by coronary arteriography for a stable or unstable coronary syndrome by using iopromide. They were divided into 2 groups: group 1, patients with one vessel disease; group 2, patients with multiple vessel disease. A >50% reduction of the lumen diameter by on-line quantitative angiography was considered a significant coronary stenosis. Coronary arteriography was performed by hand injection of 5 ml of iopromide avoiding the use of nitrates during the procedure. Doppler echocardiography monitoring was performed immediately before the coronary arteriography and at the end of the last coronary injection. The following parameter were recorded: E peak velocity (E) (cm/s), A peak velocity (A) (cm/s), E/A ratio, E deceleration time (EDT) (ms), isovolumic relaxation time (IRT) (ms), and left ventricular ejection fraction (EF) (%). RESULTS: No complications were observed during the procedures. A mean amount of 40+/-8 ml of iopromide was used. No significant variation of heart rate and arterial pressure was shown during coronary arteriography. No changes were observed either for E, A, E/A ratio or for left ventricular EF in any group of patients. A significant increase of EDT and IRT in comparison with baseline values was documented only in group 2 (from 140+/-77 to 199+/-44 and from 98+/-33 to 144+/-44, p<0.01), returning to baseline values after 10+/-3 minutes. A positive correlation was observed between EDT and IRT shift from baseline values (r=0.77; p<0.01). CONCLUSION: In conclusion, iopromide temporarily impairs left ventricular diastolic dynamics during selective coronary angiography, but only in patients with multivessel CAD.
Abstract: The aim of this multicenter, prospective, non-randomized study was to examine the procedural, in-hospital, and mid-term clinical and angiographic outcome of patients undergoing coronary angioplasty with the Tecnic Carbostent system. Between October 2001 and March 2002, 123 consecutive patients were treated with coronary implantation of the Tecnic Carbostent. Stable angina (54%), unstable angina (37%) and silent ischemia (9%) were clinical indications for revascularisation. The baseline lesion morphology was complex (Type B2 or C) in 59% of the cases, and the mean lesion length was 15+/-8 mm. A total of 179 stents were implanted in 149 lesions. The procedural success rate was 100%. Mean percent diameter of the stenosis decreased after the intervention from 75%+/-11% to 8%+/-4%. The mean cross-sectional area stent recoil was 8.8%+/-7.3%. No in-hospital or 30-day major adverse cardiac events were observed. During the 6-month follow-up period, there were no deaths or myocardial infarctions, whereas the incidence of target lesion revascularisation was 12.7%. The angiographic restenosis rate was 14.1%: a focal or limited pattern (class I or II) was found in 83% of cases, whereas the remaining 17% had a proliferative morphology (class III or IV). In conclusion, this study indicates that a good clinical and angiographic outcome may be obtained with the Tecnic Carbostent coronary system in consecutive patients with de novo coronary lesions.
Abstract: BACKGROUND: In the TARGET study, sub-optimal platelet inhibition with tirofiban was held responsible for the higher incidence of periprocedural CK-MB release compared to abciximab. Since then, a new, higher bolus dose of tirofiban has been proposed to increase blood concentrations very soon after the start of treatment. OBJECTIVE: The aim of this study was to explore the bleeding risk and clinical outcome at 30 days in a series of patients undergoing percutaneous coronary intervention (PCI) with the new dosing regimen of tirofiban (25 microg/kg bolus followed by a 0.15 microg kg(-1) min(-1) infusion for 18 h). METHODS: A total of 133 consecutive patients underwent a PCI and received a high bolus dose of tirofiban. Platelet function inhibition was measured using the Ultegra RPFA (Accumetrics) 10 min and 8 and 24 h after the start of therapy in the first 38 cases. RESULTS: The procedural success rate was 98.5%. The mean level of platelet inhibition 10 min after the start of therapy was 94.7 +/- 5.9%. No major bleedings, no need for red blood cell transfusion and no episodes of severe thrombocytopoenia were recorded. Groin haematoma was observed in seven patients (5.3%). The cumulative incidence of 30-day major adverse cardiovascular events was 4.6% (five myocardial infarctions and one repeat PTCA for sub-acute stent thrombosis). CONCLUSIONS: The use of a high bolus dose of tirofiban in patients undergoing PCI seems to be safe and not associated with an increased risk of major bleeding. This high bolus dose may help to further reduce the rate of periprocedural adverse events.
Abstract: AIM: To investigate the effect of abciximab on microvascular integrity and left ventricular (LV) functional recovery in patients with acute myocardial infarction (MI) treated by primary coronary angioplasty (PTCA). METHODS AND RESULTS: Thirty-one patients (27 males; age 39-76 years) with first, acute MI (<6 h after onset) were randomized to receive either abciximab+primary PTCA (n=17) or primary PTCA alone (n=14). Baseline characteristics of the two groups were similar. Myocardial reperfusion was studied shortly after PTCA by corrected TIMI frame count (cTFC) and intracoronary myocardial contrast echocardiography (MCE), after 48 h by intravenous MCE using intermittent, harmonic power Doppler, and after 1 month by intravenous MCE and 99 mTc-tetrofosmin SPECT. The patients treated with abciximab showed a shorter cTFC (23+/-4 vs 30+/-9 frames; P<0.05), a more preserved microvascular integrity shortly after PTCA (77% vs 55%; P<0.01), after 48 h (86% vs 50%; P<0.005) and at 1-month follow-up (86% vs 54% by MCE, P<0.001, and 68% vs 60% by SPECT, P<0.005) than patients treated with PTCA alone. Abciximab patients also showed a better recovery of LV function, as demonstrated by greater reduction in wall motion score index (1.4+/-0.3 vs 1.5+/-0.2; P<0.05) and increase in LV ejection fraction (53+/-7% vs 48+/-5%; P<0.001). CONCLUSIONS: Abciximab improves microvascular perfusion and LV functional recovery in primary PTCA.
Abstract: The percutaneous closure of patent forame ovale (PFO) is currently performed in patients with cryptogenic stroke or paradoxical systemic embolism. The availability of new user friendly devices and the increase in knowledge of the pathophysiology, epidemiology, and follow-up of these patients has broadened the indications and drastically reduced the morbidity related to the intervention. This review considers the main pathophysiological and epidemiological features of PFO and discusses the indications and results of the intervention.
Abstract: The Tsunami is a new, balloon-expandable, stainless steel, tubular coronary stent whose design is based on a number of radial, diamond-shaped cells joined by double connectors. The aim of this two-centre, prospective, nonrandomized study was to examine the procedural, in-hospital, and long-term clinical and angiographic outcomes of patients undergoing angioplasty with the Tsunami stent. Sixty-one consecutive unselected patients were treated by means of the implantation of 74 Tsunami stents in 72 coronary lesions. Most of the patients (64%) had unstable angina or acute myocardial infarction. The baseline lesion morphology was complex in 76% of cases, and the mean lesion length was 14 +/- 6 mm. The procedural success rate was 98%. Mean percentage diameter of the stenosis decreased after the intervention from 79 +/- 12% to 10 +/- 6%. The in-hospital major adverse cardiac event rate was 3.3%. During the six-month follow-up, there was one cardiac death and nine subjects (14.5%) underwent target vessel revascularization. The six-month event-free survival rate was 80%. The angiographic restenosis rate was 17%: a focal or limited pattern (class I or II) was found in 43% of cases, whereas the remaining 57% had a proliferative morphology (class III or IV). In conclusion, this study indicates the good clinical and angiographic performance of the Tsunami coronary stent system in consecutive unselected patients.
Abstract: The aim of this study was to assess the impact of two nonionic low-osmolar monomers (iopamidol and iopromide) and one ionic low-osmolar dimeric contrast medium (ioxaglate) on 30-day major adverse cardiac events in patients undergoing coronary interventions involving the use of new-generation stents and appropriate antiplatelet agents. Thirteen hundred and eight patients treated with stent implantation were randomized to receive ioxaglate (438 patients), iopamidol (442 patients), or iopromide (428 patients). Most of them (55%) had an acute coronary syndrome. Glycoprotein IIb/IIIa inhibitors were used in 37% of cases. All of the patients were on aspirin and ticlopidine for 1 month after the procedure. There was no significant between-group difference in the incidence of the primary composite endpoint of major adverse cardiac events 30 days after stenting (ioxaglate 3.6%; iopamidol 2.3%; iopromide 4.2%; P = 0.27). Adverse drug reactions were more frequent in the ioxaglate group (4.6% vs. 1.1% vs. 0.5%; P = 0.001). Multivariate analysis showed that intracoronary thrombus (P = 0.002), diabetes mellitus (P = 0.01), and postprocedure minimum lumen diameter (P = 0.04) independently correlated with an adverse outcome after 1 month. In conclusion, no significant differences in 30-day major ischemic complications were observed in this unselected population of patients undergoing coronary stenting who received ioxaglate, iopamidol, or iopromide. These data seem to suggest that the use of nonionic low-osmolar contrast media does not adversely affect stent patency.
Abstract: BACKGROUND: The aim of this study was to evaluate the risk factors for cardiovascular diseases, clinical presentation and coronary anatomical size differences in women. METHODS: From January 1999 to December 2000, 244 female and 980 male patients were submitted to coronary angioplasty (PTCA). For both groups the following were considered: risk factors for cardiovascular diseases, clinical presentation and angiographic data. The clinically confirmed 6 months restenoses were evaluated. We performed intravascular ultrasound (IVUS) with three-dimensional reconstruction and quantitative coronary angiography (QCA) on the proximal left anterior descending (LAD) coronary artery segments free of significant atherosclerosis in 60 men and 50 women matched for age and clinical characteristics. The arterial and luminal areas were measured by planimetry and corrected for body surface area. We also evaluated the external elastic membrane diameter (EEMd), the minimal lumen diameter (MLD) and the intima-media thickness (IMT). RESULTS: At the time of admission, women were older than men, were shorter, weighed less, and had a smaller body surface area; they had more severe angina, diabetes mellitus and hypercholesterolemia. There was no difference between women and men in the incidence of clinical restenosis at 6 months of follow-up. At IVUS, the mean uncorrected LAD arterial area was smaller in women than in men (12.7 +/- 3 vs 15.9 +/- 3.3 mm2, p < 0.05), as was the mean LAD luminal area (9.9 +/- 3 vs 12.9 +/- 2.7 mm2, p < 0.005). Both the MLD and the EEMd as well as the IMT were smaller in women than in men (MLD 3.3 +/- 0.6 vs 3.9 +/- 0.5 mm, p < 0.05; EEMd 3.7 +/- 0.6 vs 4.2 +/- 0.4 mm, p < 0.005; IMT 0.29 +/- 0.1 vs 0.4 +/- 0.1 mm, p < 0.05). QCA confirmed the IVUS results (MLD 2.9 +/- 0.6 vs 3.5 +/- 0.8 mm, p < 0.05). After correction for body surface area, univariate associations between sex and both the arterial and luminal areas were no longer present. CONCLUSIONS: Women submitted to PTCA were older. The incidence of hypertension, diabetes mellitus and hypercholesterolemia was higher than in men. There was no sex difference in the rate of clinical restenosis at 6 months of follow-up. The LAD artery is smaller in women, independently of body size. This suggests an intrinsic sex effect on coronary dimensions.
Abstract: BACKGROUND: Few data are available concerning the effects on clinical outcome and left ventricular function of abciximab administration in patients undergoing rescue percutaneous transluminal coronary angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction. The aim of the study was to investigate such effects. METHODS: Eighty-nine consecutive patients referred to our laboratory from other hospitals for rescue PTCA within 24 hours from the onset of chest pain were prospectively randomized before the procedure to abciximab treatment (44 patients) or placebo (45 patients). No significant differences in baseline characteristics were observed between the 2 groups. Study end points were the occurrence of major adverse cardiac events (MACE) such as death, reinfarction, congestive heart failure, target lesion revascularization, or recurrent ischemia at 30-day and 6-month follow-up and the occurrence of periprocedural bleeding. RESULTS: Mean time from symptom onset to reperfusion was 8.5 +/-5.4 hours; rescue PTCA was successful in 96% of patients. The incidence of major, moderate, and minor bleeding was similar in the 2 groups. At 30-day follow-up, the echocardiographic left ventricular wall motion score index showed a significantly higher improvement in the abciximab group versus the placebo group (P <.001). At 6-month follow-up, the incidence of MACE was 11% in the abciximab group versus 38% in the placebo group (P =.004). Abciximab administration (P =.003) and cardiogenic shock (P =.005) were the only independent predictors of the occurrence of MACE at multivariable analysis. CONCLUSION: Treatment with abciximab during rescue PTCA positively affects clinical outcome at 6-month follow-up without increasing periprocedural bleeding.
Abstract: The role of coronary stenting in challenging situations, such as small vessels and long lesions, remains controversial. The aim of this study was to examine the procedural, in-hospital, and long-term clinical outcomes of patients undergoing angioplasty with long stents in small coronary vessels. We evaluated the procedural success rate and clinical outcomes in 252 consecutive subjects treated by means of the implantation of a single coronary stent in vessels with a mean reference diameter of < 2.5 mm; 128 patients received a short stent (< or = 16 mm) and 124 a long stent (> or = 18 mm). Lesion morphology was more complex in patients treated with long stents (P < 0.05). The mean stent length was 14 +/- 2 mm in the short-stent group and 25 +/- 3 mm in the long-stent group (P < 0.001). The overall procedural success rate (98.4% vs. 97.6%; P = NS) and the rate of major in-hospital adverse events (death, acute myocardial infarction, or target vessel revascularization; 1.6% vs. 2.4%; P = NS) was similar in the two groups. After 11.7 +/- 7 months of follow-up, there was no difference in the incidence of mortality and myocardial infarction (5% vs. 6.6%; P = NS), but revascularization tended to occur more frequently in the patients treated with long stents (21.7% vs. 13.9%; P = NS). In conclusion, the procedural success rate of single short or long stents in small coronary vessels was similar. Although the incidence of target vessel revascularization tended to be higher in the patients treated with longer stents, 2-year event-free survival was equivalent in the two groups (65% vs. 70%; P = NS).
Abstract: The NIR stent is a "second-generation" slotted-tube stent that was developed after the Palmaz Schatz and the Gianturco-Roubin stents, and introduced into clinical practice in 1992. This review of the literature describes its clinical performance and the long-term outcomes after implantation in different anatomical and clinical subsets of patients. It also considers clinical experience with the gold-plated NIR stent.
Abstract: BACKGROUND: Coronary artery disease (CAD) alters the vasomotor response to a variety of pharmacological agents. We tested the hypothesis that CAD also has an impact on the coronary vasomotor response to radiologic contrast media. METHODS AND RESULTS: We performed quantitative coronary angiography in 42 patients without angiographic evidence of CAD and 38 patients with CAD in the left coronary artery. Angiographically smooth coronary segments (n=235) were analyzed for changes on luminal diameters and coronary venous oxygen saturation in response to 3 media: the nonionic dimer iodixanol, the nonionic monomer iopromide, and the ionic agent ioxaglate. In subjects without CAD, we assessed the effects of intracoronary administration of the nitric oxide synthase inhibitor N(G)-monomethyl-L-arginine and of the cyclooxygenase inhibitor indomethacin on such changes. Iodixanol induced coronary vasodilation in subjects without CAD (8.8+/-8.6%, P<0.001). Patients with CAD exhibited no significant diameter changes in segments >/=20 mm apart from a stenosis (4.7+/-9.4%, P=NS) and significant constriction in segments <20 mm from a stenosis (-3.8+/-4.6%, P<0. 05). Similar results were obtained with iopromide, but no changes were found with ioxaglate. All contrast media induced transient (<35 seconds) increases in coronary venous oxygen saturation in all subjects. Indomethacin, but not N(G)-monomethyl-L-arginine, blunted the vasodilating effect of iodixanol and iopromide (by 80% and 76%, respectively; P<0.001). CONCLUSIONS: Nonionic contrast media induce a vasodilatory response in normal vessels not by a mechanism involving increased flow or endothelial nitric oxide synthesis, but rather by depending on preserved vascular cyclooxygenase activity. CAD changes normal epicardial vasodilatory response into vasoconstriction.
Abstract: Previous observational studies have shown a relationship between carotid intima-media thickness (IMT) and coronary artery disease (CAD). In this study the authors evaluated the accuracy of the common carotid IMT measurement in predicting the presence and severity of CAD and the additional information offered by the detection of carotid, iliac, and lower limb plaques. One hundred and fifty consecutive patients were subjected to coronary angiography and carotid, iliac, and lower limb ultrasound scan. The mean value of six IMT measurements of the far wall of the common carotid artery was calculated in each patient. The mean IMT was significantly correlated to the number of stenosed coronary vessels (r = 0.43, p<0.001), although the positive and negative predictive value of mean IMT in identifying patients with CAD was low (81% and 46%, respectively). The combined information offered by IMT measurements and peripheral (carotid, iliac, and lower limb) plaque detection was then used to obtain the best multivariate regression model able to predict CAD status. The multivariate model showed a highly significant multiple correlation coefficient (r = 0.60, p<0.0001) and a sharp improvement in the negative predictive value (92%) with respect to the univariable model. B-mode ultrasound scan including common carotid IMT measurement and peripheral plaque detection may be of clinical value in the screening of patients with CAD.
Abstract: The association of calcific aortic valve disease and isolated coronary ostial stenosis is rare. A 80-year-old woman was found to have severe aortic stenosis with critical narrowing of the ostium of the left main coronary artery. She was successfully managed by simultaneous aortic valve replacement and patch angioplasty of the left main coronary artery, using a patch of autologous pericardium fixed in glutaraldehyde. Angiographic control at 1 month coupled with intravascular echographic imaging showed adequate relief of the ostial stenosis and patency of the left main trunk.
Abstract: Atherosclerosis has an impact on the vasomotor reaction of coronary segments to iodinated non-ionic contrast agents. Angiographically normal coronary segments show divergent vasomotor reactions to iodixanol or iopromide according to the presence of, and distance from, a coronary atherosclerotic lesion. The mechanism responsible for the above-mentioned vasomotor effect does not seem to involve flow-mediated vasodilation or endothelial nitric oxide synthesis. On the other hand, a cyclooxygenase product may be, at least in part, responsible for the vasodilating effect of non-ionic agents on epicardial coronary arteries. These findings have potential clinical implications that are herein discussed.
Abstract: To assess the effects of percutaneous transluminal coronary angioplasty on endothelin-1 (ET-1) release, we assessed ET-1 concentrations at different sites of the coronary circulation in patients submitted to elective procedures. ET-1 levels immediately downstream from the plaque and ET-1 aortocoronary gradient increased significantly after the procedure, which was related to mechanical wall stress in patients only receiving balloons, but not in those undergoing stent percutaneous transluminal coronary angioplasty. No changes were found in the coronary sinus; these results suggest ET-1 release from the plaque rather than an ischemia/reperfusion-related production from the distal myocardium.
Abstract: AIM: The goal of this study was to investigate the role of left ventricular outflow tract obstruction and myocardial hypertrophy on autonomic cardiac function in patients with hypertrophic cardiomyopathy. METHODS AND RESULTS: The sympatho-vagal function was evaluated by spectral analysis of heart rate variability in 28 patients with hypertrophic obstructive cardiomyopathy, 22 patients with hypertrophic non-obstructive cardiomyopathy, 12 with systemic hypertension and left ventricular hypertrophy and 28 healthy subjects. Left ventricular out-flow tract pressure gradient in patients with hypertrophic cardiomyopathy was evaluated by echo-Doppler methods and the quantitative assessment of left ventricular hypertrophy was based on an echocardiographic index. At rest, patients with hypertrophic non-obstructive cardiomyopathy showed normal spectral patterns, while in patients with hypertrophic obstructive cardiomyopathy and in patients with systemic hypertension we observed, respectively, a significant reduction and increase in the low frequency component relative to the control (P < 0.05). During tilt, the physiological increases in the low frequency component and in the low to high frequency ratio were markedly blunted, or even reverted, only in patients with hypertrophic obstructive cardiomyopathy. In these patients, the heart rate increase during tilt was delayed in comparison to the other groups. Finally, in the hypertrophic obstructive cardiomyopathy group, the impairment of sympathetic activation (lack of increase in the low frequency component during tilt) was significantly correlated to the echocardiographic index of left ventricular hypertrophy (r = -0.800, P < 0.001) rather than to the left ventricular outflow tract pressure gradient (r = 0.295, P: ns). CONCLUSION: Among patients with hypertrophic cardiomyopathy, only those with outflow tract obstruction show spectral signs of altered autonomic cardiac control. Within this group, the autonomic dysfunction appears to be correlated to myocardial hypertrophy rather than to left ventricular outflow tract obstruction.
Abstract: AIMS: We explored the role of microcirculation integrity following the chronic occlusion of an infarct-related artery to assess the behaviour of collateral circulation during and after reperfusion by coronary angioplasty METHODS AND RESULTS: Eighteen patients with a proximally occluded left anterior descending artery and firm evidence of intercoronary collateral circulation were studied with selective coronary angiography and selective intracoronary myocardial contrast echocardiography, before coronary angioplasty, and at 5 and 15 min and 12 h later. Myocardial enhancement during myocardial contrast echocardiography was evaluated with a semiquantitative score (0-3), which was correlated to basal and 6 months' regional left ventricular wall motion results. 16/18 procedures were successfully performed; four patients with an inadequate acoustic window were excluded. Restenosis was evident at the 6 months' follow-up in two patients. Basal myocardial contrast echocardiography indicated that 81/192 segments from the left anterior descending coronary artery and 90/192 from the right coronary artery were perfused; no perfusion was observed in 21 segments either before or after coronary angioplasty. After coronary angioplasty, the angiographic intercoronary collateral circulation immediately disappeared, and myocardial contrast echocardiography revealed that there was a progressive reduction of segments perfused by the right coronary artery and an increase in segments perfused by the left anterior descending coronary artery. Regional left ventricular wall motion analysis demonstrated that there was abnormal motion in 51/192 segments. There was no improvement in segments with score 0 and abnormal motion after 6 months (100% sensitivity), but 16/17 segments with score 3 did show an improvement (98% specificity). The predictive value of intermediate scores (1-2) in detecting long-term improvement, was only 43%. CONCLUSION: These data show that the adaptive mechanism observed in the behaviour of epicardial and microvascular circulation after reperfusion of a chronic occluded infarct-related artery can vary. In addition, this study clearly shows that microvascular integrity detected by myocardial contrast echocardiography can provide myocardial viability.
Abstract: The peripheral vascular complications following cardiac catheterization for interventional procedures are increasing. The aim of our study is to evaluate the importance of the early removal of the arterial sheath in reducing vascular complications. We examined 451 consecutive patients, submitted to percutaneous transluminal coronary angioplasty (PTCA) by femoral approach. In 229 patients (Group A), we removed the arterial sheath 12-14 hours after PTCA; in 222 patients (Group B) the arterial sheath was removed as soon as possible at the end of PTCA. In 31 Group A and 5 Group B patients we performed a coronarographic study after 12-14 hours. In total, 16 patients (11 Group A, 5 Group B) presented vascular complications. None of the risk factors that we have considered was predictive for complications, except that iliacofemoral atherosclerotic disease. In patients undergoing complex procedures we have found a greater amount of vascular complications. The coronarographic control revealed some pathologic lesion (dissection, occlusive thrombus) only in patients with clear ischemic signs or symptoms, both in Group A and B. In our opinion, an early removal of the arterial sheath reduces the incidence of vascular complications and the period of in-hospital stay.
Abstract: Altered sympathetic activity may play an important role in the pathogenesis of hypertrophic obstructive cardiomyopathy (HOCM). Spectral analysis of heart rate variability was employed to assess the sympatho-vagal function and balance in 18 patients with HOCM (11 males, 7 females, mean age 42 years, range 19-59) and in 15 healthy control subjects (9 males, 6 females, mean age 44 years, range 18-65). Electrocardiographic recordings obtained both at rest and during 60 degrees passive tilt, were digitized and analyzed by fast Fourier transform in order to obtain the power spectrum of heart rate variability. The low-frequency band (LF: 0.05-0.17 Hz) and the high-frequency band (HF: 0.18-0.34) of power spectrum were considered as indexes of sympathetic and vagal activities respectively. A semiquantitative two-dimensional echocardiographic score (SES) was used to assess the entity of myocardial hypertrophy whereas the entity of the intraventricular gradient was determined by continuous wave Doppler. Low-frequency band at rest was slightly but significantly reduced in HOCM group with respect to controls (35.2 +/- 2.0 vs 45.0 +/- 2.5 nu, respectively; p < 0.01), whereas the HF band and the LF/HF ratio were not different in the 2 groups. During tilt, control subjects showed a significant reduction of the HF band (-35%, p < 0.001), an increase in the LF band (+36%, p < 0.001) and a sharp increase in the LF/HF ratio (+105%, p < 0.001). On the contrary the baroreflex increase in the LF band and LF/HF ratio during tilt was markedly blunted, or even reverted, in patients with HOCM (-9%, NS and +5%, NS, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)
