Effects of intraaortic balloon pumping on coronary hemodynamics after coronary angioplasty in patients with acute myocardial infarction.

It has been reported that intraaortic balloon pumping can prevent reocclusion after coronary angioplasty for acute myocardial infarction. The speculated mechanism has been the production of markedly enhanced diastolic coronary perfusion pressure; however, most studies have reported that intraaortic balloon pumping has little effect on coronary blood flow. To assess the effectiveness of this procedure, we studied 12 patients with acute anterior myocardial infarction who were undergoing coronary angioplasty and intraaortic balloon pumping. After successful angioplasty, coronary blood flow velocity was measured with a coronary Doppler catheter before and during intraaortic balloon pumping. Although mean coronary blood flow velocity was unchanged, intraaortic balloon pumping increased peak coronary blood flow velocity from 34.6 +/- 5.0 cm/sec (mean +/- SEM) to 46.7 +/- 5.8 cm/sec (p < 0.005). Such an increase in peak coronary blood flow velocity seemed to be a mechanism by which intraaortic balloon pumping could prevent reocclusion after coronary angioplasty for acute myocardial infarction.     

Treatment of in-stent restenosis with excimer laser coronary angioplasty

Diffuse in-stent restenosis remains an important problem in percutaneous transluminal coronary angioplasty (PTCA). In this trial, we studied the early and mid-term outcomes of excimer laser coronary angioplasty (ELCA) on diffuse in-stent restenosis. ELCA was performed in 23 patients (19 males). The mean length of the lesions was 14.3 +/- 3 mm and the mean age was 58 +/- 7 years. The minimal lumen diameter (MLD) was measured by on-line quantitative coronary angiography. Before the procedure, MLD was 0.9 +/- 0.4. The Q/non-Q-wave myocardial infarction (MI), coronary artery bypass graft (CABG), PTCA, and mortality were recorded during the procedure and at 6 months follow up. The fluence of laser emission was 45 mj/m2 and the repetition rate was 25 pulses per second. Adjunctive balloon angioplasty was performed in all of the cases at a mean 7 +/- 2 atm pressure. The procedure was successfully performed in all of the cases. Type-B dissection developed, after ELCA in 1 patient (4%). Perforation, death, cerebrovascular accidents, emergency CABG, PTCA or Q/non-Q wave myocardial infarction were not observed. MLD was 0.9 +/- 0.4 mm before ELCA, 1.8 +/- 0.9 mm (P<0.05) after ELCA, and 3.1 +/- 0.7 mm after PTCA. At 6 months follow up, there were 2 (8.7%) Q-wave myocardial infarctions and 2 (8.7%) recurrent anginal pain cases. Control angiography was obtained in 20 cases (87%). Control angiography was not accepted by 3 patients. Their maximal exercise test was negative. Angiographic restenosis was observed in 6 cases (30%). The rate of target lesion revascularization (TLR) was 5 of 23 (22%) in the patients treated with ELCA. It is concluded, ELCA is a safe and efficient debulking technology for treating diffuse in-stent restenosis.     

Emergency Coronary Stenting with Wiktor Stent Ñ Immediate and Late Results

In case of failed angioplasty, coronary stenting has gradually emerged as a non-surgical method to restore vessel patency and optimize coronary blood flow. There is still little clinical and angiographic information on the use of radiopaque single loose interdigitating wire stents in angioplasty complicated by threatened or acute closure. Seventy-one patients received Wiktor stents after threatened vessel closure in 53 cases and acute closure in 18 cases. Stent delivery was successful in 98%. In-hospital death occurred in 1 case (1.4%). Stents occlusion were faced in 10 cases (14%), of which 6 presented early and 4 late after the procedure. Urgent bypass surgery was needed in 9 cases (12%) and 7 patients (10%) developed acute myocardial infarction. Serious bleeding complications occurred in 7 cases (10%) and vascular repair was performed in 4 patients (5%). During a follow-up of 20 +/- 10 months, 2 patients died, no myocardial infarction was observed and recurrence of angina was noted in 17 patients (24%). Angiographic analysis showed an acute gain in minimal lumen diameter of 1.71 +/- 0.22 mm and a late loss of 0.63 +/- 0.17 mm. Angiographic restenosis (diameter stenosis > 50%) presented in 20% of patients. Therefore, Wiktor stenting yields similar results than currently used stents in acute closure and strictly defined threatened vessel closure following angioplasty.     

Comparison of effectiveness of excimer laser angioplasty in patients with acute coronary syndromes in those with versus those without normal left ventricular function

Depressed left ventricular (LV) ejection fraction (EF) adversely affects procedural outcome during percutaneous coronary revascularization. This study examined the acute results, effectiveness, and safety of excimer laser coronary angioplasty (ELCA) in patients with acute coronary ischemic syndromes whose LVEF was depressed (<40%) versus those with preserved LVEF. One hundred patients with acute coronary syndromes (51 with unstable angina and 49 with acute myocardial infarction) underwent ELCA. Twenty-five patients (group 1) (29 lesions; 72% thrombotic) had decreased LVEF (mean 28 +/- 6%) and 75 patients (group 2) (81 lesions; 60% thrombotic) had preserved LVEF (mean 53 +/- 8%). Group 1 had a higher incidence of 3-vessel disease, Q-wave acute myocardial infarction, cardiogenic shock, diabetes, and hypertension. High laser success (87% group 1 vs 93% group 2, p = NS) and procedural success (93% group 1 vs 98% group 2, p = NS) were achieved in both groups. Minimal luminal diameter in group 1 increased from 0.7 +/- 0.5 to 1.4 +/- 0.5 mm after the laser procedure and finally to 3.0 +/- 0.4 mm; in group 2, minimal luminal diameter increased from 0.7 +/- 0.4 to 1.3 +/- 0.5 mm after the procedure to a final of 3.0 +/- 0.5 mm. The laser energy vaporized 75% of thrombus burden from the target lesion in group 1 versus 79% in group 2 (p = NS). Thrombolysis In Myocardial Infarction flow in group 1 increased from 1.4 +/- 1.2 to 2.7 +/- 0.7 by laser and finally to 2.9 +/- 0.3, and in group 2 from 2.0 +/- 1.0 to 2.8 +/- 0.6 after the laser procedure to a final of 2.9 +/- 0.4. There were no deaths, emergency bypass surgeries, strokes, or acute vessel closures in either group. Thus, ELCA is a safe and feasible revascularization modality for patients with acute coronary syndromes whose LVEF is depressed. The laser energy vaporizes a large thrombus burden from the treated plaque. Angiographic intracoronary thrombus does not adversely affect device and procedural success in these select patients.     

Coronary angioplasty in the acute phase of myocardial infarction in a low-volume center

The efficacy of coronary angioplasty in the treatment of acute myocardial infarction was assessed in a low volume centre. Between January 1994 and May 1999, 148 consecutive patients (mean age 59 years, 81% men) with acute myocardial infarction, admitted within 12 hours, were included in this retrospective analysis. On admission, 14% of patients were in cardiogenic shock. The average time between the onset of chest pain and arrival at hospital was 244 +/- 183 mins. Reperfusion (TIMI 3 flow) was obtained on average 111 +/- 60 mins after arrival at hospital and 81 mins after informing the on-call team. After angioplasty, residual stenosis < 50% was obtained in 91% of cases. TIMI 3 flow was obtained in 85% of cases (TIMI 2 + 3 in 93% of cases). Over the years, the delay before treatment decreased and the results of angioplasty improved. In the last 79 patients, residual stenosis < 50% was obtained in 95% of cases, TIMI 3 flow in 87% of cases (TIMI 2 + 3 in 97% of cases). The stenting rate increased from 16% before 1997 to 61% thereafter. The hospital mortality was 4%. Direct or salvage angioplasty in the first 12 hours of myocardial infarction in some low volume centres may be carried out safely with intervention times and success rates comparable to those reported in the literature.     

Percutaneous laser-facilitated thrombectomy: an innovative, easily applied, and effective therapeutic option for recanalization of acute and subacute thrombotic hemodialysis shunt occlusions.

PURPOSE: To report our experience with excimer laser-facilitated recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts. METHODS: Twenty-one patients (16 women; mean age 54+/-19 years, range 31-76) presented with acute and subacute thrombotic occlusions of their hemodialysis shunts (4 Cimino, 17 prosthetic; 18 forearm, 3 upper arm); mean occlusion time was 4.1+/-3 days (range 1-14), and the thrombotic occlusion measured a mean 17.4+/-9 cm (range 5-27). Fresh thrombus was observed in addition to the total shunt occlusion in all cases. All patients were treated initially with a pulsed ultraviolet (308-nm) excimer laser. Eighteen (85.7%) patients received adjunctive local thrombolysis for treatment of residual thrombus. Nineteen (90.5%) patients underwent angioplasty of the underlying anastomotic stenosis. RESULTS: The angiographic occlusion was reduced from 100% to 63%+/-28% after laser treatment and to 36%+/-18% after 1 hour of thrombolytic therapy (20 mg tissue plasminogen activator). TIMI flow increased significantly from grade 0 to 2.7+/-0.5 following laser ablation (p<0.001) and to 3.0+/-0.2 upon completion of the angioplasty procedure (p>0.001 versus baseline). The immediate procedural success was 95.2% (20/21). Detectable thrombotic embolization and laser-related complications were not observed in any case. Primary patency was 85%; 3 patients had abnormal Doppler flow within 6 weeks and underwent reintervention (secondary patency 100%). All successfully treated shunts were usable for further dialysis at the 6-week follow-up. CONCLUSION: Percutaneous excimer laser-facilitated thrombus vaporization is safe and effective for recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.     

Laser balloon angioplasty: clinical, angiographic and histologic results

Laser balloon angioplasty combines conventional coronary angioplasty with laser energy to transiently heat vascular tissue. Laser balloon angioplasty, was performed in 21 patients (aged 56 +/- 13 years), including 10 patients treated urgently after acute failure of conventional angioplasty and 11 patients treated with elective laser balloon angioplasty. Immediately after conventional angioplasty, laser doses (1 to 10 doses of 205 to 380 J each) were delivered during inflation of the laser balloon to a pressure of 4 atm. Seven (70%) of 10 patients with acute failure of conventional angioplasty were successfully treated with laser balloon angioplasty, but 3 (30%) were unsuccessfully treated with the laser procedure and required emergency coronary artery bypass surgery. In all three failures, the 3 mm laser balloon angioplasty catheter was not the optimal size for the vessel. In the 11 patients treated with elective laser balloon angioplasty (reference diameter 2.94 +/- 0.22 mm), the minimal luminal diameter increased from 0.45 +/- 0.25 to 1.85 +/- 0.46 mm after conventional angioplasty and to 2.44 +/- 0.29 mm after laser balloon angioplasty (p less than 0.001). This corresponded to a decrease in diameter stenosis from 84 +/- 9% before to 35 +/- 16% after conventional angioplasty and to 15 +/- 10% after laser balloon angioplasty (p less than 0.001). There were no instances of myocardial infarction, emergency coronary artery bypass surgery or death and no acute complications related to delivery of laser energy in this group. Follow-up coronary angiography was performed 5.5 +/- 1.1 months after laser balloon angioplasty in 18 patients discharged from the hospital after a successful procedure. Ten patients (56%) had angiographic restenosis, defined as recurrent diameter stenosis greater than 50%. Six patients were subsequently treated by directional coronary atherectomy, which revealed intimal proliferation indistinguishable from that in patients with restenosis after conventional angioplasty. In conclusion, laser balloon angioplasty may be effective in sealing severe coronary dissections and reversing abrupt closure associated with failed conventional angioplasty. After uncomplicated conventional angioplasty, laser balloon angioplasty improves immediate luminal dimensions, but restenosis appears to be mediated by intimal hyperplasia, similar to that seen after conventional angioplasty.     

Myocardial infarction and disseminated lupus erythematosus

Myocardial infarction is an underestimated complication of disseminated lupus erythematosus (DLE). Its features, treatment and prognosis are poorly understood. From June 1988 to December 2002, out of 1572 consecutive patients admitted during the first hours of acute myocardial infarction with ST elevation, 7 (5 women, aged 38 +/- 7 years) had DLE. The commonest risk factor was smoking (N = 4). There was a higher incidence of anterior infarction (N = 5). The infarct occurred 7 +/- 5 years after diagnosis of DLE. There were other complications of DLE in all cases. Three patients had antiphospholipid syndromes. The culprit artery was usually the left anterior descending (N = 5). The lesions included stenosing atheroma (N = 5) and extensive thrombosis (N = 5). The coronary disease was usually limited to a single vessel (N = 5). Revascularisation procedures include pre-hospital thrombolysis (N = 3) followed by immediate angioplasty (N = 2) or primary angioplasty (N = 4). TIMI grade 3 flow was obtained in all cases, 278 +/- 162 min after the onset of symptoms. The clinical course was characterised by acute reocclusion in 3 patients, recurrent in 2 patients with an antiphospholipid syndrome, and death in 1 case. Acute myocardial infarction occurs in already complicated cases of DLE, in young patients, associating atherosclerosis and extensive thrombosis. The risk of early reocclusion after reperfusion is high, especially in cases with the antiphospholipid syndrome.     

Long-term recovery of left ventricular function after primary angioplasty for acute myocardial infarction.

AIMS: To investigate changes in left ventricular function in the first 6 months after acute myocardial infarction treated with primary angioplasty. To assess clinical variables, associated with recovery of left ventricular function after acute myocardial infarction. METHODS: Changes in left ventricular function were studied in 600 consecutive patients with acute myocardial infarction, all treated with primary angioplasty. Left ventricular ejection fraction was measured by radionuclide ventriculography in survivors at day 4 and after 6 months. Patients with a recurrent myocardial infarction within the 6 months were excluded. RESULTS: Successful reperfusion (TIMI 3 flow) by primary angioplasty was achieved in 89% of patients. The mean ejection fraction at discharge was 43.7%+/-11.4, whereas the mean ejection fraction after 6 months was 46.3%+/-11.5 (P<0.01). During the 6 months, the mean relative improvement in left ventricular ejection fraction was 6%. An improvement in left ventricular function was observed in 48% of the patients; 25% of the patients had a decrease, whereas in the remaining patients there was no change. After univariate and multivariate analysis, an anterior infarction location, an ejection fraction at discharge < or =40% and single-vessel disease were significant predictors of left ventricular improvement during the 6 months. CONCLUSIONS: After acute myocardial infarction treated with primary angioplasty there was a significant recovery of left ventricular function during the first 6 months after the infarction. An anterior myocardial infarction, single-vessel coronary artery disease, and an initially depressed left ventricular function were independently associated with recovery of left ventricular function. Multivessel disease was associated with absence of functional recovery. Additional studies, investigating complete revascularization are needed, as this approach may potentially improve long-term left ventricular function.     

Percutaneous transluminal coronary angioplasty in patients with prior myocardial infarction: angioplasty at a distance from the prior infarct zone

Patients undergoing coronary angioplasty who have had a prior transmural myocardial infarction in the distribution of a contralateral coronary artery are considered a high-risk group because of potentially severe left ventricular dysfunction if an ischemic complication occurs. The purpose of this study was to evaluate the safety and efficacy of coronary angioplasty in 28 patients with prior myocardial infarction remote from the artery undergoing dilatation. Prior myocardial infarction was defined by the presence of pathologic Q waves on ECG or segmental akinesis on ventriculography. Angioplasty was successful in 30 of 33 lesions (91%) and in 25 of 28 patients (89%). Mean stenosis diameter was reduced from 91% +/- 7% to 28% +/- 16%; mean translesional gradient after angioplasty was 6 +/- 5 mm Hg. No patient developed severe hemodynamic deterioration from transient coronary occlusion during balloon inflation or from an acute ischemic complication. Three patients underwent coronary artery bypass surgery after unsuccessful angioplasty. There were no new Q wave infarctions or deaths. The results of coronary angioplasty in patients with prior infarction were compared with those of 203 patients without prior remote infarction. Primary success and occurrence of major complications were comparable in both groups. At a mean follow-up of 12 +/- 6 months, 18 of the 25 patients (72%) who underwent initially successful dilatation have remained symptom free with angioplasty alone. Therefore, coronary angioplasty is a suitable therapeutic procedure in carefully selected patients with angina pectoris and prior myocardial infarction at a distance from the site of angioplasty.     

Comparative efficacy of primary angioplasty with stent implantation and thrombolysis in restoring basal coronary artery flow in acute ST segment elevation myocardial infarction: quantitative assessment using the corrected TIMI frame count

Following thrombolysis and primary percutaneous transluminal coronary angioplasty (PTCA) for acute ST segment elevation myocardial infarction, basal flow in the culprit artery is known to influence prognosis. The purpose of this study was to determine if differences exist in basal flow in culprit and nonculprit coronary arteries in patients with acute ST segment elevation myocardial infarction who were treated with thrombolysis or primary PTCA with stent implantation. Twenty patients were randomized to thrombolysis (with recombinant tissue plasminogen activator) and 24 to primary PTCA with stent implantation within 3 hours of onset of acute ST segment elevation myocardial infarction. Coronary angiography was performed 90-120 minutes after thrombolysis or immediately after PTCA with stent implantation and again at 18-36 hours after intervention in both groups. Patients who failed to achieve thrombolysis in myocardial infarction (TIMI) grade 2 or 3 flow were excluded. The corrected TIMI frame count was used as the index of basal coronary artery flow. Early after intervention the mean corrected TIMI frame count in the culprit coronary artery was significantly lower in the primary PTCA with stent group (27.4 +/- 7.7 frames) than in the thrombolysis group (39.8 +/- 10 frames, p < 0.001). Eight thrombolysis patients (40%) and 20 primary PTCA patients (83%, p < 0.01) achieved TIMI grade 3 flow early after intervention. By 18-36 hours after intervention there were no significant differences in the mean correct TIMI frame count between the thrombolysis and primary PTCA with stent groups. There were no significant differences in the mean corrected TIMI frame count between these two groups in the nonculprit coronary artery, either early after intervention or at 18-36 hours. In successfully reperfused coronary arteries following acute ST segment elevation myocardial infarction, primary angioplasty with stent implantation reestablished TIMI grade 2 or 3 flow faster and more effectively than thrombolysis did.     

Recurrence of stenosis after first and repeat coronary angioplasty. Clinical and angiographic follow-up

The incidence of restenosis after initially successful first coronary angioplasty and the long-term effectiveness of repeat angioplasty for recurrence were examined on the basis of data on 282 consecutive patients with successful angioplasty. Primary success of first coronary angioplasty was obtained in 86% of patients and major complications (death, acute myocardial infarction and emergency coronary bypass surgery) occurred in 5% of patients. Control coronary angiography 10 +/- 6 months after successful angioplasty in 195 patients documented recurrence of stenosis in 33%. Repeat angioplasty was attempted in 52 patients with a primary success of 92%. One patient sustained an acute infarction as a complication of the procedure (2%). Control coronary angiography 7 +/- 4 months after a successful second procedure in 28 patients documented a second recurrence of stenosis in 39%. Recurrence rates after first and second coronary angioplasty were comparable (33 vs 39%, ns) but, for lesions of the left anterior descending coronary artery, recurrence was observed more frequently after second than after first angioplasty (47 vs 31%, p less than 0.05). Restenosis after second angioplasty, but not after first, was more frequent in women than in men. Patients with second recurrence were older than those with continuing angiographic success (59 +/- 8 vs 50 +/- 12 years, p less than 0.05). Recurrence was treated by a third coronary angioplasty in 5 patients, with success in all. Clinical follow-up 8 +/- 6 months after the last successful procedure was available for all 43 patients with repeat angioplasty who did not cross over to coronary surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospective analysis of possible myocardial damage or hemolysis occurring as a result of prolonged autoperfusion angioplasty in humans.

OBJECTIVES. The purpose of this study was to further explore the procedural safety of prolonged (15-min) dilation using an autoperfusion coronary angioplasty balloon by assessing the degree of myocardial damage or hemolysis, if any, occurring as a result of the procedure. BACKGROUND. Prolonged balloon inflation periods may be beneficial during percutaneous transluminal coronary angioplasty. The duration of standard balloon angioplasty is often limited by the occurrence of myocardial ischemia due to loss of anterograde blood flow. Autoperfusion angioplasty allows continued myocardial perfusion during balloon inflation and has previously been shown to reduce but not totally eliminate acute myocardial ischemia during prolonged (up to 15 min) balloon inflation. The risk of intravascular hemolysis as a result of autoperfusion angioplasty has not yet been fully delineated. METHODS. Sixty-two consecutive patients (76% men; mean age 58 years) undergoing elective percutaneous transluminal coronary angioplasty of a single lesion were studied. Serial electrocardiographic and creatine kinase MB isoenzyme data were examined to detect evidence of myocardial damage. Tests for hemolysis (plasma free hemoglobin, serum haptoglobin and serum lactate dehydrogenase) were obtained in the 1st 24 consecutive patients. RESULTS. Inflation time was 14 +/- 4 min (mean +/- SD) and the procedure was successful (less than or equal to 50% residual lesion stenosis) in 59 patients (95%). Electrocardiographic evidence of myocardial infarction (greater than 1 mm persistent ST segment depression, greater than 1 mm ST segment elevation or new Q waves) was not observed in any patient. Cardiac enzyme assays were within the normal range in all patients. No evidence of hemolysis was found in the 24 consecutive patients studied. CONCLUSIONS. We conclude that prolonged autoperfusion angioplasty can be performed in patients without clinical evidence of myocardial damage or hemolysis.     

Initial results and 6 month clinical follow-up after implantation of a silicon carbide coated coronary stent]

INTRODUCTION AND OBJECTIVES: To present the initial Spanish experience with the Tenax coronary stent, a laser sculpted from high-precision 316L stainless steel coated with hydrogen rich amorphous silicon carbide that reduces thrombogenecity and improves biocompatibility. PATIENTS AND METHODS: From July 1998 to July 1999, 206 patients (62 +/- 5 years) underwent implantation of 231 Tenax stents in 9 centers as the only revascularization procedure. The most frequent clinical indication was unstable angina (66%), and most of the lesions were complex (class B2 and C). The target vessels were the left anterior descending (51%) and right coronary arteries (36%). The ejection fraction was < 0.5 in 19% cases. RESULTS: Revascularization was complete in 70%, elective in 80%, and the implantation was direct in 25% of the cases. The procedure was successful in all the lesions, reducing stenosis from 62 +/- 16 to 16 +/- 10% and increasing the minimal luminal diameter from 0.81 +/- 0.40 to 2.61 +/- 0.59 mm. The TIMI flow was reduced in 30%, but normalized after the stent in all but one case. The incidence of cardiac events was minimal: 1 acute thrombosis (0.5%) resolved by a new angioplasty and 1 non-Q myocardial infarction (0.5%). At the 6-month clinical follow-up 10% of the patients presented complaints of angina greater than class II, and a new angioplasty was carried out in 1.9% of these cases. CONCLUSION: Clinical and angiographic data suggest that the hydrogenated silicon carbide coating of the Tenax coronary stent may indeed play a beneficial role in patient outcome, and should therefore be evaluated by prospective clinical trials.     

Elective coronary stent implantation in cardiogenic shock complicating acute myocardial infarction: in-hospital and six-month clinical and angiographic results.

Effective treatment of patients with acute myocardial infarction and cardiogenic shock depends on restoring persistent patency of the infarct-related artery. Coronary stenting, reducing abrupt or delayed closure related to dissection and suboptimal result, may improve PTCA results in cardiogenic shock. Eighteen patients (14 males and 4 females, mean age 59 +/- 7 years), referred to catheterization laboratory for acute myocardial infarction and shock, had elective stent implantation during 14 primary and 4 rescue PTCA. Time delay between shock onset and PTCA was 4.1 +/- 3 hr (range, 30 min to 12 hr). The IRA was LAD in seven patients (38%), LCx in two (11%), and RCA in eight (45%). One patient (5.%) had distal LMCA occlusion. Stent deployment was successful in 100% of patients and resulted in TIMI 3 flow in 13 (72%) patients. In 13 (72%) cases, cardiogenic shock gradually resolved and the patients were discharged alive. Five patients (28%) died because of irreversible hemodynamic deterioration without evidence of reinfarction. At 6-month follow-up, all the discharged patients were alive and no patient had reinfarction or recurrent angina. Heart transplant was required in one patient 5 months after stenting because of refractory congestive heart failure. Angiography demonstrated patency of all the coronary arteries treated, with TIMI 3 flow in all patients. Stent restenosis rate was 30%, and target lesion revascularization with CABG or re-PTCA was not required in any case. LV function improved from 39% +/- 15% to 51% +/- 15% (P < 0.01). Elective coronary stenting is an effective treatment for acute myocardial infarction complicated by cardiogenic shock and may improve acute and long-term survival.     

Outcome after combined reperfusion therapy for acute myocardial infarction, combining pre-hospital thrombolysis with immediate percutaneous coronary intervention and stent.

BACKGROUND: Primary therapies in acute myocardial infarction (thrombolysis and angioplasty) have inherent limitations which may be overcome by combining them. So far, no trial has demonstrated a clinical benefit in combining mechanical and pharmacological treatment strategies. METHODS: From January 1995 to December 1999, out of 1010 patients admitted to our institution for acute myocardial infarction, 148 had received pre-hospital full dose thrombolysis within 12 h of onset. One hundred and thirty-one patients were included and underwent immediate angioplasty and stenting when suitable, independent of the infarct-artery patency (TIMI grade flow 0-3). In-hospital outcome was assessed and clinical information was collected for a mean (+/-SD) of 2+/-1 years. RESULTS: Ninety-minute angiography revealed a patent (TIMI grade 3) infarct artery in 65 patients (49%). Immediate angioplasty was performed in 119 patients (91%) with stent implantation in 114 (96%). Angioplasty achieved TIMI 2, 3 flow in 98%, and complete patency (TIMI 3 flow) in 92%. Six other patients underwent deferred revascularization (surgery in one patient, angioplasty in five) and six received medical treatment. Stent thrombosis and reinfarction occurred in three patients (2.3%). In-hospital death occurred in six patients (4.6%), including four patients presenting with cardiogenic shock. Major bleeding was observed in 2.3% of cases. No patient had emergency surgery. Freedom from death and reinfarction at 2 years was 90% and freedom from death, reinfarction and target vessel revascularization was 83%. CONCLUSION: A strategy of combined reperfusion using full dose pre-hospital thrombolysis and immediate angioplasty with stent implantation in a non-selected acute myocardial infarction population is safe and achieves high and early patency rates. This preliminary experience suggests that a combined strategy in acute myocardial infarction may have a significant impact on both early and long-term outcomes.     

Outcome after prolonged balloon inflations of greater than 20 minutes for initially unsuccessful percutaneous transluminal coronary angioplasty.

Prolonged balloon inflation with or without autoperfusion techniques is a common initial approach to major dissection or abrupt occlusion after percutaneous transluminal coronary angioplasty (PTCA). To assess such a strategy in the setting of unsuccessful angioplasty, 40 patients who underwent prolonged balloon inflations of greater than 20 minutes between January and July of 1991 after initially unsuccessful angioplasty were studied. These patients (median age 59 years) underwent PTCA for progressive or unstable angina (16[40%]), symptomatic or asymptomatic residual stenosis after myocardial infarction (10[25%]), acute myocardial infarction (3[8%]), stable angina (3[8%]), reinfarction (2[5%]), and other indications (6[15%]). The significant stenoses were primarily in the proximal and midportions of the right coronary (53%), left anterior descending (30%) and left circumflex (17%) coronary arteries. Before prolonged balloon inflation, the longest single inflation was 11 +/- 6 minutes and the total time of all inflations was 17 +/- 8 minutes (mean +/- standard deviation). Stenosis was reduced from 91 +/- 9 to 68 +/- 16% before prolonged inflation. After prolonged balloon inflation of 30 +/- 9 minutes, the residual stenosis was 47 +/- 21% (p = 0.0001 vs value before prolonged inflation). Furthermore, improvements in the appearance of filling defects or dissections, or both, occurred in 19 patients (48%). Procedural success was obtained in 32 of 40 patients (80%). Coronary bypass grafting was performed in 8 patients (20%): 4 after unsuccessful PTCA (3 emergently) and 4 electively after initially successful PTCA. Although 5 patients had creatine kinase-MB elevations greater than 20 IU/liter after the procedure, only 1 sustained a Q-wave myocardial infarction. There were no deaths in the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial infarction in young women: apropos of 22 cases. Pathogenic and prognostic approach]

The authors report 22 cases of myocardial infarction documented by selective left ventriculography and coronary angiography in women under 45 years of age. The average age in this series was 36 +/- 6.8 years. Two patient groups were identified: Group I (n = 16) with the cardiovascular risk factor of oral contraception (mean age 33.9 +/- 5 years); and Group II (n = 6) comprising older patients (43.8 +/- 1.8 years) with a high prevalence of other risk factors (hyperlipidaemia, hypertension, diabetes). Myocardial infarction tended to be the inaugural event in Group I (9 out of 16 cases, 56.2%) whereas symptoms of effort angina were commonly observed in Group II (5 out of 6 cases, 83.3%). Coronary angiography showed more severe coronary lesions in Group II (score 1.5) than in Group I (score 0.75) in which isolated, single vessel disease mainly affecting the left anterior descending artery or normal coronary angiography was observed. Thrombolytic therapy was performed in 8 patients: percutaneous transluminal angioplasty was performed in 4 patients in the first month with a primary success in 3 cases. Coronary bypass surgery was performed in 1 case. The outcome during follow-up lasting 44.5 +/- 4.2 months was mainly favourable as 15 of the 20 patients had no secondary complications. Nevertheless, 2 patients died in the hospital period (1 from cardiogenic shock and 1 from complications of transluminal coronary angioplasty), 2 patients died less than 1 year after acute myocardial infarction (1 sudden death, 1 cardiogenic shock). Although oral contraception was withdrawn in all cases, many women continued to smoke.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous coronary excimer laser-assisted balloon angioplasty: initial clinical and quantitative angiographic results in 50 patients

The initial clinical experience and quantitative angiographic results of percutaneous coronary excimer laser-assisted balloon angioplasty are described for 55 lesions in 50 patients. With use of a xenon chloride (308 nm) excimer laser generator and 1.5 to 1.75 mm catheters, excimer laser angioplasty was attempted at 135 ns pulse width, 25 to 40 Hz repetition rate, 2 to 5 s laser delivery time and 30 to 60 mJ/mm2 energy fluence. Laser success (greater than 20% reduction in absolute percent diameter stenosis) was achieved in 41 (75%) of 55 lesions, with 100% subsequent balloon angioplasty success (less than 50% residual stenosis). By quantitative digital caliper technique, the percent diameter stenosis (mean +/- SE) was reduced from 81 +/- 1% to 50 +/- 3% after excimer laser angioplasty (p less than 0.001) and to 20 +/- 1% after balloon angioplasty (p less than 0.001); minimal luminal diameter increased from 0.56 +/- 0.04 to 1.46 +/- 0.08 mm (p less than 0.001) and 2.03 +/- 0.07 mm (p less than 0.001), respectively. By videodensitometric techniques, the percent area stenosis decreased from 86 +/- 2% to 54 +/- 3% after excimer angioplasty (p less than 0.001) and to 26 +/- 3% after balloon angioplasty (p less than 0.001). There were no perforations, need for emergency bypass surgery or deaths. The overall incidence of abrupt closure (3.6%), dissection (1.8%), embolization (1.8%), filling defect (6%), myocardial infarction (5.5%), side branch occlusion (3.6%) or spasm (3.6%) was infrequent and more related to subsequent balloon angioplasty than to the laser procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty in octogenarians: comparisons to coronary bypass surgery

Coronary angioplasty was performed in 74 patients 80 years of age and older (mean 83 +/- 3). Single vessel coronary disease was present in 34% and multivessel coronary disease in 66%. Angioplasty of a single vessel was performed in 51 patients (69%), while 23 (31%) had angioplasty of multiple vessels. Angioplasty was successful in 59 of 74 patients (80%). Angioplasty was unsuccessful but uncomplicated in 12 (16%) due to (unyielding) calcified lesions or (impassable) old occlusions. Of these 12, 8 were discharged on medical therapy and 4 underwent elective uncomplicated bypass surgery prior to discharge. Three (4%) patients required emergency coronary bypass surgery due to abrupt vessel closure during the angioplasty procedure, with one hospital death (1.4%). Follow-up (mean 24 +/- 22 months) was obtained in all patients. Of the 59 successful angioplasty patients, late mortality was 10% (cardiac 7% and non-cardiac 3%). Survival and survival without myocardial infarction were both 90%; survival without either infarction or bypass surgery was 86%. Actuarial 3-year survival was 91% and 3-year freedom from death, infarction or bypass surgery was 87% by life-table analysis. Repeat angioplasty for restenosis was performed in 7 patients (12%) without complications.