Brand, M.J.B.M. van den

Impact of completeness of revascularization on the five-year outcome in percutaneous coronary intervention and coronary artery bypass graft patients (from the ARTS-II Study) (Article)

2010-11-15T00:00:00Z

The aim of this study was to compare clinical outcome at 5 years in patients with complete and incomplete revascularization treated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents. Baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization. Patients treated with PCI for incomplete revascularization were stratified according to Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score tertiles. Complete revascularization was achieved in 360 of 588 patients (61.2%) in the PCI with sirolimus-eluting stent group and 477 of 567 patients (84.1%) in the CABG group (p <0.05). There was no significant difference in 5-year survival without major adverse cardiac and cerebrovascular events (MACCEs; death, cerebrovascular accident, myocardial infarction, and any revascularization) between patients with complete and incomplete revascularization treated with PCI or CABG. Survival free from MACCEs in patients with incomplete revascularization treated with PCI was significantly lower than those with complete revascularization treated with CABG (hazard ratio 1.66, 0.96 to 1.80, log-rank p = 0.001). The 5-year MACCE-free survival in patients with incomplete revascularization treated with PCI stratified according to SYNTAX score tertiles showed a significantly lower MACCE survival in the higher SYNTAX tertile compared to the low (hazard ratio 0.56, 0.32 to 0.96, log-rank p = 0.04) and intermediate (hazard ratio 0.50, 0.28 to 0.91, log-rank p = 0.02) tertiles, whereas survival between the low and intermediate SYNTAX tertiles was not significantly different (hazard ratio 1.13, 0.60 to 2.13, log-rank p = 0.71). In conclusion, this study suggests that patients with complex coronary disease, in whom complete revascularization cannot be achieved with PCI, should be offered surgical revascularization. However, in those patients with less complex disease, PCI is a valid alternative even if complete revascularization cannot be achieved.

Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease (Article)

2009-03-05T00:00:00Z

BACKGROUND Percutaneous coronary intervention (PCI) involving drug-eluting stents is increasingly used to treat complex coronary artery disease, although coronary-artery bypass grafting (CABG) has been the treatment of choice historically. Our trial compared PCI and CABG for treating patients with previously untreated three-vessel or left main coronary artery disease (or both). METHODS We randomly assigned 1800 patients with three-vessel or left main coronary artery disease to undergo CABG or PCI (in a 1:1 ratio). For all these patients, the local cardiac surgeon and interventional cardiologist determined that equivalent anatomical revascularization could be achieved with either treatment. A noninferiority comparison of the two groups was performed for the primary end point - a major adverse cardiac or cerebrovascular event (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) during the 12-month period after randomization. Patients for whom only one of the two treatment options would be beneficial because of anatomical features or clinical conditions, were entered into a parallel, nested CABG or PCI registry. Results Most of the preoperative characteristics were similar in the two groups. Rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001); as a result, the criterion for noninferiority was not met. At 12 months, the rates of death and myocardial infarction were similar between the two groups; stroke was significantly more likely to occur with CABG (2.2%, vs. 0.6% with PCI; P = 0.003). CONCLUSIONS CABG remains the standard of care for patients with three-vessel or left main coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year. (CIinicaITriaIs.gov number, NCT00114972.).

Cyphering the Complexity of Coronary Artery Disease Using the Syntax Score to Predict Clinical Outcome in Patients With Three-Vessel Lumen Obstruction Undergoing Percutaneous Coronary Intervention (Article)

2007-04-15T00:00:00Z

The Syntax score (SXscore) was recently developed as a comprehensive angiographic scoring system aiming to assist in patient selection and risk stratification of patients with extensive coronary artery disease undergoing contemporary revascularization. A validation of this angiographic classification scheme is lacking. We assessed its predictive value in patients who underwent percutaneous intervention (PCI) for 3-vessel disease and explored its performance in comparison with the modified lesion classification system of the American Heart Association/American College of Cardiology. The SXscore, applied to 1,292 lesions in 306 patients who underwent PCI for 3-vessel disease in the Arterial Revascularization Therapies Study Part II, was 4 to 54.5, and after a median of 370 days (range 274 to 400) predicted the rate of major adverse cardiac and cerebrovascular events (hazard ratio 1.08/U increase, 95% confidence interval 1.05 to 1.11, p <0.0001), with patients in the highest SXscore tertile having a significantly higher event rate (27.9%) than patients in the lowest tertile (8.7%, hazard ratio 3.5, 95% confidence interval 1.7 to 7.4, p = 0.001). By multivariable analyses, SXscore independently predicted outcome with an almost fourfold adjusted increase in the risk of major adverse cardiac and cerebrovascular events in patients with high versus low values based on the discrimination level provided by classification and regression tree analysis. Compared with the modified lesion classification scheme of the American Heart Association/American College of Cardiology, SXscore showed a greater discrimination ability (c-index 0.58 ± 0.08 vs 0.67 ± 0.08, respectively, p <0.001) and a better goodness of fit with the Hosmer-Lemeshow statistic. In conclusion, the SXscore is a promising tool to risk stratify outcome in patients with extensive coronary artery disease undergoing contemporary PCI.

One year cost effectiveness of sirolimus eluting stents compared with bare metal stents in the treatment of single native de novo coronary lesions: an analysis from the RAVEL trial (Article)

2005-01-01T00:00:00Z

OBJECTIVE: To assess the balance between costs and effects of the sirolimus eluting stent in the treatment of single native de novo coronary lesions in the RAVEL (randomised study with the sirolimus eluting Bx Velocity balloon expandable stent in the treatment of patients with de novo native coronary artery lesions) study. DESIGN: Multicentre, double blind, randomised trial. SETTING: Percutaneous coronary intervention for single de novo coronary lesions. PATIENTS: 238 patients with stable or unstable angina. INTERVENTIONS: Randomisation to sirolimus eluting stent or bare stent implantation. MAIN OUTCOME MEASURES: Patients were followed up to one year and the treatment effects were expressed as one year survival free of major adverse cardiac events (MACE). Costs were estimated as the product of resource utilisation and Dutch unit costs. RESULTS: At one year, the absolute difference in MACE-free survival was 23% in favour of the sirolimus eluting stent group. At the index procedure, sirolimus eluting stent implantation had an estimated additional procedural cost of 1286. At one year, however, the estimated additional cost difference had decreased to 54 because of the reduction in the need for repeat revascularisations in the sirolimus group (0.8% v 23.6%; p < 0.01). After adjustment of actual results for the consequences of angiographic follow up (correction based on data from the BENESTENT (Belgium Netherlands stent) II study), the difference in MACE-free survival was estimated at 11.1% and the additional one year costs at 166. CONCLUSIONS: The one year data from RAVEL suggest an attractive balance between costs and effects for sirolimus eluting stents in the treatment of single native de novo coronary lesions. The cost effectiveness of drug eluting stents in more complex lesion subsets remains to be determined.

Elevated troponin T and C-reactive protein predict impaired outcome for 4 years in patients with refractory unstable angina, and troponin T predicts benefit of treatment with abciximab in combination with PTCA (Article)

2003-01-01T00:00:00Z

AIMS: Treatment with the glycoprotein IIb/IIIa receptor antagonist abciximab before and during coronary intervention in refractory unstable angina improves early outcome. We collected 4-year follow-up data to assess whether this benefit is sustained. Additionally, we investigated the predictive value of baseline troponin T and CRP for long-term cardiovascular events. METHODS AND RESULTS: Of 1265 patients enrolled in the CAPTURE trial follow-up was available in 94% of the patients alive after 6 months (median 48 months). Survival was similar in both groups. Both elevated troponin T and CRP were associated with impaired outcome, independently of other established risk factors, but with a different time course. Elevated troponin was associated with increased procedure related risk, and elevated CRP with increased risk for subsequent events. Lower rates of the composite end-point of death or myocardial infarction with abciximab vs. placebo were sustained during long-term follow up: 15.7% vs 17.2% at 4 years (P=ns), particularly in patients with elevated troponin T: 16.9% with abciximab vs 28.4% with placebo: P=0.015. Elevated CRP was not associated with specific benefit of abciximab. CONCLUSION: Troponin T as a marker of thrombosis and CRP as a marker of inflammation are independent predictors of impaired outcome at 4 years follow-up. The initial benefit from abciximab with regard to death and myocardial infarction was preserved at 4 years. No specific benefit with abciximab was observed for patients with elevated CRP, suggesting that a chronic inflammatory process is not affected by abciximab. In contrast the benefit of treatment in patients with elevated troponin T implies that the acute thrombotic process in refractory unstable angina is treated effectively.

Soluble CD40 ligand in acute coronary syndromes (Article)

2003-01-01T00:00:00Z

BACKGROUND: CD40 ligand is expressed on platelets and released from them on activation. We investigated the predictive value of soluble CD40 ligand as a marker for clinical outcome and the therapeutic effect of glycoprotein IIb/IIIa receptor inhibition in patients with acute coronary syndromes. METHODS: Serum levels of soluble CD40 ligand were measured in 1088 patients with acute coronary syndromes who had previously been enrolled in a randomized trial comparing abciximab with placebo before coronary angioplasty and in 626 patients with acute chest pain. RESULTS: The levels of soluble CD40 ligand were elevated (above 5.0 microg per liter) in 221 patients with acute coronary syndromes (40.6 percent). Among patients receiving placebo, elevated soluble CD40 ligand levels indicated a significantly increased risk of death or nonfatal myocardial infarction during six months of follow-up (adjusted hazard ratio as compared with patients with low levels of the ligand [< or =5.0 microg per liter], 2.71; 95 percent confidence interval, 1.51 to 5.35; P=0.001). The prognostic value of this marker was validated in the patients with chest pain, among whom elevated soluble CD40 ligand levels identified those with acute coronary syndromes who were at high risk for death or nonfatal myocardial infarction (adjusted hazard ratio as compared with those with low levels of the ligand, 6.65; 95 percent confidence interval, 3.18 to 13.89; P<0.001). The increased risk in patients with elevated soluble CD40 ligand levels was significantly reduced by treatment with abciximab (adjusted hazard ratio as compared with those receiving placebo, 0.37; 95 percent confidence interval, 0.20 to 0.68; P=0.001), whereas there was no significant treatment effect of abciximab in patients with low levels of soluble CD40 ligand. CONCLUSIONS: In patients with unstable coronary artery disease, elevation of soluble CD40 ligand levels indicated an increased risk of cardiovascular events. Elevation of soluble CD40 ligand identifies a subgroup of patients at high risk who are likely to benefit from antiplatelet treatment with abciximab.

Characteristics, treatment and outcome of patients with non-ST-elevation acute coronary syndromes and multivessel coronary artery disease: observations from PURSUIT (Platelet Glycoprotein IIb/IIIa in unstable angina: receptor suppression using integreling therapy) (Article)

2002-12-01T00:00:00Z

BACKGROUND: The 6-month clinical outcome of patients with multivessel disease enrolled in PURSUIT (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy) is described. Patients with complete angiography data were included; multivessel disease was stratified according to the treatment strategy applied early during hospitalization, i.e. medical treatment, percutaneous coronary intervention (PCI) (balloon), PCI (stent), or coronary artery bypass grafting (CABG). METHODS: Patients were divided into three groups according to the treatment strategy applied during the first 30 days of enrolment. Patients who did not undergo a percutaneous or surgical coronary intervention were classified as medically treated. Patients who underwent a PCI (prior to a possible CABG) were separated from those who underwent a CABG (prior to a possible PCI). The PCI group was further subdivided: patients receiving >/=1 coronary stents were separated from those in whom no stents were used. RESULTS: The mortality rate at 30 days was 6.7, 3.9, 2.4 and 4.8% for the medical treatment, PCI (balloon), PCI (stent) and CABG groups, respectively (p value = 0.002). Differences as observed at 30 days were still present at 6-month follow-up with 11.1, 5.8, 5.5 and 6.5% mortality event rates for the aforementioned groups (p value = 0.002). The 30-day myocardial infarction (MI) rate according to the opinion of the Clinical Events Committee was lower among medically than non-medically treated patients, with the highest event rate observed in the CABG group (27.7%). Approximately half of the MIs in the PCI and CABG subgroups occurred within 48 h after the procedure. CONCLUSIONS: The observed differences in clinical outcomes are explained by an imbalance in baseline characteristics and comorbid conditions between the analyzed groups of patients.

Persistent inhibition of neointimal hyperplasia after sirolimus-eluting stent implantation: long-term (up to 2 years) clinical, angiographic, and intravascular ultrasound follow-up. (Article)

2002-09-24T00:00:00Z

Background— Early results of sirolimus-eluting stent implantation showed a nearly complete abolition of neointimal hyperplasia. The question remains, however, whether the early promising results will still be evident at long-term follow-up. The objective of our study was to evaluate the efficiency of sirolimus-eluting stent implantation for up to 2 years of follow-up. Methods and Results— Fifteen patients with de novo coronary artery disease were treated with 18-mm sirolimus-eluting Bx-Velocity stents (Cordis) loaded with 140 µg sirolimus/cm2 metal surface area in a slow release formulation. Quantitative angiography (QCA) and intravascular ultrasound (IVUS) were performed according to standard protocol. Sirolimus-eluting stent implantation was successful in all 15 patients. During the in-hospital course, 1 patient died of cerebral hemorrhage after periprocedural administration of abciximab, and 1 patient underwent repeat stenting after 2 hours because of edge dissection that led to acute occlusion. Through 6 months and up to 2 years of follow-up, no additional events occurred. QCA analysis revealed no significant change in stent minimal lumen diameter or percent diameter stenosis, and 3-dimensional IVUS showed no significant deterioration in lumen volume. In 2 patients, additional stenting was performed because of significant lesion progression remote from the sirolimus-eluting stent. Conclusion— Sirolimus-eluting stents showed persistent inhibition of neointimal hyperplasia for up to 2 years of follow-up.

The effect of completeness of revascularization on event-free survival at one year in the ARTS trial. (Article)

2002-02-20T00:00:00Z

OBJECTIVES: We sought to assess the relationship between completeness of revascularization and adverse events at one year in the ARTS (Arterial Revascularization Therapies Study) trial. BACKGROUND: There is uncertainty to what extent degree of completeness of revascularization, using up-to-date techniques, influences medium-term outcome. METHODS: After consensus between surgeon and cardiologist regarding the potential for equivalence in the completeness of revascularization, 1,205 patients with multivessel disease were randomly assigned to either bypass surgery or stent implantation. All baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization. RESULTS: Of 1,205 patients randomized, 1,172 underwent the assigned treatment. Complete data for review were available in 1,143 patients (97.5%). Complete revascularization was achieved in 84.1% of the surgically treated patients and 70.5% of the angioplasty patients (p < 0.001). After one year, the stented angioplasty patients with incomplete revascularization showed a significantly lower event-free survival than stented patients with complete revascularization (i.e., freedom from death, myocardial infarction, cerebrovascular accident and repeat revascularization) (69.4% vs. 76.6%; p < 0.05). This difference was due to a higher incidence of subsequent bypass procedures (10.0% vs. 2.0%; p < 0.05). Conversely, at one year, bypass surgery patients with incomplete revascularization showed only a marginally lower event-free survival rate than those with complete revascularization (87.8% vs. 89.9%). CONCLUSIONS: Complete revascularization was more frequently accomplished by bypass surgery than by stent implantation. One year after bypass, there was no significant difference in event-free survival between surgically treated patients with complete revascularization and those with incomplete revascularization, but patients randomized to stenting with incomplete revascularization had a greater need for subsequent bypass surgery.

Platelet GP IIb/IIIa receptor blockers for failed thrombolysis in acute myocardial infarction, alone or as adjunct to other rescue therapies; single centre retrospective analysis of 548 consecutive patients with acute myocardial infarction (Article)

2002-01-01T00:00:00Z

In order to study the safety of 'rescue' strategies in the treatment of patients with failed thrombolysis, all 548 patients admitted with evolving myocardial infarction to the Thoraxcenter, Rotterdam, from January 1997 until April 1999 were reviewed. Of these patients, 49% had received thrombolysis. Of patients treated with thrombolysis and not referred from other hospitals (n = 154) 36% received rescue therapy for failed thrombolysis. Three rescue therapies were used after failed thrombolysis: percutaneous coronary intervention (74%), retreatment with thrombolysis (39%) and platelet glycoprotein (GP) IIb/IIIa receptor blockers (53%), often in combination. Platelet GP IIb/IIIa receptor blockers were administered in 64% of patients treated with rescue percutaneous coronary intervention. Major bleeding occurred in 14% of all thrombolysis treated patients, and in 30% of patients who received multiple rescue therapies. Bleeding was related to heparin usage and platelet GP IIb/IIIa receptor blockers, as was the insertion of catheters for percutaneous coronary intervention or intra-aortic balloon pumps. Major bleeding resulted in one death due to a ruptured ventricle, one haemorrhagic stroke, and three cases of tamponade for which surgery was needed. Four of these patients had received combination rescue therapy. Rescue therapy is a widely used strategy for failed thrombolysis, but is associated with a high bleeding rate. Alternative reperfusion strategies to avoid failed thrombolysis should be considered in high risk patients.

Persistent inhibition of neointimal hyperplasia after sirolimus-eluting stent implantation: long-term (up to 2 years) clinical, angiographic, and intravascular ultrasound follow-up (Article)

2002-01-01T00:00:00Z

BACKGROUND: Early results of sirolimus-eluting stent implantation showed a nearly complete abolition of neointimal hyperplasia. The question remains, however, whether the early promising results will still be evident at long-term follow-up. The objective of our study was to evaluate the efficiency of sirolimus-eluting stent implantation for up to 2 years of follow-up. METHODS AND RESULTS: Fifteen patients with de novo coronary artery disease were treated with 18-mm sirolimus-eluting Bx-Velocity stents (Cordis) loaded with 140 microg sirolimus/cm2 metal surface area in a slow release formulation. Quantitative angiography (QCA) and intravascular ultrasound (IVUS) were performed according to standard protocol. Sirolimus-eluting stent implantation was successful in all 15 patients. During the in-hospital course, 1 patient died of cerebral hemorrhage after periprocedural administration of abciximab, and 1 patient underwent repeat stenting after 2 hours because of edge dissection that led to acute occlusion. Through 6 months and up to 2 years of follow-up, no additional events occurred. QCA analysis revealed no significant change in stent minimal lumen diameter or percent diameter stenosis, and 3-dimensional IVUS showed no significant deterioration in lumen volume. In 2 patients, additional stenting was performed because of significant lesion progression remote from the sirolimus-eluting stent. CONCLUSION: Sirolimus-eluting stents showed persistent inhibition of neointimal hyperplasia for up to 2 years of follow-up.

Coronary restenosis elimination with a sirolimus eluting stent: first European human experience with 6-month angiographic and intravascular ultrasonic follow-up. (Article)

2001-12-08T00:00:00Z

AIMS: Coronary stenting is limited by a 10%-60% restenosis rate due to neointimal hyperplasia. Sirolimus is a macrocyclic lactone agent that interacts with cell-cycle regulating proteins and inhibits cell division between phases G1 and S1. The hypothesis tested in this study is that local delivery of sirolimus with an eluting stent can prevent restenosis. METHODS AND RESULTS: Fifteen patients were treated with 18 mm sirolimus eluting BX VELOCITY stents. Quantitative angiography and three-dimensional quantitative intravascular ultrasound were performed at implantation and at the 6 months follow-up. All stent implantations were successful. One patient died on day 2, of cerebral haemorrhage and one patient suffered a subacute stent occlusion due to edge dissection (re-PTCA, CKMB 42). At 9 months no further adverse events had occurred and all patients were angina free. Quantitative coronary angiography revealed no change in minimal lumen diameter and percent diameter stenosis and hence no in-lesion or in-stent restenosis. Quantitative intravascular ultrasound showed that intimal hyperplasia volume and percent obstruction volume at follow-up were negligible at 5.3 mm(3)and 1.8%, respectively. No edge effect was observed in the segments proximal and distal to the stents. CONCLUSION: Implantation of a sirolimus-eluting stent seems to effectively prevent intimal hyperplasia.

Long-term clinical outcome after coronary balloon angioplasty: identification of a population at low risk of recurrent events during 17 years of follow-up. (Article)

2001-07-20T00:00:00Z

AIMS: This study reports the clinical outcome, up to 17 years, of the first 856 consecutive patients treated by coronary angioplasty at a single centre and attempts to identify a subgroup of patients at low risk of adverse events. METHODS AND RESULTS: Follow-up status was established via hospital and general practitioner records and the civil registry. Median follow-up was 16 years. The overall 5-, 10-, 15- and 17-year survival was 90%, 78%, 64% and 58%, respectively and corresponding event-free survival was 53%, 33%, 22% and 19%. After 32% of patients had experienced a major adverse cardiac event in the first year, the annual coronary re-intervention incidence thereafter and, even beyond year 10, remained at 2%--3%. Using multivariable Cox regression, significant independent predictors of mortality were advanced age, diabetes, multivessel disease and impaired left ventricular function at the time of PTCA. A subgroup of 26% of the patients with none of these risk factors had a survival rate similar to the general Dutch population matched for age and gender (at 5 years: 96%, at 10 years: 89% and at 15 years: 83%). CONCLUSION: Although the majority of patients (>80%) experienced a further cardiac event during the 17 years after their first angioplasty procedure, in those non-diabetics under 60 years with single-vessel disease and good left ventricular function, prognosis was similar to the general population.

Pharmacodynamics and safety of lefradafiban, an oral platelet glycoprotein IIb/IIIa receptor antagonist, in patients with stable coronary artery disease undergoing elective angioplasty (Article)

2001-01-01T00:00:00Z

OBJECTIVE: Lefradafiban is the orally active prodrug of fradafiban, a glycoprotein IIb/IIIa receptor antagonist. The present phase II study aimed to determine the dose of lefradafiban that provides 80% blockade of the glycoprotein IIb/IIIa receptors by fradafiban, and to study the pharmacodynamics and safety of different doses in patients with stable angina undergoing angioplasty. DESIGN: A double blind, placebo controlled, dose finding study. SETTING: Four academic and community hospitals in the Netherlands. PATIENTS: 64 patients with stable coronary artery disease undergoing elective percutaneous transluminal coronary angioplasty. INTERVENTIONS: 30 mg, 45 mg, and 60 mg of lefradafiban three times daily or placebo was given for 48 hours. MAIN OUTCOME MEASURES: The primary safety end point was the occurrence of bleeding, classified as major, minor, or insignificant according to the thrombolysis in myocardial infarction (TIMI) criteria. Efficacy indices included per cent fibrinogen receptor occupancy (FRO), ex vivo platelet aggregation, and plasma concentrations of fradafiban. RESULTS: Administration of lefradafiban 30, 45, and 60 mg three times daily resulted in a dose dependent increase in median FRO levels of 71%, 85%, and 88%, respectively. Inhibition of platelet aggregation was closely related to FRO. There were no major bleeding events. The 60 mg lefradafiban group had a high (71%) incidence of minor and insignificant bleeding. The incidence of bleeding was 44% in the 30 mg and 45 mg groups, compared with 9% in placebo patients. Puncture site bleeding was the most common event. The odds of bleeding increased by 3% for every 1% increase in FRO. CONCLUSIONS: Lefradafiban is an effective oral glycoprotein IIb/IIIa receptor blocker. The clinical effectiveness of doses up to 45 mg three times daily should be investigated.

Three dimensional intravascular ultrasonic assessment of the local mechanism of restenosis after balloon angioplasty (Article)

2001-01-01T00:00:00Z

OBJECTIVE: To assess the mechanism of restenosis after balloon angioplasty. DESIGN: Prospective study. PATIENTS: 13 patients treated with balloon angioplasty. INTERVENTIONS: 111 coronary subsegments (2 mm each) were analysed after balloon angioplasty and at a six month follow up using three dimensional intravascular ultrasound (IVUS). MAIN OUTCOME MEASURES: Qualitative and quantitative IVUS analysis. Total vessel (external elastic membrane), plaque, and lumen volume were measured in each 2 mm subsegment. Delta values were calculated (follow up - postprocedure). Remodelling was defined as any (positive or negative) change in total vessel volume. RESULTS: Positive remodelling was observed in 52 subsegments while negative remodelling occurred in 44. Remodelling, plaque type, and dissection were heterogeneously distributed along the coronary segments. Plaque composition was not associated with changes in IVUS indices, whereas dissected subsegments had a greater increase in total vessel volume than those without dissection (1.7 mm(3) v -0.33 mm(3), p = 0.04). Change in total vessel volume was correlated with changes in lumen (p < 0.05, r = 0.56) and plaque volumes (p < 0.05, r = 0.64). The site with maximum lumen loss was not the same site as the minimum lumen area at follow up in the majority (n = 10) of the vessels. In the multivariate model, residual plaque burden had an influence on negative remodelling (p = 0.001, 95% confidence interval (CI) -0.391 to -0.108), whereas dissection had an effect on total vessel increase (p = 0.002, 95% CI 1.168 to 4.969). CONCLUSIONS: The mechanism of lumen renarrowing after balloon angioplasty appears to be determined by unfavourable remodelling. However, different patterns of remodelling may occur in individual injured coronary segments, which highlights the complexity and influence of local factors in the restenotic process.

Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease (Article)

2001-01-01T00:00:00Z

BACKGROUND: The recent recognition that coronary-artery stenting has improved the short- and long-term outcomes of patients treated with angioplasty has made it necessary to reevaluate the relative benefits of bypass surgery and percutaneous interventions in patients with multivessel disease. METHODS: A total of 1205 patients were randomly assigned to undergo stent implantation or bypass surgery when a cardiac surgeon and an interventional cardiologist agreed that the same extent of revascularization could be achieved by either technique. The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events at one year. The costs of hospital resources used were also determined. RESULTS: At one year, there was no significant difference between the two groups in terms of the rates of death, stroke, or myocardial infarction. Among patients who survived without a stroke or a myocardial infarction, 16.8 percent of those in the stenting group underwent a second revascularization, as compared with 3.5 percent of those in the surgery group. The rate of event-free survival at one year was 73.8 percent among the patients who received stents and 87.8 percent among those who underwent bypass surgery (P<0.001 by the log-rank test). The costs for the initial procedure were $4,212 less for patients assigned to stenting than for those assigned to bypass surgery, but this difference was reduced during follow-up because of the increased need for repeated revascularization; after one year, the net difference in favor of stenting was estimated to be $2,973 per patient. CONCLUSION: As measured one year after the procedure, coronary stenting for multivessel disease is less expensive than bypass surgery and offers the same degree of protection against death, stroke, and myocardial infarction. However, stenting is associated with a greater need for repeated revascularization.

Assessment of coronary angiograms prior to and after treatment with abciximab, and the outcome of angioplasty in refractory unstable angina patients. Angiographic results from the CAPTURE trial. (Article)

1999-11-19T00:00:00Z

BACKGROUND: The CAPTURE study (c 7E3 A nti P latelet T herapy in U nstable Re fractory angina) was designed to assess outcome in patients with refractory angina undergoing angioplasty, receiving either abciximab or placebo. METHODS: One thousand two hundred and sixty-five patients with refractory unstable angina, defined as recurrent myocardial ischaemia despite medical treatment including heparin and nitrates were enrolled. After angiography, patients received an infusion of abciximab or placebo over 18-24 h preceding angioplasty, continuing until 1 h after the procedure. In 1197 patients undergoing angioplasty the angiographic committee centrally reviewed the baseline as well as the procedural angiograms. Coronary flow and lesion characteristics were assessed in the baseline angiogram as well as before intervention. Angiographic outcome, reason for failure as well as complications were assessed after angioplasty. RESULTS: At 30 days follow-up, patients receiving abciximab (n=595) compared with placebo (n=602) had a 30% reduction in the composite primary end-point death, myocardial infarction or urgent (re)intervention: 10.8% vs 15.4% (P=0.017). Baseline demographics were identical in the angiogram available group compared with the total study group. At 30 days, the non-angiogram available patients showed a higher incidence of events compared to those in whom the angiogram was reviewed: 19.4 vs 13.1% (P=ns). Lesion characteristics and coronary flow were not different at baseline between the placebo and abciximab groups. A primary end-point was reached in 9.6% of both placebo and abciximab patients with type A or B(1)lesions, in 17.0% vs 12.0% with type B(2)lesions, and in 19.1% vs 11.5% with type >B(2)or C lesions. Sixty-one percent of placebo and abciximab patients had TIMI 3 flow at baseline angiography. Pre-angioplasty TIMI 3 flow was observed in 69% and 72% respectively. The thrombus was resolved between the angiograms in 22% and 43% respectively, in the placebo and abciximab groups (P=0. 033). Angiographic success of the procedure was achieved in 88% and 94% in the placebo and abciximab patients, respectively (P<0.001). Stents were implanted in the ischaemia-related artery in 56 and 60 patients, respectively. However, failure of the stent procedure was more frequent in the placebo group than in the abciximab group, nine vs no patients (P=0.003). CONCLUSION: More frequent thrombus resolution was observed and a higher angiographic success rate was achieved in patients treated with abciximab before and during angioplasty compared with placebo. Patients with complex lesions as the underlying pathology reached fewer end-points if treated with abciximab before and during angioplasty.

Continuous ST-segment monitoring associated with infarct size and left ventricular function in the GUSTO-I trial (Article)

1999-09-21T00:00:00Z

Background: The aim of this study was to evaluate whether in patients with myocardial infarction, the intensity and duration of myocardial ischemia as measured by continuous ST monitoring are associated with infarct size and residual left ventricular function. Methods and Results: The analyses included patients with myocardial infarction, receiving thrombolytic therapy, who were enrolled in the electrocardiographic substudy of GUSTO-I, monitored by a vector-derived 12-lead electrocardiographic recording system, and in whom either infarct size (defined as cumulative release of α-hydroxybutyrate dehydrogenase activity per liter of plasma over a 72-hour period [Q(72)]) or left ventricular ejection fraction (LVEF) was determined. With the use of linear regression analysis, we investigated the association of various ST- trend characteristics with Q(72) (206 patients) and with LVEF (180 patients). A higher area under the ST trend since thrombolysis until 50% ST recovery and a higher area under recurrent ischemic episodes (ST reelevations) were significantly associated with a higher Q(72), whereas only a higher area under recurrent ischemic episodes was significantly associated with a lower LVEF. These associations remained after adjusting for other patient characteristics such as age, sex, infarct location, and time to treatment. Conclusions: These findings support the physiologic hypothesis that both the intensity and duration of myocardial ischemia (both reflected by the estimated areas under the ST-trend curve) determine myocardial damage and thus are associated with infarct size and ejection fraction in patients with acute myocardial infarction who receive thrombolytic therapy.

Minimal myocardial damage during coronary intervention is associated with impaired outcome (Article)

1999-08-01T00:00:00Z

AIMS: Studies on the glycoprotein IIb-IIIa receptor blocker abciximab in patients undergoing percutaneous coronary intervention consistently show a reduction in procedure-related myocardial infarction. Some such infarcts are characterized by elevated creatine kinase or creatine kinase-MB, without apparent clinical symptoms. The clinical relevance of such 'creatine kinase leaks' has been questioned. Therefore we investigated the relationship between post-procedural creatine kinase-MB elevation and outcome at the 6 month follow-up. METHODS AND RESULTS: Creatine kinase-MB, or total creatine kinase values were analysed in 5025 out of 6156 patients enrolled in the CAPTURE, EPIC and EPILOG studies. A consistent gradual increase in 6 month mortality was observed as creatine kinase-MB or creatine kinase levels increased: 1.1%, 2.1%, 1.8%, 3. 6% and 6.7% for creatine-MB or creatine ratios (relative to upper limit of normal) <1, 1-3, 3-5, 5-10 and >/=10, respectively. Also the incidence of death or (recurrent) myocardial infarction was related to creatine kinase-MB or creatine kinase ratios. Subsequent revascularization was not related to periprocedural myocardial infarction. By multivariable analysis, correcting for clinical and angiographic characteristics, mortality at 6 months was related to the enzyme (creatine kinase, creatine kinase-MB) ratio, a history of heart failure and age. The combined end-point of death and myocardial infarction was also related to these factors, as well as to a history of bypass surgery and unstable angina. CONCLUSION: Modest elevation of cardiac enzymes (creatine kinase-MB, creatine kinase) after percutaneous coronary intervention is associated with an increased risk of mortality and reinfarction during the 6 month follow-up. Measures to reduce such periprocedural infarcts are warranted.

Abciximab in the treatment of acute myocardial infarction eligible for primary percutaneous transluminal coronary angioplasty (Article)

1999-05-01T00:00:00Z

OBJECTIVES: We sought to study the effect of early infusion of abciximab on coronary patency before primary angioplasty in patients with acute myocardial infarction. BACKGROUND: Glycoprotein IIb/IIIa antagonists have proved to be effective in reducing ischemic events associated with coronary angioplasty. The present study explores whether abciximab alone, without administration of thrombolytic therapy, may induce reperfusion in patients with acute myocardial infarction. METHODS: In the Glycoprotein Receptor Antagonist Patency Evaluation pilot study 60 patients with less than 6 h signs and symptoms of acute myocardial infarction eligible for primary angioplasty received in the emergency room a bolus of abciximab 250 microg/kg followed by a 12-h infusion of 10 microg/min. All patients were also treated with an oral dose of 160 mg aspirin and 5,000 IU of heparin intravenously. As soon as possible a diagnostic angiography was performed to evaluate the patency of the infarct-related artery. RESULTS: The median time between onset of symptoms and the administration of the abciximab bolus was 150 min (range 45 to 345), and the median time between abciximab bolus and first contrast injection in the infarct-related artery was 45 min (range 10 to 150). In 24 patients (40%, 95% confidence interval 28% to 52%) Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3 was observed at a median time of 45 min (range 10 to 150) after abciximab bolus; TIMI flow grade 3 was observed in 11 patients (18%, 95% confidence interval 9% to 28%). There was no difference in percentage of TIMI flow grade 2 or 3 between patients who received abciximab within 2.5 h after onset of symptoms or thereafter. CONCLUSIONS: Abciximab therapy given in the emergency room in patients awaiting primary angioplasty is associated with full reperfusion (TIMI flow grade 3) in about 20% and with TIMI flow grade 2 or 3 in about 40% of the patients at a median time of 45 min. These figures are higher than those in primary angioplasty trials without such pretreatment. Randomized controlled trials of very early infusion of abciximab, either prehospital or in-hospital, in patients eligible for angioplasty are warranted.

Long term outcome after coronary stent implantation: a 10 year single centre experience of 1000 patients (Article)

1999-01-01T00:00:00Z

OBJECTIVE: To describe the long term clinical outcome (up to 11 years) after coronary stenting. DESIGN: A single centre observational study encompassing 1000 consecutive patients with a first stent implantation (1560 stents) between 1986 and 1996, who were followed for at least one year with a median follow up of 29 months (range 12-132 months). RESULTS: Up to July 1997 the cumulative incidence of the major adverse cardiac events (MACE) of death, non-fatal acute myocardial infarction, coronary artery bypass grafting, and repeat percutaneous transluminal coronary angioplasty was 8.2%, 12.8%, 13.1%, and 22.4%, respectively. Survival at one, three, and five years was 95%, 91%, and 86%, respectively. Comparison of MACE incidence during the "anticoagulant era" and the "ticlopidine era" revealed significantly improved event free survival with ticlopidine (27% v 13%; p < 0.005). Multivariable analyses showed that ejection fraction < 50% (relative risk (RR) 4. 1), multivessel disease (RR 3.0), diabetes (RR 2.9), implantation in saphenous vein graft (RR 2.1), indication for unstable angina (RR 1. 9), and female sex (RR 1.7) were independent predictors of increased mortality after stenting. Independent predictors of any MACE were multivessel stenting (RR 2.0), implantation in saphenous bypass graft (RR 1.6), diabetes (RR 1.5), anticoagulant treatment (versus ticlopidine and aspirin) (RR 1.5), bailout stenting (RR 1.5), multivessel disease (RR 1.4), and multiple stent implantation (RR 1. 5). CONCLUSIONS: Long term survival and infarct free survival was good, particularly in non-diabetic men with single vessel disease and good ventricular function, who had a single stent implanted in a native coronary artery. A dramatic improvement was observed in event free survival, both early and late, with the replacement of anticoagulation by ticlopidine. This, of course, cannot be separated from improved stent implantation techniques between 1986 and 1995. Ultimately, almost 40% of the patients experienced an adverse cardiac event (mainly repeat intervention) in the long term. New advances in restenosis treatments and in secondary prevention must be directed at this aspect of patient management after stenting.

Angiographic findings in patients with refractory unstable angina according to troponin T status (Article)

1999-01-01T00:00:00Z

BACKGROUND: The CAPTURE (C7E3 fab AntiPlatelet Therapy in Unstable REfactory angina) trial enrolled patients with refractory unstable angina and documented a therapeutic benefit for abciximab, a platelet glycoprotein IIb/IIIa receptor antagonist, that was particularly evident in patients with elevated troponin T (TnT) levels. In the current study, we related the angiographic data to the TnT status of the CAPTURE patients. METHODS AND RESULTS: In 853 patients, angiographic data at baseline and 18 to 24 hours after treatment were available and assessed by an Angiographic Committee with respect to TIMI flow, lesion severity, and visibility of thrombus. TnT levels >0.1 microg/L were found in 30.9% of the patients. Before randomization, thrombus was visible in 14.6% of TnT-positive patients (TnT levels >0.1 microg/L) and 4.2% of TnT-negative patients (P=0.004). Complex lesion characteristics B2+/C (72.0% versus 53.9%; P<0.001) and TIMI flow <2 (15.6% versus 5. 1%; P<0.001) were more frequent in TnT-positive patients. Abciximab was effective with respect to reduction of visible thrombus, increase of TIMI flow, and reduction of cardiac events in TnT-positive patients only. Multivariate analysis identified TnT status, but not angiographic findings, as an independent predictor for both outcome and efficacy of treatment with abciximab. CONCLUSIONS: Complex lesion characteristics and visible thrombus formation at baseline were significantly linked to TnT elevation. However, TnT status was a more powerful predictor of increased cardiac risk and efficacy of treatment with abciximab than either. Relative to the angiogram, TnT can thus be considered a more sensitive marker for the underlying pathology, identifying patients with unstable angina who will particularly benefit from antiplatelet treatment.

Abciximab: een nieuwe plaatjesaggregatieremmer voor toepassing bij coronaire angioplastiek (Article)

1998-01-01T00:00:00Z

Angioplasty of coronary arteries (PTCA) is an accepted treatment modality for patients with symptomatic coronary artery disease. Despite technological improvements it is still plagued by (mainly thrombotic) complications in around 10% of all patients. A number of new antithrombotic and antiplatelet agents have been tried in the setting of angioplasty. The monoclonal glycoprotein IIb-IIIa receptor blocker abciximab appears to control the thrombotic process most effectively before, during and after the procedure. Three large randomized trials with abciximab in patients with stable, unstable or refractory unstable angina pectoris were conducted. All three showed a relative reduction by 35% to 56% in the primary combined endpoint, consisting of mortality, myocardial infarction or urgent intervention, at 30 days. Severe bleeding, which affected 14.0% of patients on abciximab in the first trial, was reduced, after adjusting heparin dosing and issuing sheath removal guidelines, to 3.8% in the second and 2.0% in the final study. In the placebo groups the percentages of severe bleeding were 6.6, 1.9, and 3.1, respectively. Abciximab appears to reduce the thrombotic complications of PTCA substantially. The extent of this reduction and the severity of complications prevented justifies its more general use during angioplasty.

Women fare no worse than men 10 years after attempted coronary angioplasty. (Article)

1996-09-01T00:00:00Z

A retrospective review of cardiac events occurring in all patients who underwent attempted coronary angioplasty in the first 5 years of our experience (1980-1985) was undertaken. Follow-up data were obtained from the civil registry, hospital records, patient, family, and referring physician. Patient survival curves were constructed and the outcome of women and men was compared. Eight hundred fifty-six patients, 172 women and 684 men with a mean age of 60.0 and 55.3 years, respectively, underwent attempted coronary angioplasty with an overall procedural success rate of 82%, 77.7% in women and 83.1% in men. Follow-up data were obtained in 837 patients (97.8%) with a mean period of 9.6 years (range 0-13.3 years). The estimated 10 year survival in women was identical to men [79%, 95% confidence interval (CI) 72.6–85.4% vs. 78%, 95% CI 74.6–81.4%] as was the 10 year event-free survival (men 36%, 95% CI 32.0–40.0% vs. women 37%, 95% CI 29.2-44.8%), with a similar proportion of major cardiac events—death, myocardial infarction, coronary artery bypass surgery, and repeat angioplasty. When women were matched to men for age and previous myocardial infarction, factors found to be associated with an adverse outcome, there was no significant difference. Additionally, outcome was compared after patients were matched for maximum nominal balloon size as an estimate of vessel size, with no significant difference between women and men. At follow-up, women complained of significantly more anginal symptoms than men (59.2% vs. 44.0%, P < 0.05) and took significantly more antianginal medication.

Clinical outcome 10 years after attempted percutaneous transluminal coronary angioplasty in 856 patients. (Article)

1996-06-01T00:00:00Z

Abstract OBJECTIVES: This study reports the 10-year outcome of 856 consecutive patients who underwent attempted coronary angioplasty at the Thoraxcenter during the years 1980 to 1985. BACKGROUND: Coronary balloon angioplasty was first performed in 1977, and this procedure was introduced into clinical practice at the Thoraxcenter in 1980. Although advances have been made, extending our knowledge of the long-term outcome in terms of survival and major cardiac events remains of interest and a valuable guide in the treatment of patients with coronary artery disease. METHODS: Details of survival, cardiac events, symptoms and medication were retrospectively obtained from the Dutch civil registry, medical records or by letter or telephone or from the patient's physician and entered into a dedicated data base. Patient survival curves were constructed, and factors influencing survival and cardiac events were identified. RESULTS: The procedural clinical success rate was 82%. Follow-up information was obtained in 837 patients (97.8%). Six hundred forty-one patients (77%) were alive, of whom 334 (53%) were symptom free, and 254 (40%) were taking no antianginal medication. The overall 5- and 10-year survival rates were 90% (95% confidence interval [CI] 87.6% to 92.4%) and 78% (95% CI 75.0% to 81.0%), respectively, and the respective freedom from significant cardiac events (death, myocardial infarction, coronary artery bypass surgery and repeat angioplasty) was 57% (95% CI 53.4% to 60.6%) and 36% (95% CI 32.4% to 39.6%). Factors that were found to adversely influence 10-year survival were age > or = 60 years (> or = 60 years [67%], 50 to 59 years [82%], < 50 years [88%]), multivessel disease (multivessel disease [69%], single-vessel disease [82%]), impaired left ventricular function (ejection fraction < 50% [57%], > or = 50% [80%]) and a history of previous myocardial infarction (previous myocardial infarction [72%], no previous infarction [83%]). These factors were also found to be independent predictors of death during the follow-up period by a multivariate stepwise logistic regression analysis. Other factors tested, with no influence on survival, were gender, procedural success and stability of angina at the time of intervention. CONCLUSIONS: The long-term prognosis of patients after coronary angioplasty is good, particularly in those <60 years old with single-vessel disease and normal left ventricular function. The majority of patients are likely to experience a further cardiac event in the 10 years after their first angioplasty procedure.

Repeat interventions as a long-term treatment strategy in the management of progressive coronary artery disease. (Article)

1996-05-01T00:00:00Z

Objectives. This study investigates whether repeat coronary interventions, applied over an extended time period, can successfully curtail the progression of ischemic symptoms and angiographic lumen narrowing. Background. Coronary artery disease is a chronic and generally progressive disorder, and potential treatment strategies should be examined and compared with this chronicity in mind. Percutaneous interventional revascularization procedures could theoretically be useful in controlling progression of the disease through repeated use as new coronary lesions arise. However, the outcome of this long-term management concept has not previously been subjected to detailed investigation. Methods. From a consecutive series of 4,357 interventional cardiac procedures, 544 patients were identified who received two or more interventions during the 13-year study period. These patients were categorized into one of three groups: restenosis (repeat interventions limited to the same target segment, N = 261), new stenosis (all repeat interventions directed to stenoses not previously treated, N = 155) or both (repeat interventions directed both to the same and to different target lesions, N = 128). Results. Two to five procedures were performed per patient; the time period (mean ± SD) separating each procedure was significantly less (p < 0.0001) for the restenosis group (4.2 ± 2.3 months) than for the new stenosis (24.2 ± 23.5 months) or the “both” groups (11.4 ± 11.0 months). Despite the need for repeat procedures, the severity of angina (mean New York Heart Association functional class 1.6 ± 0.9) after 6.2 ± 2.3 years of follow-up was substantially better than before the initial procedure (mean functional class 3.2 ± 0.8), with a similar magnitude of change found in all three groups. This long-term functional improvement was mirrored by a corresponding anatomic improvement, with the mean number of diseased vessels remaining constant at the time of each procedure (1.5 ± 0.7, 1.5 ± 0.7 and 1.6 ± 0.7, respectively, for the first, second and third procedures, P = NS). The restenosis and the new stenosis groups also demonstrated statistically similar annual rates of mortality (1.9% vs. 1.8%) and coronary surgery (2.3% vs. 2.6%), although the restenosis group had a lower rate of infarction (1.4% vs. 3.2%, P = 0.002). Conclusions. Repeat interventional treatment of newly acquired stenoses provides a rational approach for the long-term management of chronic coronary artery disease. In addition to yielding a favorable late outcome, the use of this strategy can result in sustained functional improvement and can check the progression of clinically significant stenoses.

Vectorcardiographic monitoring to assess early vessel patency after reperfusion therapy for acute myocardial infarction (Article)

1995-01-01T00:00:00Z

Reperfusion therapy has lowered mortality in patients suffering from acute myocardial infarction. Failure to reperfuse is associated with an increased short- and long-term mortality. In a prospective study we used dynamic vectorcardiography to monitor 96 patients with acute myocardial infarction treated with reperfusion therapy to non-invasively assess coronary patency. The results from continuous monitoring were compared to those obtained from angiography. By using trend-analysis of QRS vector difference and ST vector magnitude, we were able to correctly identify 58 of the 70 patients (83%) with a reperfused infarct-related artery, and 19 of the 26 patients (73%) with a persistently occluded artery demonstrated at an early angiogram (diagnostic accuracy 80%). In patients with high-grade collateral flow to the infarct-related area, the results of the vectorcardiographic monitoring and of angiography showed the largest disagreement, whereas the accuracy of vectorcardiographic monitoring was high: 88% among patients without collaterals. The present results suggest that QRS complex and ST segment vectorcardiographic monitoring is a useful tool for assessing early coronary artery patency, and that dynamic vectorcardiography may help in identifying candidates for emergency coronary angiography.

Antiplatelet therapy in therapy-resistant unstable angina: A pilot study with REO PRO (c7E3) (Article)

1995-01-01T00:00:00Z

Patients with unstable angina, refractory to intensive medical therapy, are at high risk of developing thrombotic complications, such as myocardial infarction and coronary occlusion during coronary angioplasty. As platelet aggregation and thrombus formation play an important role in this ongoing ischaemic process, a monoclonal platelet GPIIb/IIIa receptor antibody (c7E3) has been designed to modify the clinical course and underlying coronary lesion morphology. To evaluate whether c7E3 could influence the incidence of complications, we randomized 60 patients to c7E3 or placebo after initial angiography had demonstrated a culprit lesion amenable for angioplasty. All patients exhibited dynamic ECG changes and recurrent pain attacks, despite intensive medical therapy. After study drug bolus and infusion, angiography was repeated and angioplasty performed. Recurrent ischaemia during study drug infusion occurred in nine and 16 patients from the c7E3 and placebo groups, respectively (P = 0.06). Major events defined as death, myocardial infarction or urgent intervention occurred in one and seven patients, respectively (P = 0.03). One patient from the placebo group died as a result of recurrent infarction. Resolution of clots was only observed in the c7E3 group, combined with improvement in TIMI flow grade in 20% of patients. Quantitative angiography showed an improvement in percentage diameter stenosis in the c7E3 group, which was not observed in the placebo group, although the difference between the two treatment groups was not significant. No excess bleeding was observed in the treatment group. Thus, c7E3 bolus and infusion, combined with heparin and aspirin improved the clinical course, the coronary lesion morphology and rheology in patients with unstable angina, refractory to medical treatment.

Acute and long-term outcome of directional coronary atherectomy for stable and unstable angina (Article)

1994-10-05T00:00:00Z

The clinical efficacy and safety of directional coronary atherectomy for the treatment of stable and unstable angina were assessed in 82 patients with stable and 68 patients with unstable angina. Therefore, clinical and angiographic follow-up was obtained in a prospectively collected consecutive series of 150 atherectomy procedures. Restenosis was assessed clinically and by quantitative angiography. The overall clinical success rate of atherectomy for patients with unstable and stable angina was 88% and 91%, respectively. No significant differences were found for in-hospital event rates between the unstable and stable angina groups: death (1.5% vs 0%), myocardial infarction (10% vs 6%), and emergency bypass operation (3% vs 2%). These clinical events were related to the occurrence of abrupt occlusions (8.8% in patients with stable and 6.1% in those with unstable angina; p = NS). Clinical follow-up was achieved in 100% of the patients with stable and unstable angina at a mean interval of 923 and 903 days, respectively. Two-year survival rates were 96% and 97% in the populations with unstable and stable angina, respectively. There were no significant differences with respect to bypass surgery and angioplasty, but event-free survival at 2 years was significantly lower in the unstable (54%) than the stable (69%) angina group. Quantitative coronary angiography did not detect any difference in luminal renarrowing during the 6-month angiographic follow-up period. Although directional coronary atherectomy can be performed effectively in patients with unstable and stable angina, the long-term clinical outcome was less favorable in the unstable angina group.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictive value of reactive hyperemic response on reperfusion on recovery of regional myocardial function after coronary angioplasty in acute myocardial infarction (Article)

1994-01-01T00:00:00Z

BACKGROUND: The objective of the study was to determine the coronary vasodilatory reserve in reperfused myocardium in patients with acute myocardial infarction and its relation to regional myocardial function. METHODS AND RESULTS: The study population consisted of 22 patients with acute myocardial infarction who underwent successful coronary angioplasty. The vasodilatory reserve in the reperfused myocardium was assessed quantitatively using computer-assisted digital subtraction cine-angiography immediately after angioplasty and at follow-up angiography before hospital discharge. Myocardial contrast medium appearance time and density were determined before and after pharmacological hyperemia induced by an intracoronary injection of 12.5 mg papaverine. Global and regional left ventricular functions were determined from contrast angiography. After papaverine, the mean contrast medium appearance time decreased significantly from 3.5 +/- 0.7 to 2.7 +/- 0.7 cardiac cycles (P < .000005) immediately after successful coronary angioplasty and from 3.8 +/- 0.7 to 2.7 +/- 0.9 cardiac cycles (P < .000005) at angiography before hospital discharge. The mean contrast medium density increased significantly from 48.7 +/- 13.8 to 61.0 +/- 19.0 pixels (P < .003) and from 49.6 +/- 19.7 to 80.3 +/- 29.6 pixels (P < .000005), respectively. As a consequence, the calculated coronary flow reserve increased significantly from 1.8 +/- 0.7 to 2.6 +/- 1.0 (P < .0008). The global ejection fraction increased significantly from 52 +/- 12% to 58 +/- 14% (P < .03), primarily because of a significant improvement in the regional myocardial function of the infarct zone from 20.8 +/- 9.0% to 26.0 +/- 10.5% (P < .001). Coronary flow reserve correlated well with regional myocardial function both during the acute phase (R = .79, P < .002) and at follow-up angiography (R = .82, P < .000004). Interestingly, coronary flow reserve measurement on reperfusion, immediately after angioplasty, correlated significantly with regional myocardial function at follow-up angiography (R = .81, P < .00003). CONCLUSIONS: The results indicate that there is a pharmacologically inducible vasodilatory reserve in reperfused ischemic myocardium after successful coronary angioplasty in patients with acute myocardial infarction and that this is increased at 10-day follow-up angiography. More important, the degree of reactive hyperemic response on reperfusion has a predictive value regarding the ultimate degree of recovery of regional myocardial function. Quantitative assessment of reperfusion may be useful in investigating the role of coronary reperfusion and salvage of myocardial function.

Complicaties kort na percutane transluminale angioplastiek of na coronariachirurgie bij 183 vergelijkbare patienten met een meervatscoronaria-aandoening (Article)

1994-01-01T00:00:00Z

Acute and long-term outcome of directional coronary atherectomy for stable and unstable angina (Article)

1994-01-01T00:00:00Z

Randomized trial of a GPIIb/IIIa platelet receptor blocker in refractory unstable angina (Article)

1994-01-01T00:00:00Z

BACKGROUND: Patients with unstable angina despite intensive medical therapy, ie, refractory angina, are at high risk for developing thrombotic complications: myocardial infarction or coronary occlusion during percutaneous transluminal coronary angioplasty (PTCA). Chimeric 7E3 (c7E3) Fab is an antibody fragment that blocks the platelet glycoprotein (GP) IIb/IIIa receptor and potently inhibits platelet aggregation. METHODS AND RESULTS: To evaluate whether potent platelet inhibition could reduce these complications, 60 patients with dynamic ST-T changes and recurrent pain despite intensive medical therapy were randomized to c7E3 Fab or placebo. After initial angiography had demonstrated a culprit lesion suitable for PTCA, placebo or c7E3 Fab was administered as 0.25 mg/kg bolus injection followed by 10 micrograms/min for 18 to 24 hours until 1 hour after completion of second angiography and PTCA. During study drug infusion, ischemia occurred in 9 c7E3 Fab and 16 placebo patients (P = .06). During hospital stay, 12 major events occurred in 7 placebo patients (23%), including 1 death, 4 infarcts, and 7 urgent interventions. In the c7E3 Fab group, only 1 event (an infarct) occurred (3%, P = .03). Angiography showed improved TIMI flow in 4 placebo and 6 c7E3 Fab patients and worsening of flow in 3 placebo patients but in none of the c7E3 Fab patients. Quantitative analysis showed significant improvement of the lesion in the patients treated with c7E3 Fab, which was not observed in the placebo group, although the difference between the two treatment groups was not significant. Measurement of platelet function and bleeding time demonstrated > 90% blockade of GPIIb/IIIa receptors, > 90% reduction of ex vivo platelet aggregation to ADP, and a significantly prolonged bleeding time during c7E3 Fab infusion, without excess bleeding. CONCLUSIONS: Combined therapy with c7E3 Fab, heparin, and aspirin appears safe. These pilot study results support the concept that effective blockade of the platelet GPIIb/IIIa receptors can reduce myocardial infarction and facilitate PTCA in patients with refractory unstable angina.

Restenosis after directional coronary atherectomy and balloon angioplasty: comparative analysis based on matched lesions (Article)

1993-01-01T00:00:00Z

OBJECTIVES. Late lumen narrowing after directional coronary atherectomy was assessed by quantitative coronary angiography and compared with that after balloon angioplasty. BACKGROUND. Directional coronary atherectomy has been introduced as an alternative technique for balloon angioplasty and may reduce the incidence of restenosis. METHODS. A prospectively collected consecutive series of 87 native coronary artery lesions successfully treated with atherectomy were matched with 87 coronary artery lesions selected from a consecutive series of lesions that had been successfully dilated by balloon angioplasty. Late angiographic analysis was performed in 158 lesions. The net gain index represents the ultimate gain in minimal lumen diameter at follow-up study, normalized for the vessel size. This index is the result of the relative gain attained during the procedure (the ratio of the change in minimal lumen diameter and reference diameter) and the relative loss observed during the follow-up period (the ratio of the change in minimal lumen diameter during the follow-up period and the reference diameter). RESULTS. Matching for clinical and angiographic variables resulted in two comparable groups with similar baseline stenosis characteristics. Atherectomy resulted in a more pronounced increase in minimal lumen diameter than did balloon angioplasty (mean +/- SD 1.17 +/- 0.29 to 2.44 +/- 0.42 mm vs. 1.21 +/- 0.38 to 2.00 +/- 0.36 mm, p < 0.001). However, this favorable immediate result was subsequently lost during late angiographic follow-up, so that the minimal lumen diameter at follow-up and the net gain index did not differ significantly between the two groups (1.76 +/- 0.62 vs. 1.77 +/- 0.59 mm, p = 0.93, and 0.18 +/- 0.19 vs. 0.17 +/- 0.17, p = 0.70). Consequently, the relative gain and relative loss were higher in the atherectomy group. For both techniques, the relative gain was linearly related to the relative loss but the slope of the regression line was steeper for atherectomy, suggesting that the relative loss in the atherectomy group is proportionally even larger for a given relative gain compared with that in the angioplasty group. CONCLUSIONS. In matched groups of patients, atherectomy induces a greater initial gain in minimal lumen diameter than does balloon angioplasty. However, the vascular wall injury induced by the device is of a different nature (debulking vs. dilating) that leads to more relative loss over the follow-up period in the atherectomy group.

Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over (Article)

1992-01-01T00:00:00Z

OBJECTIVE: To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician. SETTING--A tertiary referral cardiac centre. PATIENTS--166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients). RESULTS--The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease. CONCLUSIONS--Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.

Restenosis after coronary angioplasty: the paradox of increased lumen diameter and restenosis (Article)

1992-01-01T00:00:00Z

Restenosis after coronary angioplasty is the single complication that most limits this revascularization procedure in clinical practice. The process is largely unpredictable and the lesion-related factors predisposing to restenosis are poorly understood, with little consensus in published reports. In this study using detailed quantitative angiographic measurements to assess 490 lesions, the simple lesion characteristics associated with restenosis were defined and the relation to the restenosis process documented. Restenosis was defined as an absolute deterioration in the minimal lumen diameter by greater than or equal to 0.72 mm, a criterion based on the 95% confidence intervals for repeat angiographic measurements. This was chosen in an attempt to separate spurious changes due to a poor angiographic result and the variability of angiographic measurements from significant changes due to the restenosis process. The principal determinants of restenosis were found to be a large improvement in the minimal lumen diameter at the time of dilation (1.13 mm for the restenosis group compared with 0.86 mm for the no restenosis group [p less than 0.0001]) and an optimal postangioplasty result (minimal lumen diameter 2.28 mm in the restenosis group compared with 2.05 mm [p less than 0.001] in the no restenosis group, corresponding to a 25% and a 30% diameter stenosis, respectively [p less than 0.0001]). These observations reported for the first time suggest that the distinction needs to be made between a "clinical restenosis" of greater than or equal to 50% diameter stenosis and the "restenosis process" as measured by the absolute changes occurring during and after angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Histological changes in the aortic valve after balloon dilatation: evidence for a delayed healing process (Article)

1992-01-01T00:00:00Z

OBJECTIVE--To investigate whether balloon dilatation of the aortic valve induces long-term macroscopic or histological changes or both to explain the restenosis process. DESIGN--Prospective study of 39 consecutive patients. Sixteen later (mean (SD) 12 (10) months) required operation. This non-randomised subgroup was compared with 10 patients who had aortic valve replacement without prior dilatation. SETTING--University cardiology and cardiac surgery centre and pathology department. PATIENTS--16 patients who had aortic valve replacement because of failure of or restenosis after balloon dilatation of the aortic valve. Twelve resected valves were examined. INTERVENTIONS--Percutaneous balloon dilatation of the aortic valve (maximal balloon size: trefoil 3 x 12 mm balloon or bifoil 2 x 19 mm balloon) and surgical inspection before excision of the aortic valve leaflets during open-chest aortic valve replacement. Fixation, decalcification, and staining for histology. MAIN OUTCOME MEASURES--Presence of long-term pathological changes in the resected valve and their relation to restenosis after balloon dilatation. RESULTS--Macroscopically the previously dilated valves were indistinguishable from valves from the patients who had valve replacement only. Microscopically, the dilated aortic valves showed areas of young scar tissue that were not seen in a control group of surgically excised stenotic aortic valves. This persistent scarring reaction was seen around small tears or lacerations of the collagenous valve stroma, fractures in calcified areas, and splits in commissures. Young scar tissue without collagenisation was still present 24 months after dilatation. CONCLUSION--Organisation and collagenisation of scar tissue develops slowly after balloon dilatation of the aortic valve. This prolonged scarring reaction may explain the late development of restenosis in some patients.

Acute coronary artery occlusion during and after percutaneous transluminal coronary angioplasty. Frequency, prediction, clinical course, management, and follow-up (Article)

1991-01-01T00:00:00Z

BACKGROUND. Acute coronary artery occlusion after percutaneous transluminal coronary angioplasty (PTCA) continues to remain a serious complication despite significant improvement in operator performance and technological advancements. This retrospective study was performed to ascertain the frequency, predictive variables, management, and outcome of acute coronary artery occlusion. METHODS AND RESULTS. The study was based on data from 1,423 consecutive patients who underwent an elective coronary angioplasty between January 1986 and December 1988. Acute coronary artery occlusion occurred in 104 patients (7.3%). Acute occlusion developed during the dilatation procedure in 80 patients (5.6%) and within 24 hours after the procedure in 24 patients (1.7%). Four clinical and 14 angiographic variables predictive for acute coronary artery occlusion were analyzed in these 104 patients with a complicated procedure and were compared with those in 104 representative patients with successful attempts. Multivariate analysis found three independent predictive variables: unstable angina, multivessel disease, and complex lesions. The overall clinical outcome after management of acute coronary artery occlusion including immediate repeat dilatation (95 patients), use of intracoronary streptokinase (34 patients), or autoperfusion catheter (12 patients) was successful (reduction of lumen diameter to less than 50%, no death, no myocardial infarction [MI], and no emergency surgery) in 42 patients (40%), was a failure without major complication in four patients (4%), and was a failure with major complication (death, MI, and emergency surgery) in 58 patients (56%). The overall mortality rate was 6% (six patients), the overall MI rate was 36% (37 patients), and emergency bypass surgery was required in 30% of patients (31 patients). At 6 months' follow-up of 42 patients with successful management, recurrent angina pectoris due to restenosis occurred in 10 patients (24%), and a late MI occurred in one patient (3%). At 6 months' follow-up of 56 survivors with unsuccessful management (development of MI or need for emergency bypass surgery), recurrent angina occurred in nine patients (16%), and cardiac death in two patients (4%). However, the majority of patients in both groups were either symptom free or had mild angina pectoris. CONCLUSION. Acute coronary artery occlusion during PTCA is often unpredictable, but its frequency is higher in patients with unstable angina, multivessel disease, and complex lesions. Despite immediate redilatation, use of intracoronary streptokinase, and emergency bypass surgery, PTCA is associated with a high mortality and morbidity.

Acute complications of percutaneous transluminal coronary angioplasty for total occlusion (Article)

1991-01-01T00:00:00Z

The incidence of major complications after percutaneous coronary angioplasty (PTCA) of a totally occluded artery was assessed retrospectively. A total of 1649 PTCA procedures were analyzed. After exclusion of procedures for acute myocardial infarction or total occlusion that resulted from restenosis, 90 patients were selected. Forty-four patients (49%) had stable angina and 46 (51%) had unstable angina. The estimated duration of occlusion was 87 +/- 78 days in patients with stable angina, as compared with 10 +/- 8 days in patients with unstable angina (p less than 0.001). Abrupt vessel closure during PTCA occurred only in patients with unstable angina (0% versus 17%, p less than 0.05). The major complication rate was 2.5% in the stable angina group, and 20% in unstable angina group (p less than 0.01). This rate was also significantly higher than the complication rate of 8% observed in 442 procedures that were performed during the same period in patients with the unstable angina and nonocclusive stenosis (p less than 0.01). Patients with unstable angina who undergo PTCA of a totally occluded artery represent a subset of high risk for major complications.

Long-term follow-up after attempted angioplasty of saphenous vein grafts: the Thoraxcenter experience 1981-1988 (Article)

1991-01-01T00:00:00Z

Between 1981 and 1988, 107 percutaneous transluminal coronary angioplasty (PTCA) procedures, including repeat PTCA, were performed in 84 patients with previous coronary artery bypass grafting (CABG). Fifty-nine patients underwent a first angioplasty of the vein graft alone, and 25 underwent a first PTCA of the graft and one or more native vessels. Seventeen patients underwent two procedures, four patients three procedures and one patient four procedures. In 84 first angioplasties, 133 lesions were attempted; 40 lesions in native vessels and 93 graft lesions (28 ostial stenoses, 33 shaft stenoses, and 32 stenoses at the distal anastomosis). Three patients died during their hospital stay. Two patients underwent emergency CABG. Seven patients sustained an acute myocardial infarction (AMI), among whom five underwent a PTCA of an occluded vessel. The clinical primary success rate per patient was 82%. After five years, 70% of patients were alive. At a median follow-up of 2.1 years, 41% of patients were alive and event-free (no AMI, no repeat CABG, no repeat PTCA). Symptomatic improvement was maintained in 36% of patients. Angioplasty of grafts may be an alternative to re-operation in selected patients with previous bypass surgery.

The importance of adequate anticoagulation to prevent early thrombosis after stenting of stenosed venous bypass grafts (Article)

1991-01-01T00:00:00Z

Stent implantation in native coronary arteries may be complicated by acute thrombosis, despite the use of stringent anticoagulation. Thrombotic occlusion of stented venous grafts may occur less frequently, possibly because of the larger caliber of these grafts. We report our experience with 46 stents (Wallstent, Medinvent, Lausanne, Switzerland) implanted in 35 lesions of 24 consecutive patients (mean age 64 years, range 43 to 75). Two overlapping stents were implanted in seven patients, and three overlapping stents were positioned in two. After implantation, activated partial thromboplastin time was maintained at two to three times the control level by intravenous administration of heparin (160 to 550 mg daily) until thrombotest values were reduced 5% to 10% by acenocoumarol. Impending thrombotic occlusion was recognized in two suboptimally anticoagulated patients: patient A after implantation of four stents and patient B after anticoagulation therapy was discontinued because of acute upper gastrointestinal bleeding. Coronary artery bypass grafting was performed successfully in both patients. A third patient had a myocardial infarction on day 7 after stent implantation, in spite of adequate anticoagulation and optimal medical drug therapy. It is concluded that stringent anticoagulation therapy appears mandatory to maintain graft patency after stent implantation.

Quantitative angiography after directional coronary atherectomy (Article)

1991-01-01T00:00:00Z

OBJECTIVE: To assess by quantitative analysis the immediate angiographic results of directional coronary atherectomy. To compare the effects of successful atherectomy with those of successful balloon dilatation in a series of patients with matched lesions. DESIGN--Case series. SETTING--Tertiary referral centre. PATIENTS--62 patients in whom directional coronary atherectomy was attempted between 7 September 1989 and 31 December 1990. INTERVENTIONS--Directional coronary atherectomy. MAIN OUTCOME MEASURES--Increase in minimal luminal diameter of coronary artery segment. RESULTS--Angiographic success on the basis of intention to treat was obtained in 54 patients (87%). In four patients the lesion could not be crossed by the atherectomy device; all four had an uneventful conventional balloon angioplasty. Four of the 58 patients who underwent atherectomy were subsequently referred for coronary bypass surgery because of failure or complications; three of them sustained a transmural infarction. In the successful cases, coronary atherectomy resulted in an increase in the minimal luminal diameter from 1.1 mm to 2.5 mm with a concomitant decrease of the diameter stenosis from 62% to 22%. In the subset of 37 patients in which the changes induced were compared with conventional balloon angioplasty atherectomy increased the minimal luminal diameter more than balloon angioplasty (1.6 v 0.8 mm; p less than 0.0001). Conventional histology showed media or adventitia in 26% of the atherectomy specimens. In hospital complications occurred in six patients who had undergone a successful procedure: two transmural infarctions, two subendocardial infarctions, one transient ischaemia attack, and one death due to delayed rupture of the atherectomised vessel. All patients were clinically evaluated at one and six months. One patient had persisting angina (New York Heart Association class II), one patient sustained a myocardial infarction, one patient underwent a percutaneous transluminal coronary angioplasty for early restenosis, and one patient underwent coronary bypass surgery because of a coronary aneurysm formation. At six months 80% (36/47) of the patients were symptom free. CONCLUSIONS--Coronary atherectomy achieved a better immediate angiographic result than balloon angioplasty; however, in view of the complication rate in this preliminary series, which may be related to a learning curve, a randomised study is needed to show whether this procedure is as safe as a conventional balloon angioplasty.

Inability of coronary blood flow reserve measurements to assess the efficacy of coronary angioplasty in the first 24 hours in unselected patients (Article)

1991-01-01T00:00:00Z

To determine functional and anatomic changes in the first 24 hours after coronary angioplasty, we studied at random 15 patients (9 men, mean age 60 years) who underwent coronary angioplasty of 16 coronary arteries. Quantitative coronary angiography and coronary flow reserve measurements from digitized coronary angiograms were performed before, immediately after, and 24 hours after coronary angioplasty. Calculated were the minimal luminal diameter, obstruction area, and percentage diameter stenosis from two preferably orthogonal projections. Prior myocardial infarction in the myocardial region of interest was present in four patients. Seven patients had multivessel disease. Collateral vessels supplying the compromised flow region were observed in three patients. Six patients had refractory unstable angina pectoris. After coronary angioplasty, angiographically visible dissection was noted in six patients, whereas side branch occlusion was observed in one. Minimal luminal diameter before, immediately after, and 24 hours after was 0.93 +/- 0.18 mm, 1.53 +/- 28 mm, and 1.53 +/- 0.21 mm, respectively; obstruction area was 0.70 +/- 0.26 mm2, 1.92 +/- 0.69 mm2, and 1.87 +/- 0.51 mm2, respectively; diameter stenosis was 60.4 +/- 8.0%, 36.8 +/- 11.4%, and 37.6 +/- 5.3%, respectively. The coronary flow reserve (lower limit of normal with this technique 3.4) was essentially the same before and immediately after coronary angioplasty (1.26 +/- 0.59 vs 1.30 +/- 0.42, p = NS) with a slight improvement to 1.78 +/- 0.90 (p less than 0.05) 1 day later. Coronary artery dimensions correlated poorly with coronary blood flow reserve before and after angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Tissue plasminogen activator in refractory unstable angina. A randomized double-blind placebo-controlled trial in patients with refractory unstable angina and subsequent angioplasty (Article)

1991-01-01T00:00:00Z

To evaluate the effect of recombinant tissue plasminogen activator (alteplase) on the clinical course, angiographic changes and the outcome of subsequent coronary angioplasty, 36 patients with angina at rest, despite bedrest and medical treatment including heparin, and with concomitant ECG changes, were studied. After diagnostic angiography, patients were randomized to receive either alteplase 100 mg in 3 h (19 patients), or placebo (17 patients). The mean interval between qualifying anginal episode and initial angiography was 10 and 9 h for the alteplase and placebo group, respectively. Angiography was repeated and angioplasty was performed within 24 hours. Between the first and the second angiogram, five patients in the alteplase and seven in the placebo group had recurrent ischaemic episodes, while four alteplase and three placebo patients showed signs of myocardial necrosis (creatine kinase (CK) rise greater than or equal to twice the upper limit for normal). Intracoronary clots were recognized in three alteplase patients and one placebo patient at the first angiogram, while two alteplase patients and one placebo patient showed total occlusion of the ischaemic-related vessel. After infusion, thrombi were present in four alteplase patients and one placebo patient, and total occlusion in three alteplase patients and one placebo patient. Quantitative coronary angiography showed no change in the percentage diameter stenosis of the ischaemia-related segment after drug infusion, (alteplase 67 +/- 16 to 69 +/- 16%; placebo 65 +/- 11 to 63 +/- 12%). Angioplasty was successful in 14 of 19 alteplase and 14 of 16 placebo patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valvuloplasty of calcific aortic stenosis with monofoil and trefoil balloon catheters: practical considerations (Article)

1990-12-01T00:00:00Z

In order to evaluate the relation between balloon design (monofoil, trefoil) and valvular configuration, experimental aortic valvuloplasty was performed in four post-mortem hearts with calcific aortic stenosis of various morphology. The degree of obstruction of the aortic orifice was assessed by computed axial tomography during inflation of monofoil 15 and 19 mm and trefoil 3 x 12 mm balloon catheters. We also evaluated the hemodynamic repercussion of balloon inflation (fall in systolic aortic pressure) in four elderly patients with acquired aortic stenosis who underwent a percutaneous transluminal aortic balloon valvuloplasty, with stepwise increasing balloon sizes of 15 mm, 19 mm and 3 x 12 mm, as during our in vitro experiments, and who underwent aortic valve replacement later on. In these patients, we correlated the anatomy of the excised aortic valves with the retrospective analysis of aortic pressure curves recorded during previous valvuloplasty procedures. Our experimental and clinicopathological observations showed that the degree of obstruction of the aortic orifice in post-mortem specimens and the tolerance to balloon inflation in live patients are dependent of the valvular configuration. Although trefoil balloons have the theoretical advantage to avoid complete obstruction of the aortic orifice during inflation, we observed that in presence of a tricuspid configuration, they could be potentially more occlusive than monofoil balloons since each of the 3 individual components of the trefoil balloon occupied the intercommissural spaces while inflated. However, they offered more residual free space when inflated in aortic valves with a bicuspid configuration (i.e. congenitally bicuspid valves or tricuspid valves with one fused commissure). In our opinion, these observations are relevant, since degenerative disease of the aortic valve (i.e. tricuspid valve without commissural fusion) is now recognized as the most common etiology of aortic stenosis in the elderly.

Assessment of the "long sheath" technique for percutaneous aortic balloon valvuloplasty (Article)

1990-01-01T00:00:00Z

A 100 cm-long 16.5 F valvuloplasty catheter introducer was assessed as an adjunct for percutaneous transluminal aortic valvuloplasty (PTAV) via the femoral artery in 31 patients with severe aortic stenosis. Observed improvements in peak systolic gradient (81.6 +/- 29.9 mm Hg vs. 35.5 +/- 16.0 mm Hg, P less than 0.000001) and aortic valve area (0.6 +/- 0.4 cm2 vs. 1.0 +/- 0.6 cm2, P less than 0.00001) were similar to those achieved in a control group (C) of 17 patients in which no femoral sheath was used. However, a shorter procedure duration (211 +/- 81 min vs. 117 +/- 30 min, P less than 0.001) and a reduced rate of vascular complications at the femoral puncture site (41% vs. 6.5%) were observed in patients in whom the long sheath (LS) technique was used. The frequency of other PTAV-related complications was comparable (C = 35%, LS = 29%, P = n.s.). Other technical advantages of this device are: 1) prevention of looping and bending of the balloon catheter in tortuous vessels and easy positioning of the balloon across the aortic orifice provided by the LS trackability, 2) stabilisation of the balloon during inflation, 3) monitoring of supravalvular aortic pressure provided by the side-arm of the LS and reliable measurement of systolic gradient, and 4) the ability to perform aortograms without the need of another catheter in the ascending aorta. Thus, in our experience, the long sheath technique is a valuable adjunct for PTAV.

Directionele coronaria-atherectomie; eerste Nederlandse ervaringen met een nieuwe percutane revascularisatiemethode (Article)

1990-01-01T00:00:00Z

Comparison of costs of percutaneous transluminal coronary angioplasty and coronary bypass surgery for patients with angina pectoris (Article)

1990-01-01T00:00:00Z

To determine the costs of a procedure, the total costs of the department that provides the service must be considered and, in addition, the direct cost of the specific procedure. Applying this principle to the cost accounting of angioplasty and bypass surgery results in a direct, i.e. procedural, cost, including the initial hospital stay, of respectively 8694 Dfl and 20,987 Dfl. A review of the follow-up data for the first year after the original intervention revealed a 2% reintervention rate for bypass surgery, while this percentage was 29% for angioplasty. Adding the first year costs involved with reinterventions to the procedural costs results in a 1-year cost of angioplasty and bypass operation of 13,625 Dfl and 21,363 Dfl, respectively. It is concluded that because of reinterventions in the first year, a mark up of 57% on the procedural cost of angioplasty must be added to cover 1-year costs, while for bypass surgery this is only 1%. Nevertheless, the 1-year cost for angioplasty is still 36% less than for bypass surgery. As reinterventions after PTCA may stay considerably higher than for CABG for several years, the mark-up percentages will be substantially higher for longer time spans. This may tend to equalize the total costs of PTCA and CABG over time spans of perhaps 5-8 years. Sufficient data are not available to verify this statement. Clinicians must realize that choosing the most appropriate procedure is not only a matter of medical assessment but also a matter of cost effectiveness. CABG can be seen as an 'investment decision' while PTCA tends to become a decision with characteristics of 'maintenance planning'!

Recovery of regional myocardial dysfunction after successful coronary angioplasty early after a non-Q wave myocardial infarction (Article)

1990-01-01T00:00:00Z

More aggressive therapy has been suggested for patients who have a non-Q wave myocardial infarction (MI) because of the frequency of subsequent unstable angina, recurrent MI, and high mortality rate compared to patients with Q wave MI. The present study was undertaken to investigate the effect of coronary angioplasty on regional myocardial function of the infarct zone in patients with angina early after a non-Q wave MI. The study population consisted of 36 patients undergoing successful coronary angioplasty within 30 days of a non-Q wave MI, in whom sequential left ventricular angiograms of adequate quality were obtained before the initial procedure and at follow-up angiography. The global ejection fraction increased significantly from 60 +/- 9% to 67 +/- 6% (p = 0.0003). This significant increase in the global ejection fraction was primarily due to a significant improvement in the regional myocardial function of the infarct zone. The results of the present study show not only that ischemic attacks early after a non-Q wave MI may lead to prolonged regional myocardial dysfunction but more important that this depressed myocardium has the potential to achieve normal contraction after successful coronary angioplasty.

Percutane transluminale coronaria-angioplastiek bij patienten ouder dan 70 jaar; korte- en lange-termijnresultaten (Article)

1990-01-01T00:00:00Z

Quantitative angiographic assessment of elastic recoil after percutaneous transluminal coronary angioplasty (Article)

1990-01-01T00:00:00Z

Little is known about the elastic behavior of the coronary vessel wall directly after percutaneous transluminal coronary angioplasty (PTCA). Minimal luminal cross-sectional areas of 151 successfully dilated lesions were studied in 136 patients during balloon inflation and directly after withdrawal of the balloon. The circumvent geometric assumptions about the shape of the stenosis after PTCA, a videodensitometric analysis technique was used for the assessment of vascular cross-sectional areas. Elastic recoil was defined as the difference between balloon cross-sectional area of the largest balloon used at the highest pressure and minimal luminal cross-sectional area after PTCA. Mean balloon cross-sectional area was 5.2 +/- 1.6 mm2 with a mean minimal cross-sectional area of 2.8 +/- 1.4 mm2 immediately after inflation. Oversizing of the balloon (balloon artery ratio greater than 1) led to more recoil (0.8 +/- 0.3 vs 0.6 +/- 0.3 mm, p less than 0.001), suggestive of an elastic phenomenon. A difference in recoil of the 3 main coronary branches was observed: left anterior descending artery 2.7 +/- 1.3 mm2, circumflex artery 2.3 +/- 1.2 mm2 and right coronary artery 1.9 +/- 1.5 mm2 (p less than 0.025). The difference was still statistically significant if adjusted for reference area. Thus, nearly 50% of the theoretically achievable cross-sectional area (i.e., balloon cross-sectional area) is lost shortly after balloon deflation.

Emergency stenting for refractory acute coronary artery occlusion during coronary angioplasty (Article)

1990-01-01T00:00:00Z

Myocardial release of hypoxanthine and lactate during percutaneous transluminal coronary angioplasty (Article)

1989-01-01T00:00:00Z

The response of myocardial lactate and hypoxanthine metabolism during percutaneous transluminal coronary angioplasty was studied in a series of 15 patients undergoing this procedure. A minimum of 4 balloon inflations was performed per patient with an average duration per occlusion of 49 +/- 11 seconds (mean +/- standard deviation) for a total occlusion time of 192 +/- 40 seconds. Thermodilution coronary venous blood flow measured in the great cardiac vein decreased from control values of 72 +/- 4 ml/min (mean +/- standard error of the mean) to 47 +/- 10 ml/min with the fourth coronary occlusion (p less than 0.005). Arteriovenous lactate and hypoxanthine showed peak differences during the reactive hyperemia after the first 2 occlusions which did not increase after subsequent occlusions. Within minutes after the procedure, lactate and hypoxanthine efflux was no longer seen, demonstrating the reversibility of the metabolic disturbances after repeated ischemia. The results of this study indicate that there is no permanent alteration in lactate or hypoxanthine metabolism after percutaneous transluminal coronary angioplasty with 4 coronary occlusions of 40 to 60 seconds' duration, with a total occlusion time of 192 +/- 40 seconds.

Short-, medium-, and long-term follow-up after percutaneous transluminal coronary angioplasty for stable and unstable angina pectoris (Article)

1989-01-01T00:00:00Z

The first 840 consecutive patients who underwent percutaneous transluminal coronary angioplasty (PTCA) performed in the same institution were retrospectively assessed at an average follow-up period of 25 months after the initial procedure. The study population consisted of 506 patients with stable angina pectoris (group 1) and 334 patients with unstable angina pectoris (group 2). Clinical end points were death, nonfatal myocardial infarction, recurrent angina pectoris necessitating bypass surgery or repeat PTCA, and event-free survival. The two groups were comparable with respect to age, sex, previous myocardial infarction, ejection fraction, and number of diseased vessels. PTCA was successful in 83.0% of group 1 and 87.1% of group 2. Follow-up rates were expressed as events per attempted PTCA in a patient group. No difference in survival was observed between the two groups, the mortality rate being approximately 2.8% at 25 months. In the group with stable angina pectoris there was a lower incidence of nonfatal myocardial infarction within the first 24 hours after angioplasty; 4.3% vs 9.0% (p less than 0.01). During long-term follow-up the increase in the incidence of nonfatal myocardial infarction was similar, resulting in an overall long-term follow-up infarction rate of 8.3% and 14.2%, respectively (p less than 0.01). A higher event-free survival was observed in group 1 within 24 hours after PTCA: 93.7% vs 84.2% (p less than 0.01). During subsequent follow-up the difference in event-free survival between the two groups was no longer significant: 68.5% vs 61.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Fracture of a balloon on a wire device during coronary angioplasty (Article)

1989-01-01T00:00:00Z

In a 61-year-old patient with unstable angina an attempt was made to dilate a severe stenosis in a tortuous obtuse marginal branch. The initial attempt with conventional equipment was not successful; although the wire could be advanced distal to the stenosis, a 2.0 balloon did not cross the stenosis. A second attempt with a balloon on a wire device resulted in fracture of this catheter, with the distal 2.8-cm-long fragment looped in the left coronary artery. Immediate bypass surgery was performed and the broken fragment was easily removed from the left coronary ostium. The patient made an uneventful recovery.

Percutaneous transluminal angioplasty of a totally occluded venous bypass graft: a challenge that should be resisted (Article)

1989-01-01T00:00:00Z

Haemodynamic observations during percutaneous transluminal coronary angioplasty in the presence of synchronised diastolic coronary sinus retroperfusion (Article)

1988-01-01T00:00:00Z

Animal studies have demonstrated that synchronised coronary sinus retroperfusion with arterial blood can provide effective perfusion of ischaemic myocardium. Preliminary clinical studies have shown that the technique can also be used with safety in human beings, and in the present study its effectiveness was assessed in three patients undergoing repeated coronary artery occlusions during percutaneous transluminal coronary angioplasty. Arterial blood was removed via an 8F catheter positioned in the femoral artery and delivered by a retroperfusion pumping system to a 7F retroperfusion balloon catheter positioned in the anterior cardiac vein. Ischaemia-related indices were monitored both before and during coronary sinus retroperfusion. These indices included high fidelity left ventricular pressure recordings and pressure derived indices (including velocities of isovolumic contraction and relaxation), as well as electrocardiographic changes and symptoms. Analysis of these variables showed that the ischaemic changes induced during coronary artery occlusion were not prevented by this type of coronary sinus retroperfusion. There was no major complication in any of the patients. It may be that adaptation of the technique or the use of alternative end points will establish a benefit, but further modifications of the delivery system are necessary for effective clinical use.

Incidence of restenosis after successful coronary angioplasty: a time-related phenomenon. A quantitative angiographic study in 342 consecutive patients at 1, 2, 3, and 4 months (Article)

1988-01-01T00:00:00Z

Data from experimental, clinical, and pathologic studies have suggested that the process of restenosis begins very early after coronary angioplasty. The present study was performed to determine prospectively the incidence of restenosis with use of the four National Heart, Lung, and Blood Institute and the 50% or greater diameter stenosis criteria, as well as a criterion based on a decrease of 0.72 mm or more in minimal luminal diameter. Patients were recatheterized at 30, 60, 90, or 120 days after successful percutaneous transluminal coronary angioplasty (PTCA). After PTCA all patients received 10 mg nifedipine three to six times a day and aspirin once a day until repeat angiography. Of 400 consecutive patients in whom PTCA was successful (less than 50% diameter stenosis), 342 underwent quantitative angiographic follow-up (86%) by use of an automated edge-detection technique. A wide variation in the incidence of restenosis was found dependent on the criterion applied. The incidence of restenosis proved to be progressive to at least the third month for all except NHLBI criterion II. At 4 months a further increase in the incidence of restenosis was observed when defined as a decrease of 0.72 mm or more in minimal luminal diameter, whereas the criteria based on percentage diameter stenosis showed a variable response. The lack of overlap between the different restenosis criteria applied affirms the arbitrary nature of angiographic definitions currently in use. Restenosis should be assessed by repeat angiography, and preferably ascertained according to the change in absolute quantitative measurements of the luminal diameter.

Percutaneous transluminal coronary angioplasty for angina pectoris after a non-Q-wave acute myocardial infarction (Article)

1988-01-01T00:00:00Z

Despite initially favorable prognosis in patients with non-Q-wave acute myocardial infarction (AMI), long-term mortality in this subset of patients appears to be similar to or even greater than that in patients with Q-wave AMI. The relatively poor late prognosis is primarily due to a high incidence of unstable angina and recurrent AMI. Between January 1982 and January 1987, 114 patients with suitable coronary narrowing underwent percutaneous transluminal coronary angioplasty (PTCA) for angina pectoris (present either at rest or during mild exertion, and despite optimal pharmacologic therapy), a median of 31 (range 2 to 362) days after a non-Q-wave AMI. Success was achieved in dilating the obstructed artery in 98 patients (113 of the 129 dilated arteries). Emergency bypass surgery was performed in 7 patients. Mean clinical follow-up of 20 (range 3 to 59) months was obtained in all patients and revealed no deaths. Of the 98 patients with successful PTCAs, 6 (6%) developed a nonfatal recurrent AMI and 62 (63%) were asymptomatic. However, recurrent angina affected 31 patients (32%) and was treated by repeat PTCA (n = 18), coronary bypass surgery (n = 5) or pharmacologic therapy (n = 8). At follow-up, 74% of the patients (73 of 98) were asymptomatic after a successful PTCA and, if necessary, a repeat PTCA, without incidence of recurrent AMI, coronary bypass surgery or death. The high initial success rate, low incidence of subsequent death and late recurrent AMI and sustained symptomatic benefit suggest that PTCA is an effective initial treatment strategy in these selected patients.

Coronary blood flow velocity during percutaneous transluminal coronary angioplasty as a guide for assessment of the functional result (Article)

1988-01-01T00:00:00Z

To investigate the clinical usefulness of intracoronary Doppler recordings during percutaneous transluminal coronary angioplasty (PTCA), the changes of intracoronary blood flow velocity during PTCA were assessed in 20 patients with single proximal coronary stenosis, using a Doppler probe end-mounted on the tip of a PTCA catheter. A mean of 4 inflations was performed in each patient. Intracoronary velocities were measured before and after each inflation and during peak reactive hyperemia after each transluminal occlusion. Quantitative analysis of the coronary stenosis was assessed before and after PTCA, and the dilatation resulted in an increase in minimal luminal cross-sectional area from 1.1 +/- 0.8 to 2.7 +/- 1.2 mm2. A gradual and significant improvement in velocities was observed after the first 3 dilatations, but in 15 of the 20 patients the resting and hyperemic velocities were not affected by the fourth dilatation. Coronary flow reserve measured during reactive hyperemia after the last dilatation with the PTCA catheter across the lesion was 1.9. This value of coronary flow reserve is compatible with the residual stenosis measured after PTCA when corrected for the presence of the Doppler balloon catheter (0.68 mm2). This application of the Doppler technique may provide a new method of on-line functional monitoring of the PTCA procedure in individual patients, but does not yet allow an accurate prediction of the change in coronary geometry brought about by PTCA.

Change in diameter of coronary artery segments adjacent to stenosis after percutaneous transluminal coronary angioplasty: failure of percent diameter stenosis measurement to reflect morphologic changes induced by balloon dilation (Article)

1988-01-01T00:00:00Z

To determine the changes in stenotic and nonstenotic segments of a dilated coronary artery, detailed quantitative angiographic measurements were performed in 342 patients (398 lesions) immediately after angioplasty and at a predetermined follow-up time of 30, 60, 90 or 120 days after the dilation. Measurements of the stenotic segments were expressed as minimal luminal diameter, and the adjacent nonstenotic segments were expressed as interpolated reference diameter (both in millimeters). A follow-up rate of 86% was achieved. In the patients followed up at 30 and 60 days, there was no significant change in either the mean minimal luminal diameter or the mean reference diameter. However, at 90 and 120 days, there was significant deterioration in both the mean minimal luminal diameter (-0.37 and -0.42 mm, respectively) and the mean reference diameter (-0.17 and -0.26 mm, respectively), all of the changes being highly significant (p less than 0.00001). The reference diameter is involved in the dilation process and may be subject to the same restenosis process that takes place in initially stenotic segments. Percent diameter stenosis measurements, which are conventionally used to express the change in the severity of a stenosis after angioplasty, will tend to underestimate the change when there is a simultaneous reduction in the reference diameter.

Coronary angioplasty for unstable angina: immediate and late results in 200 consecutive patients with identification of risk factors for unfavorable early and late outcome (Article)

1988-01-01T00:00:00Z

Two hundred patients (mean age 56 years, range 36 to 74) with unstable angina (chest pain at rest, associated with ST-T changes) underwent coronary angioplasty. In 65 patients with multivessel disease, only the "culprit" lesion was dilated. The initial success rate was 89.5% (179 of 200 patients). At least one major procedure-related complication occurred in 21 patients (10.5%): (death in 1, myocardial infarction in 16 and urgent surgery in 18). All patients were followed up for 2 years. Five patients died late; 8 had a late nonfatal myocardial infarction and 52 had recurrence of angina pectoris. The restenosis rate was 32% (51 of 158) in the patients with initial successful angioplasty who had repeat angiography. At the 2 year follow-up, after attempted coronary angioplasty in all 200 patients, the total incidence rate of death was 3% (one procedure related; five late deaths), of nonfatal myocardial infarction 12% (16 procedure related and 8 late after angioplasty), and 13% (26 patients) were still symptomatic although they had improved in functional class. Multivariate analysis showed that variables indicating an increased risk 1) for major procedure-related complications were: ST segment elevation, persistent negative T wave and stenosis greater than or equal to 65% (odds ratio 3.7, 3.7 and 3.3, respectively); 2) for angiographic restenosis were: presence of collateral vessels, ST segment depression, multivessel disease, left anterior descending coronary artery stenosis and history of recent onset of symptoms (odds ratio: 2.2, 2.0, 1.9, 1.9 and 0.54, respectively); and 3) for late coronary events (recurrence of angina, late myocardial infarction or late death) were: multivessel disease, total occluded vessel and ST segment elevation (odds ratio 3.7, 2.8 and 0.44, respectively). Thus, coronary angioplasty for unstable angina can be performed with a high initial success rate, but at an increased risk of major complications. The prognosis is favorable after initial successful coronary angioplasty.

Percutaneous balloon valvuloplasty for calcific aortic stenosis. A treatment sine cure? (Article)

1988-01-01T00:00:00Z

Twenty-five elderly patients with calcific aortic stenosis, 12 male (48%) and 13 female (52%), mean age 74.8 +/- 7.6 years, underwent percutaneous aortic balloon valvuloplasty between March 1986 and September 1987. Twenty-two patients (88%) were in class III-IV of the New York Heart Association, 13 (52%) had a history of previous angina and 7 (28%) of syncopal attacks. All patients had been considered either unsuitable or high-risk candidates for aortic-valve replacement because of age or associated diseases. Balloons of increasing size (area ranging from 1.3 to 3.8 cm2 during inflation) were successively passed retrogradely from the femoral artery and manually inflated to 3-7 atmospheres. Inflation duration ranged from 15 to 260 s (mean 40 s). Post-dilatation there were significant changes in left ventricular peak-systolic and end-diastolic pressures (P less than 0.00001 and P less than 0.01, respectively), mean systolic aortic transvalvular gradient (from 73 to 43 mmHg, P less than 0.000001), mean systolic aortic flow (from 176 to 208 ml s-1, P less than 0.0001) and aortic valve area (from 0.47 to 0.72 cm2, P less than 0.000001). Major complications included: in-hospital deaths of two patients (8%) admitted in cardiogenic shock; left haemiplegia (4%); transient haemianopia (8%); development of grade III aortic insufficiency (4%); and persistent complete atrioventricular block (4%). Complications at the puncture-site occurred in 7 patients (28%)--including two femoral pseudoaneurysms and the need for surgical removal of a balloon remnant after rupture in one patient. No local haemorrhagic complications were observed in the latter eight procedures, performed using a 16.5 French 100-cm long arterial introducer. At a mean follow-up of 13.0 +/- 5.0 months, an important functional improvement persisted in 14 patients (56%), no major changes in pre-valvuloplasty symptoms were observed in 3 patients (12%), while five patients (20%) required surgical treatment after a successful valvuloplasty because of recurrence of symptoms (late valve restenosis). Percutaneous aortic balloon valvuloplasty is a possible palliative therapy in elderly patients with calcific aortic stenosis. However, its inherent immediate risk, limited haemodynamic result and the possible development of valve restenosis at medium-term follow-up, suggest that the application of this technique should be limited to poor surgical candidates.

Regional cardioprotection by subselective intracoronary nifedipine is not due to enhanced collateral flow during coronary angioplasty (Article)

1987-01-01T00:00:00Z

Twelve patients with proximal stenosis of the left anterior descending artery, normal myocardial wall motion but without angiographically demonstrable collateral circulation, were studied during transluminal occlusion. Prior to the first transluminal occlusion before crossing the lesion with the balloon, patients were randomly given 0.2 mg nifedipine or its solvent in the left mainstem. The same dose was repeated via the balloon catheter, positioned across the lesion, immediately prior to the second transluminal occlusion. In all patients great cardiac venous flow and ST-elevation were monitored during and after each transluminal occlusion. The lactate extraction ratio A-GCV/A (A = arterial, GCV = great cardiac vein) was determined prior to the angioplasty procedure, 10-15 seconds after each transluminal occlusion and 10 minutes after the third transluminal occlusion. Great cardiac venous flow rose significantly to an average of 160% of basal flow when nifedipine was administered into the mainstem before the angioplasty procedure while its solvent had no effect. During each transluminal occlusion, great cardiac venous flow diminished on average by 30% in those who received nifedipine and by 28% in those who received only its solvent. This difference was statistically not significant. After angioplasty great cardiac venous flow was slightly, but not significantly, increased in both groups with respect to basal flow (104% resp. 120% of control). Patients who received nifedipine in the post-stenotic area just before the second transluminal occlusion, had significantly lower lactate production, measured immediately after the transluminal occlusion compared with the patients who received only its solvent (P less than 0.01). The ST-elevation during the second transluminal occlusion was significantly lower in the nifedipine group (0.1 mm in nifedipine group versus 1.4 mm in solvent group; P less than 0.05, unpaired t-test). Nifedipine given intracoronary in the post-stenotic area just before coronary angioplasty reduces lactate release and electrocardiographic signs of myocardial ischemic injury. This regional cardioprotective effect seems not due to an enhanced collateral flow, but to a regional cardioplegic effect, which precedes the ischemic event.

Percutane transluminale ballonvalvuloplastiek bij oudere patienten met een verworven aortaklepstenose (Article)

1987-01-01T00:00:00Z

Intracoronary thrombolysis in patients with acute myocardial infarction: The Netherlands randomized trial and current status (Article)

1987-01-01T00:00:00Z

Coronary angioplasty early after diagnosis of unstable angina (Article)

1987-01-01T00:00:00Z

Coronary angioplasty (PTCA) was performed early after diagnosis of unstable angina in 71 patients who responded favorably with initial pharmacologic treatment and who also had persistent exertional angina. The patients selected for PTCA had predominantly single-vessel disease and a normal or slightly abnormal left ventricular function. PTCA was successful in 87% (62/71) of the patients and unsuccessful in 13% (9/71). There were no deaths related to PTCA. The incidence of myocardial infarction during the procedure was 10% (seven of the 71 patients). Urgent bypass surgery was necessary in 11% (eight of 71 patients) of the patients. All patients were followed up for 12 months. There was one late death and one late nonfatal myocardial infarction. During 12 months of follow-up there was recurrence of angina pectoris in 25% of the patients (14/62). The restenosis rate was 25% (13/52) in the patients with an initial successful PTCA who underwent repeat angiography. Improved cardiac functional status after sustained successful PTCA was demonstrated by the normal exercise capacity on bicycle exercise testing and the absence of ischemia on thallium 201 scintigraphy studies in 70% of the patients. At the 1-year follow-up visit after attempted coronary angioplasty in all 71 patients, the total incidence of deaths was 1.5% (one patient), myocardial infarction 11% (eight patients), and the need for revascularization 25% (emergency surgery eight patients, late surgery three patients, and repeat PTCA seven patients); 91% (64 of 70 patients) were symptom free. It is concluded that PTCA in selected patients with unstable angina initially stabilized with medical treatment is an effective treatment with an acceptable complication rate and an excellent 1-year prognosis.

Value of immediate coronary angioplasty following intracoronary thrombolysis in acute myocardial infarction (Article)

1987-01-01T00:00:00Z

A total of 533 patients with acute myocardial infarction of less than 4-h duration were enrolled in the multicenter randomized trial of intracoronary thrombolysis compared to conventional treatment. In two of the five participating centers, an additional coronary angioplasty immediately after thrombolysis was attempted in 46 patients. According to the treatment allocation and early and late patency of the infarct related vessel, patients were subdivided into three groups: conventionally treated (group A); successful coronary angioplasty following thrombolysis with persistent patent infarct related vessel (group B); and late patency of the infarct related vessel postthrombolytic therapy without angioplasty (group C). The highest global ejection fractions were observed in group B (54% +/- 10%) and group C (55% +/- 13%), while the lowest ejection fraction was found in group A (47% +/- 14%). The sequential changes in global ejection fraction from the acute to the chronic stage was + 4% (p = 0.05) in group B, while no significant changes could be demonstrated in group C. Furthermore, in the group successfully treated by angioplasty, the improvement in global ejection fraction was more pronounced and persisted up to three months after the intervention. This was supported by analysis of regional myocardial function of the infarct zone (+ 16% improvement, p = 0.01). The long-term clinical follow-up (median 24 months) of the patients successfully treated by combined procedure of thrombolysis and angioplasty (group B) was most favourable with a lower incidence of re-infarction (6%), and late coronary bypass surgery (13%) and/or (re)-percutaneous transluminal coronary angioplasty (3%) was performed less frequently. These results suggest that reperfusion may need to be supplemented by additional revascularization procedures in order to optimize the changes of obtaining full functional recovery and so to improve the prognosis.

Percutaneous aortic balloon dilatation for cacific aortic stenosis in elderly patients: immediate haemodynamic results and short term follow up (Article)

1987-01-01T00:00:00Z

Eight elderly patients (mean (SD) age 72.6 (8.5) years) with severe calcified stenosis of the aortic valve were considered for transluminal balloon dilatation in the Thoraxcenter between March and November 1986. In one patient the procedure could not be performed because of technical difficulties. Balloons of increasing diameter (13-25 mm) were successively passed retrogradely from the femoral artery and manually inflated with pressures of 400-600 kPa (4-6 atmospheres). Post-dilatation, there were significant changes in left ventricular pressures (from 237/21 to 204/13 mm Hg), mean systolic gradient (from 66 to 41 mm Hg, systolic aortic flow (from 172 to 202 ml/s, and aortic valve area (from 0.47 to 0.74 cm2); the cardiac index did not increase significantly (from 2.4 to 2.5 l/min/m2). One patient developed a pseudoaneurysm at the site of the femoral artery puncture that required surgical repair two months after the procedure; one patient experienced an acute left hemianopia during the procedure but had almost completely recovered at discharge. Five patients maintained a clinical improvement at a mean follow up time of 4.5 months after the procedure; two patients underwent aortic valve replacement, one because of minimal haemodynamic improvement after aortic balloon dilatation and persistence of severe dyspnoea and the other because of late recurrence of symptoms caused by restenosis after a successful procedure. Aortic balloon dilatation provides an alternative treatment for patients who are poor surgical candidates for cardiac or extracardiac reasons. At this stage the limited haemodynamic improvements suggest that the treatment can only be regarded as palliative, although proposed technical advances may achieve better immediate results in the future. Long term follow up is needed to evaluate the usefulness of this technique.

Effects of successful percutaneous transluminal coronary angioplasty on global and regional left ventricular function in unstable angina pectoris (Article)

1987-01-01T00:00:00Z

Sixty-eight patients (58 men, 10 women, mean age 56.3 years, range 31 to 72) with unstable angina pectoris, either initially stabilized with or refractory to optimal pharmacologic treatment, were studied to determine whether regional dysfunction due to stunning of the myocardium caused by attacks of chest pain at rest could be improved with percutaneous transluminal coronary angioplasty (PTCA). Patients were included in the study if they had successful 1-vessel PTCA, no angiographic restenosis, no reocclusion or late myocardial infarction and 2 serial left ventriculograms of sufficient quality to allow automated contour analysis before and after PTCA. Global ejection fraction increased significantly (from 56% to 60%, p less than 0.05) only after successful dilatation of a stenosis of the left anterior descending coronary artery. Analysis of regional wall displacement showed significant improvement of regional wall motion in the areas supplied by the dilated vessel of either the left anterior descending, the left circumflex or the right coronary artery. Thus, regional myocardial dysfunction due to stunning of the myocardium in patients with unstable angina improves after successful PTCA.

Verbeterde prognose als gevolg van vroeg thrombolyse bij patienten met een acuut hartinfarct (Article)

1986-01-01T00:00:00Z

Twee behandelingen werden vergeleken in een gerandomiseerd onderzoek waaraan 533 patiënten met een acuut infarct deelnamen, 264 patiënten werden conventioneel behandeld (groep 1) en 269 kregen een behandeling die gericht was op snelle rekanalisatie van de veelal afgesloten coronairarterie (groep 2). Bij de eerste 152 patiënten in groep 2 werd uitsluitend intracoronair streptokinase gegeven (250.000 eenheden), onmiddellijk na coronariografie. Bij de volgende 117 patiënten werd deze intracoronaire behandeling voorafgegaan door intraveneuze toediening van streptokinase (500.000 eenheden). Bij 198 van de 234 patiënten bij wie angiografie werd verricht in de acute fase van het infarct, was de met het infarct samenhangende coronairarterie doorgankelijk aan het eind van de ingreep (85). De sterfte was lager bij patiënten uit groep 2 gedurende de gehele follow-up-periode. De éénjaarsoverleving was 91 bij patiënten in groep 2 en 84 in groep 1. Het voorkomen van ventrikelfibrilleren, pericarditis en cardiogene shock in groep 2 was lager dan in de controlegroep. Daarentegen traden bij patiënten uit groep 2 vaker bloedingen en, in het bijzonder bij patiënten met een onderwandinfarct, vaker recidiefinfarcering op. Op grond van deze gegevens concluderen wij dat trombolyse een aanwinst is bij de behandeling van patiënten met een acuut hartinfarct.

Preservation of global and regional left ventricular function after early thrombolysis in acute myocardial infarction (Article)

1986-01-01T00:00:00Z

The effect of early myocardial reperfusion (within 4 hours after onset of symptoms) on regional left ventricular function in patients with acute myocardial infarction has been quantitated by analysis of segmental wall motion. Of 533 patients randomized either to conventional coronary care unit therapy or to a reperfusion strategy, in 332 high quality angiograms were obtained 2 to 8 weeks after the onset of myocardial infarction. In those assigned to thrombolytic therapy, angiographic data were also available after acute reperfusion. Analysis on an "intention to treat" basis revealed significant preservation of left ventricular function after thrombolytic therapy (ejection fraction 53%) compared with conventional treatment (ejection fraction 47%). In addition, wall motion analysis showed significant improvement of regional function in the infarct zone in both inferior and anterior infarction. In addition, significant changes occurred in regional function of the remote "noninfarct zone" in the acute as well as the chronic stage. It is concluded that improved regional and global left ventricular function can be achieved with early reperfusion and that this is the likely explanation for the reduction of early and late mortality after thrombolysis observed in this study.

Early thrombolysis in acute myocardial infarction: limitation of infarct size and improved survival (Article)

1986-01-01T00:00:00Z

The effect of thrombolysis in acute myocardial infarction on infarct size, left ventricular function, clinical course and patient survival was studied in a randomized trial comparing thrombolysis (269 patients) with conventional treatment (264 control patients). All 533 patients were admitted to the coronary care unit within 4 hours after the onset of symptoms related to the infarction. Baseline characteristics were similar in both groups. Informed consent was requested only of patients allocated to thrombolysis; no angiography was performed in 35. The infarct-related artery was patent in 65 patients and occluded in 169. Recanalization was achieved in 133 patients. The median time to angiographic documentation of vessel patency was 200 minutes after the onset of symptoms. The clinical course in the coronary care unit was more favorable after thrombolysis. Infarct size, estimated from myocardial enzyme release, was 30% lower after thrombolysis. In patients admitted within 1 hour after the onset of symptoms the reduction of infarct size was 51%, in those admitted between 1 and 2 hours it was 31% and in those admitted later than 2 hours it was 13%. Left ventricular function measured by radionuclide angiography before hospital discharge was better after thrombolysis (ejection fraction 48 +/- 15%) than in control patients (44 +/- 15%). Similar improvement was observed in patients with a first infarct only (thrombolysis 50 +/- 14%, control subjects 46 +/- 15%), in patients with anterior infarction (thrombolysis 44 +/- 16%, control subjects 35 +/- 14%) and in those with inferior infarction (thrombolysis 52 +/- 12%, control subjects 49 +/- 12%). Similar results were obtained by contrast angiography. Mortality was lower after thrombolysis. After 28 days 16 patients allocated to thrombolysis and 31 control patients had died. One year survival rates were 91 and 84%, respectively. On the other hand, nonfatal reinfarction occurred more frequently after thrombolysis (36 patients) than in control subjects (16 patients). Early thrombolysis by intracoronary streptokinase leads to a smaller infarct size estimated by enzyme release, preserves left ventricular function at the second week and leads to improved 1 year survival.

Hoe heroperatie te voorkomen bij een reeds bestaande bypass op een coronaire bypass (Article)

1986-01-01T00:00:00Z

Coronary angioplasty of the unstable angina related vessel in patients with multivessel disease (Article)

1986-01-01T00:00:00Z

This study is a retrospective analysis of the efficacy of percutaneous transluminal coronary angioplasty of the ischaemia-related vessel in patients with unstable angina. Forty-three patients had multivessel disease with dilatation of the ischaemia-related vessel only (group I; partial revascularization) while 111 patients had single vessel disease only (group II; total revascularization). The initial success rate in both groups was identical (88 versus 88%). The need for emergency coronary artery bypass surgery was similar in the two groups (group I 12% versus group II 9%; NS). The total post PTCA myocardial infarction rate (despite urgent CABG) was also similar in the two groups (group I 9% versus group II 10%; NS). The results of electrocardiographic exercise testing and Thallium-201 scintigraphy provide objective evidence for incomplete revascularization in group I. The maximum workload achieved was lower, and the frequency of exercise induced angina, ST-segment depression and reversible perfusion defect was higher than in group II. Moreover, at 6 months follow-up the recurrence rate of angina pectoris rate was higher in group I than in group II (29% versus 16% P less than 0.05). It is concluded that dilatation of the ischaemia related vessel only in patients with unstable angina and multivessel disease is as effective in the management of the acute phase of unstable angina as is dilatation of the ischaemia related vessel in patients with single vessel disease. However, due to only partial revascularization the recurrence rate of angina pectoris is higher.

Coronary angioplasty for early postinfarction unstable angina (Article)

1986-01-01T00:00:00Z

Coronary angioplasty was performed in 53 patients in whom unstable angina had reoccurred after 48 hr and within 30 days after sustained myocardial infarction. Single-vessel disease was present in 64% of the patients and multivessel disease in 36%. The preceding myocardial infarction had been small to moderate in size in the majority of the patients. The left ventricular ejection fraction was more than 50% in 80% of the patients. Forty-five patients were refractory to pharmacologic treatment; eight were initially stabilized but once again became symptomatic with light exertion. Angioplasty was performed in 35 patients 2 to 14 days and in 18 patients 15 to 30 days after infarction (average 12 +/- 7 days after infarction). The initial success rate was 89% (47/53). The success rate of the patients treated at 2 to 14 days was lower (29/35, 83%) than that of patients treated at 14 to 30 days (18/18, 100%) but did not reach statistical significance (p less than .06). There were no deaths related to the procedure. In four of the six failures, emergency bypass surgery was performed and two patients sustained a myocardial infarction. Furthermore, a myocardial infarction complicated the angioplasty procedure in two other patients; thus the overall procedure-related myocardial infarction rate was 8% (4/53). At 6 months follow-up 26% (14/53) of all the patients who underwent angioplasty had recurrence of angina, which was successfully treated with repeat angioplasty, bypass surgery, or medical therapy. There were no late deaths. Late myocardial infarction occurred in two patients. Thus the total myocardial infarction rate after angioplasty at 6 months was 11% (6/53 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative angiography of the left anterior descending coronary artery: correlations with pressure gradient and results of exercise thallium scintigraphy (Article)

1985-01-01T00:00:00Z

To evaluate, during cardiac catheterization, what constitutes a physiologically significant obstruction to blood flow in the human coronary system, computer-based quantitative analysis of coronary angiograms was performed on the angiograms of 31 patients with isolated disease of the proximal left anterior descending coronary artery. The angiographic severity of stenosis was compared with the transstenotic pressure gradient measured with the dilation catheter during angioplasty and with the results of exercise thallium scintigraphy. A curvilinear relationship was found between the pressure gradient across the stenosis (normalized for the mean aortic pressure) and the residual minimal area of obstruction (after subtracting the area of the angioplasty catheter). This relationship was best fitted by the equation: normalized mean pressure gradient = a + b . log [obstruction area], r = .74. The measurements of the percent area of stenosis (cutoff 80%) and of the transstenotic pressure gradient (cutoff 0.30) obtained at rest correctly predicted the occurrence of thallium perfusion defects induced by exercise in 83% of the patients.

Predictive value of early maximal exercise test and thallium scintigraphy after successful percutaneous transluminal coronary angioplasty (Article)

1985-01-01T00:00:00Z

Restenosis of the dilated vessel after percutaneous transluminal coronary angioplasty can be detected by non-invasive procedures but their ability to predict later restenosis soon after a successful angioplasty as well as recurrence of angina has not been assessed. A maximal exercise test and myocardial thallium perfusion scintigraphy were, therefore, performed in 91 asymptomatic patients a median of 5 weeks after they had undergone a technically successful angioplasty. Primary success of the procedure was confirmed by the decrease in percentage diameter stenosis from 64(12)% to 30(13)% as measured from the coronary angiograms and in the trans-stenotic pressure gradient (normalised for mean aortic pressure) from 0.61(0.16) to 0.17(0.09). A clinical follow up examination (8.6(4.9) months later) was carried out in all patients and a late coronary angiogram obtained in 77. The thallium perfusion scintigram showing the presence or absence of a reversible defect was highly predictive for restenosis whereas the exercise test was not. The positive predictive value of an abnormal scintigram was 82% compared with 60% for the exercise test (ST segment depression/or angina or both at peak workload). Angina or a new myocardial infarction occurred in 60% of patients with abnormal and in 21% of patients with normal scintigrams.

Early detection of restenosis after successful percutaneous transluminal coronary angioplasty by exercise-redistribution Thallium scintigraphy (Article)

1985-01-01T00:00:00Z

The value of exercise testing and thallium scintigraphy in predicting recurrence of angina pectoris and restenosis after a primary successful transluminal coronary angioplasty (PTCA) was prospectively evaluated. In 89 patients, a symptom-limited exercise electrocardiogram (ECG) and thallium scintigraphy were performed 4 weeks after they had undergone successful PTCA. Thereafter, the patients were followed for 6.4 +/- 2.5 months (mean +/- standard deviation) or until recurrence of angina. They all underwent a repeat coronary angiography at 6 months or earlier if symptoms recurred. PTCA was considered successful if the patients had no symptoms and if the stenosis was reduced to less than 50% of the luminal diameter. Restenosis was defined as an increase of the stenosis to more than 50% luminal diameter. The ability of the thallium scintigram (presence of a reversible defect) to predict recurrence of angina was 66%, vs 38% for the exercise ECG (ST-segment depression or angina at peak workload). Restenosis was predicted in 74% of patients by thallium scintigraphy, but only in 50% of patients by the exercise ECG. Thus, thallium scintigraphy was highly predictive but the exercise ECG was not (p less than 0.005). These results suggest that restenosis had occurred to some extent already at 4 weeks after the PTCA in most patients in whom it was going to occur.

Elective PTCA of totally occluded coronary arteries not associated with acute myocardial infarction; short-term and long-term results (Article)

1985-01-01T00:00:00Z

Of 652 consecutive patients referred for coronary angioplasty between September 1980 and March 1984, 49 patients presented with total or functional 'occlusion' of the involved vessel. Total vessel occlusion was defined as absent anterograde filling beyond the lesion. Functional occlusion was defined as faint, late anterograde opacification of the distal segment in the absence of a discernible luminal continuity. In 39 patients, the total or functional occlusion represented a progression, without acute myocardial infarction, of a previously diagnosed stenotic lesion. The maximal potential duration of occlusion was estimated to be 4 weeks or less in 21 patients, more than 4 to 8 weeks in 12, and more than 8 weeks in 16. Dilation of the occluded artery was attempted in the left anterior descending coronary artery in 30 patients, in the right coronary artery in 8, in the circumflex coronary in 7 and in 4 jumpgrafts. For the whole group, angioplasty was successful in 28 patients (57%). The primary success rate with the functionally occluded vessel (81%) was significantly higher than with the total occlusion (45%). In 33 patients with an occlusion estimated to be of 8 weeks or less, angioplasty was successful in 65%. In the 16 patients with an occlusion estimated to be of 8 weeks or less, angioplasty was successful in 65%. In the 16 patients with an occlusion estimated to be of more than 8 weeks duration, dilation was successful in 44%. Of the 21 patients in whom angioplasty was unsuccessful, 11 required surgery (1 urgent with persistent pain and ST elevation and 10 elective). Ten patients were maintained on medical treatment. Of the 28 patients in whom angioplasty was successful, 10 patients had recurrence of symptoms during follow-up (1-42 months). Four were kept on medical therapy, three required bypass surgery and three underwent repeat percutaneous transluminal coronary angioplasty (PTCA). After primary success, late angiographic studies obtained in 20 out of 28 patients showed reocclusion in 8. In conclusion, elective PTCA of totally occluded coronary arteries is feasible but the primary success rate is lower (57%) than that associated with conventional lesions. The long-term clinical results following successful angioplasty are satisfactory (64%), but the incidence of reocclusion is higher (40%).

Comparison of preoperative, operative and postoperative variables in asymptomatic or minimally symptomatic patients to severely symptomatic patients three years after coronary artery bypass grafting: analysis of 423 patients (Article)

1985-01-01T00:00:00Z

During a follow-up period of 3 years, among a consecutive series of 423 patients who gave informed consent for recatheterization both 1 and 3 years after coronary artery bypass grafting, the incidence of severely symptomatic patients with New York Heart Association class III or IV was 19% (79 of 423). The predictive value of approximately 80 clinical, angiographic and perioperative variables was too low to be of clinical value. Adverse clinical outcome was associated with a high closure rate of the grafts. Forty-six percent of the patients could not undergo reoperation because of unsuitable coronary anatomy. With intensive medical therapy half of these patients improved to functional class I or II, while of those patients who were reoperable 32% improved to class I or II with intensive pharmacologic treatment instead of reoperation. The nonresponders underwent reoperation, which resulted in improvement of symptoms to functional class I or II in most (83%).

Emergency coronary angioplasty in refractory unstable angina (Article)

1985-01-01T00:00:00Z

We performed percutaneous transluminal coronary angioplasty as an emergency procedure in 60 patients with unstable angina pectoris that was refractory to treatment with maximally tolerated doses of beta-blockers, calcium antagonists, and intravenous nitroglycerin. The initial success rate for angioplasty was 93 per cent (56 patients). There were no deaths related to the procedure, although total occlusion occurred in four patients. Despite emergency bypass grafting, all four sustained a myocardial infarction. All the patients were followed for at least six months. Late cardiac death occurred in one patient, whereas eight had recurrent angina pectoris. There was no progression to myocardial infarction. The restenosis rate was 28 per cent (13 of 46) in the patients with initially successful coronary angioplasty who had repeat angiography. Improved cardiac functional status after sustained successful coronary angioplasty was demonstrated by an almost normal capacity on bicycle exercise testing and the absence of ischemia during thallium isotope studies in 80 per cent. We conclude that emergency percutaneous transluminal coronary angioplasty may be useful for the treatment of selected patients with unstable angina pectoris who are unresponsive to intensive pharmacologic treatment.

Early angiography after myocardial infarction: what have we learned? (Article)

1985-01-01T00:00:00Z

Effect of intracoronary thrombolytic therapy on global and regional left ventricular function. A three year experience with randomization (Article)

1985-01-01T00:00:00Z

The effect of myocardial reperfusion on regional left ventricular function has been quantitated by analysis of segmental wall motion in 185 patients enrolled in a randomized trial comparing thrombolysis with conventional treatment in patients with acute myocardial infarction. When analyzing the hemodynamic data on an "intention to treat" basis we found a significant preservation of left ventricular function after thrombolytic therapy when compared to conventional treatment. In addition, the wall motion analysis showed that a significant improvement of regional function in the "infarct zone" was observed in inferior infarction as well as in anterior infarction, although significant changes in regional function of the remote "non infarct zone" were observed at the acute as well as at the chronic stage. However, our follow-up data indicate that as yet it has not been resolved whether this method of treatment does indeed improve prognosis in patients with acute myocardial infarction. Accordingly, we maintain the view that such invasive treatment should not be generally applied until more follow-up data become available from larger randomized trials.

Values and limitations of transstenotic pressure gradients measured during percutaneous coronary angioplasty (Article)

1985-01-01T00:00:00Z

The pressure gradient across coronary stenoses is measured routinely during angioplasty. Due to the finite size of the angioplasty catheter within the stenotic cross section, the remaining luminal area is further reduced and the transstenotic gradient may be overestimating the "true" pressure drop. This "true" pressure gradient can be approximated from the mean coronary blood flow and the stenosis geometry from theoretical models. Goal of this study was to assess the values and limitations of the in vivo measurements of the pressure gradient versus the calculated values. Therefore, flow in the great cardiac vein was measured in 13 patients before and/or after angioplasty of a proximal left anterior descending stenosis, not filled by collaterals. The Poiseuille and turbulent contributions to flow resistance were determined from stenosis geometry assessed by quantitative coronary angiography. A fourfold increase in the luminal area (from 0.7 mm2 pre- to 2.8 mm2 post angioplasty) was associated with a fourfold decrease in the in vivo measured transstenotic gradient (from 59 mm Hg pre- to 13 mm Hg post angioplasty). The occlusion area and the measured gradient were linearly correlated: gradient = 69-17 X occlusion area (r = 0.76). However, as expected, the transstenotic gradient systematically overestimated the theoretical gradient calculated from the laws of fluid dynamics. A nonlinear relation was found between the calculated gradient P and the occlusion area As: P = 15 X As-2 (r = 0.87).

Haemodynamic effects of intravenous cibenzoline in patients with coronary heart disease (Article)

1984-01-01T00:00:00Z

The effect of a single dose of cibenzoline ( (diphenyl 2,2 cyclopropyl)--2 imidazoline, Cipralan ), a new compound with antiarrhythmic properties was studied in 14 patients undergoing routine heart catheterization for suspected coronary artery disease. The effect of the drug on dP/dt, Vmax TP, Vce, negative dP/dt, heart rate (HR), left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), cardiac index (CI) and systemic vascular resistance (SVR) was measured before and after drug administration. A significant decrease in left ventricular isometric contraction parameters was manifested immediately after injection, with its maximal effect 2 to 5 min after injection. An increase in HR, a decrease in LVSP, a decrease in CI and an increase in SVR were observed; LVEDP was not significantly altered, nor was negative dP/dt. The effect of the drug on Vmax TP and LVEDP was also examined during two atrial pacing stress tests ( APST ) done before and 10 to 20 min after drug administration. Although the negative inotropic action of the drug was apparent during the second APST , the effect was less pronounced at higher paced heart rates. No difference in the two tests was found between the maximal paced heart rate, nor was there a difference in the angina threshold. Finally the plasma level of the drug and the changes in certain parameters were compared. A positive correlation was found between the plasma level and dP/dt, Vmax TP and cardiac index.

Left ventricular performance, regional blood flow, wall motion, and lactate metabolism during transluminal angioplasty (Article)

1984-01-01T00:00:00Z

The response of left ventricular function, coronary blood flow, and myocardial lactate metabolism during percutaneous transluminal coronary angioplasty (PTCA) was studied in a series of patients undergoing the procedure. From four to six balloon inflation procedures per patient were performed with an average duration per occlusion of 51 +/- 12 sec (mean +/- SD) and a total occlusion time of 252 +/- 140 sec. Analysis of left ventricular hemodynamics in 19 patients showed that the relaxation parameters, peak negative rate of change in pressure, and early time constants of relaxation, responded earliest to short-term coronary occlusion (peak effect at 17 +/- 7 sec) while other parameters, such as peak pressure, left ventricular end-diastolic pressure, and peak positive rate of change in pressure, responded more gradually, suggesting a progressive depression of myocardial mechanics throughout the procedure. Left ventricular angiograms, available for 14 patients, indicated an early onset of asynchronous relaxation concurrent with the early response in peak negative dP/dt and the time constant of early relaxation. All hemodynamic functions fully recovered within minutes after the end of PTCA. Mean blood flow in the great cardiac vein and proximal coronary sinus and the hyperemic response were measured in 20 patients. Before PTCA mean flow in the great cardiac vein was 69 +/- 17 ml/min and in the coronary sinus it was 129 +/- 34 ml/min. Reactive hyperemia (great cardiac vein) was 55% after the first PTCA and 91% after the third. A more pronounced reaction was observed when the residual functional coronary stenosis was reduced in subsequent dilatations. Arteriovenous lactate difference appeared constant during the first two occlusions (control +0.11 mmol/liter, first PTCA -0.87 mmol/liter, and second PTCA -0.82 mmol/liter) and did not increase during subsequent occlusions. Within minutes after the procedure lactate balance was again positive, demonstrating the reversibility of the metabolic disturbances after repeated ischemia. The results of this study indicate that there is no permanent dysfunction of global or regional myocardial mechanics, myocardial blood flow, or lactate metabolism after PTCA with four to six coronary occlusions of 40 to 60 sec.

Assessment of percutaneous transluminal coronary angioplasty by quantitative coronary angiography: diameter versus densitometric area measurements (Article)

1984-01-01T00:00:00Z

Cineangiograms of 138 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) were analyzed with a computer-based coronary angiography analysis system. The results before and after dilatation are presented. In a first study group (120 patients), the severity of the obstructive lesions derived from the automatically detected contours was evaluated in absolute terms and in percent-diameter reduction. In a second group of patients, 18 coronary lesions were selected for their extreme severity and symmetric aspect before angioplasty as assessed from multiple views. In the second group, the densitometric percent-area stenosis was used to assess the changes in cross-sectional area after PTCA and was compared with the circular percent-area stenosis computed from the diameter measurements. Before PTCA, a good agreement exists between the densitometric percent-area stenosis and the circular percent-area stenosis. After PTCA, important discrepancies between these 2 types of measurements are observed. It is suggested that these discrepancies in results after PTCA can be accounted for by asymmetric morphologic changes in luminal cross section, which cannot be assessed accurately from diameter measurements in a single-plane view.

Left ventricular function during transluminal angioplasty: a haemodynamic and angiographic study (Article)

1984-01-01T00:00:00Z

The response of left ventricular function, was studied in a series of patients undergoing percutaneous transluminal coronary angioplasty (PTCA). From 4 to 6 balloon inflations procedures per patient were performed with an average duration per occlusion of 51 +/- 12 sec (mean +/- SD), total occlusion time 252 +/- 140 sec. Analysis of left ventricular (LV) haemodynamics showed that the relaxation parameters peak negative rate of change in pressure and the early time constant of relaxation responded earliest to acute coronary occlusion while other parameters such as peak pressure, LV end-diastolic pressure, and peak positive rate of change of pressure responded more gradually and suggested a progressive depression in myocardial mechanics during the entire procedure. LV angiogram available in 14 patients indicate an early onset of asynchronous relaxation concurrent with the early response in peak -dP/dt and the time constant of early relaxation. All haemodynamic parameters fully recovered within minutes after the end of PTCA. The results of this study indicate no permanent dysfunction to global or regional myocardial mechanics, after PTCA with 4 to 6 coronary occlusions each lasting 40 to 60 seconds.

Is transluminal coronary angioplasty mandatory after successful thrombolysis? Quantitative coronary angiographic study (Article)

1983-01-01T00:00:00Z

Practical guidelines for treatment with beta-blockers and nitrates in patients with acute myocardial infarction (Article)

1983-01-01T00:00:00Z

Treatment of a patient with myocardial infarction might include opiates and sedatives to reduce pain and anxiety, heparin, antiarrhythmic drugs, diuretics which aim at improvement of myocardial function and drugs which might reduce the ischemic area at risk and thus mortality such as beta-blockers, vasodilators and possibly calcium antagonists. Obviously a selection of these and other therapeutic agents should be made for each individual patient. Guidelines for such a selection are presented in this paper. These are based on assessment of the hemodynamic state in a given patient: heart rate, blood pressure and presence or absence of heart failure as determined by non-invasive examination or by hemodynamic monitoring with a pulmonary artery catheter. An attempt should be made to reach an optimal hemodynamic state quickly, preferably within one hour of admission to the coronary care unit: a heart rate between 60 and 80 b.p.m., a systolic blood pressure between 100 and 140 mmHg and absence of signs of heart failure. For this purpose fast-acting intravenous drugs should be employed. Possibly myocardial preservation could also be achieved by prompt recanalization of an occluded coronary artery. At present, however, this is still an experimental procedure which should be further investigated.

Reoperation after aortocoronary bypass procedure. Results in 53 patients in a group of 1041 with consecutive first operations (Article)

1983-01-01T00:00:00Z

Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%.

The haemodynamic effect of intravenous flecainide acetate in patients with coronary artery disease (Article)

1983-01-01T00:00:00Z

Flecainide acetate has been shown to be a potent antiarrhythmic agent which is active for more than 8 h, whether given intravenously or orally. However, the negative inotropic effect demonstrated in animal studies could hamper the potential clinical utility of the drug. Ten patients with coronary artery disease but without cardiac failure were given intravenous flecainide (2 mg/kg). Stroke index (SI), left ventricular systolic pressure (LVP), end diastolic pressure (EDP) and LV contractility indices (max dP/dt, VCE 40 mm Hg, peak VCE, Vmax from total pressure (TP] were measured immediately before and 10 min after flecainide, under resting conditions and during atrial pacing with heart rates up to 133 +/- 4.2 beats/min (mean +/- s.e. mean). It is demonstrated that flecainide has a negative inotropic effect, not only under resting conditions, but also less apparently during pacing-induced tachycardia. The effect appears to be dose-related and may result in a reduction of cardiac performance.

Tien jaar coronairachirurgie; resultaten bij 1041 patienten, geopereerd in het Thoraxcentrum te Rotterdam (Article)

1983-01-01T00:00:00Z

Angina pectoris, one to 10 years after aortocoronary bypass surgery (Article)

1983-01-01T00:00:00Z

The incidence of angina pectoris (AP) after bypass surgery was assessed in 1041 patients operated on consecutively between 1971 and 1980. Of the 977 survivors, 920 (94%) participated in the study with a followup time varying from 1 to 10 years (mean 3.5 years). Post-operative angina pectoris was present at 1 year in 277 patients (30%), at 3 years in 46%, at 8 years in 50%. The pain limited usual physical activities in 17.5%, 30% and 25%, respectively at these times. Nonetheless, 89% of the respondents felt improved by surgery. Factors without predictive value for late outcome were sex, number of pre-operative diseased vessels, and pre-operative ejection fraction. A correlation was found between post-operative AP and younger age at surgery in the males only (P less than 0.001); between AP and patency rate of the bypass graft (P less than 0.005) and with the status of the coronary arterial tree at three years post-operatively (P less than 0.001) in both sexes. The percentage of patients with recurrent AP increased with time after surgery up to 3 years, but remained stable thereafter. In conclusion, post-operative AP seems initially related to decreased functioning of the bypass graft, later to progression of coronary sclerosis in the native circulation.

Clinical course after attempted thrombolysis in myocardial infarction. Results of pilot studies and preliminary data from a randomized trial (Article)

1982-01-01T00:00:00Z

Coronary recanalization in acute myocardial infarction: immediate results and potential risks (Article)

1982-01-01T00:00:00Z

Sequential intracoronary streptokinase and transluminal angioplasty in unstable angina with evolving myocardial infarction (Article)

1982-01-01T00:00:00Z

The effect of intracoronary thrombolysis with streptokinase on myocardial thallium distribution and left ventricular function assessed by blood-pool scintigraphy (Article)

1982-01-01T00:00:00Z

The effect of recanalization of the occluded coronary artery in acute myocardial infarction on left ventricular function (Article)

1982-01-01T00:00:00Z

Effets hémodynamiques de la nifédipine après injection intraveineuse ou intracoronarienne (Article)

1981-01-01T00:00:00Z

Coronary artery atherosclerosis: severity of the disease, severity of angina pectoris and compromised left ventricular function (Article)

1981-01-01T00:00:00Z

Intra aortic balloon pumping in myocardial infarction and unstable angina (Article)

1980-01-01T00:00:00Z

From 1972 to 1979 intra aortic balloon pumping (IABP) was attempted in 181 patients; catheter insertion failed in 13 (8%). More complications occurred with prolonged treatment but all three lethal complications (2%) were related to catheter insertion. Seventy-six patients had clinical cardiogenic shock after myocardial infarction (CSMI). Haemodynamically, 23 were classified as preshock: 15 (66%) could be weaned, 12 (53%) survived over 3 months; whereas only 27/51 patients (51%) haemodynamically classified as shock could be weaned and 21 (40%) survived over 3 months. Of forty-two patients with refractory angina at rest, 41 had prompt relief of pain after IABP, and subsequently underwent coronary artery bypasss grafting (CABG). Perioperative infarction rate was 8% (4/41), perioperative mortality was 7% (3/41). Total infarction rate was 11% (5/42), and total mortality 7% (3/41). Pain relief was prompt in 14/17 patients (82%) with refractory angina after infarction. Pain persisted in three patients: all three sustained an infarction, one died. Two patients were excluded from surgery. Twelve patients underwent CABG; none died, none developed MI. In eight patients persistence of pain suggested a slowly evolving MI, IABP abolished pain in seven. Conclusion: IABP has demonstrated its efficacy both in pump failure and in refractory ischaemia. However, its use is not without risks.

Intracardiac right-to-left shunts demonstrated by two-dimensional echocardiography after peripheral vein injection (Article)

1979-01-01T00:00:00Z