Stent deployment failure: reasons, implications, and short- and long-term outcomes.

Stents have revolutionized percutaneous coronary interventions (PCI), impacting on both acute and long-term results. However, despite improvements in stent design, stent deployment failure is not an unusual event. The aim of the present study was to assess the frequency and causes of stent deployment failure, as well as the outcome of these patients. Between 1997 and 2001, a total of 3,537 patients underwent stent-assisted PCI and delivery of 5,275 stents was attempted. In the majority of patients (118; 78.1%), stenting was performed as provisional; in the remaining 33 (21.8%) as a bailout procedure. A total of 175 (3.3%) stents in 151 (4.3%) patients failed. Failure to deliver the stent to the lesion site was the main cause in 139 patients (92%) and failure either to expand adequately the stent or premature disengagement of the stent from the balloon in only 12 patients (8%). Peripheral stent embolization occurred in 10 (0.3%) patients. Deployment of a different stent in place of the failed one was attempted in 122 patients and was successful in the majority (108; 88.5%). In-hospital major adverse cardiac events were observed in six patients (4%): three patients required emergency coronary artery bypass surgery, two had a myocardial infarction (MI), and one patient underwent urgent repeat coronary intervention. At a mean follow-up of 32.2 +/- 17.7 months, 22 major adverse cardiac event occurred in 17 patients (11.2%): 1 cardiac death, 3 patients had an MI, and 18 patients required target vessel revascularization. One-year event-free survival for the whole group was 91.2%. Patients with stent embolization did not have any major adverse cardiac or vascular events. Thus, the rate of stent deployment failure in our series was 3.3%, mainly due to failure to deliver the stent to the site. Another stent was successfully deployed in the majority of cases and these patients had favorable short- and long-term outcomes.     

Intracoronary stents in small vessels: short- and long-term clinical results

OBJECTIVE: To assess the clinical outcome of coronary stenting in small vessels (< 3 mm), using high pressure balloon inflation and antithrombotic therapy. PATIENTS AND METHODS: Vessel size was evaluated as < or >= 3 mm at the time of procedure and measured at a level of maximum diameter. We studied 234 consecutive patients with placement of 300 stents in 279 lesions, comprising 84 stents implanted in 79 lesions located at small vessels (< 3 mm). The standard technique included high pressure balloon inflation (15.8 +/- 2.2 atm) and post-stenting therapy with ticlopidine and aspirin for one month. Mean clinical follow-up was 17.6 +/- 10 months. RESULTS: Procedural success without in-hospital major events was similar between small and large vessels (93.7 in vessels of < 3 mm vs 93.5% in vessels of >= 3 mm; p = NS). Three small vessels presented subacute stent thrombosis, whereas no thrombotic occlusion occurred in large vessels (3.8 vs 0%; p = 0.006). At two years, small vessels had a lower target lesion revascularization free survival (73.6 vs 90.3%; p < 0.001). After adjustment for variables previously described as predictors of stent restenosis, in multivariate analysis, a small vessel of < 3 mm was an independent predictor of target lesion revascularization (p = 0.001). Although patients with stenting in small vessels did not differ significantly in terms of any cause death (4.6 vs 3.8%; p = 0.7) nor acute myocardial infarction (2.9 vs 1.1%; p = 0.3), event-free survival was significantly lower after two years (69.1 vs 86.6%; p < 0.001). CONCLUSIONS: As compared to large vessels, coronary stenting in small vessels was performed with similar rates of initial success, however they had a significantly worse clinical long-term outcome in terms of subacute stent thrombosis and target lesion revascularization at follow-up.     

On-label and off-label use of drug-eluting stents: comparison of short- and long-term outcomes

In this retrospective study, we compared the in-hospital and long-term outcomes of the on-label and off-label uses of drug-eluting stents.From April 2003 through June 2007, 1,538 patients underwent percutaneous coronary intervention with a drug-eluting stent (sirolimus or paclitaxel) at Tehran Heart Center. Off-label implantation of the drug-eluting stent was as implemented on the basis of specific clinical and procedural characteristics set forth in our text. There were 708 patients in the on-label group and 830 in the off-label group.Baseline characteristics were not significantly different between the groups. Histories of non-ST-segment-elevation myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting were more prevalent in the off-label group. Both groups had similar procedural and in-hospital complications. The follow-up rate at 1 year was 93.1% in the on-label group and 93.3% in the off-label group. During that period, the occurrence of major adverse cardiac events was not significantly different between the groups. After 1 year between the respective on- and off-label uses of the sirolimus-eluting and paclitaxel-eluting stents, and after adjustment for diabetes mellitus, myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting, there was no remarkable difference in the occurrence of major adverse cardiac events (hazard ratio, 0.688; 95% confidence interval, 0.365-1.295; P=0.2463) or target-vessel revascularization (hazard ratio, 0.69; 95% confidence interval, 0.291-1.636; P=0.3993).We found that off-label use of drug-eluting stents was safe after 1 year and that such use was not associated with increased in-hospital myocardial infarction or death.     

Drug-eluting stents: caution and concerns for long-term outcome

Recent publications on drug-eluting stents (DES) report a significant reduction in restenosis rates as compared to bare metal stents in patients mostly with single vessel disease. We have recently observed however, late stent thrombosis following CYPHER DES implantation. The patient developed a hypersensitivity reaction around stent struts limited to the polymer with aneurysmal dilatation and extensive inflammation of the arterial wall in the absence of vascular healing. This incidence promotes a cautionary view and perhaps supports the use of DES only in high-risk patients.     

Neonatal dexamethasone therapy: short- and long-term consequences.

The discovery of the adrenal steroid hormones was one of the momentous events of science and medicine in the 20th century, highlighted by the awarding of the Nobel Prize in Physiology or Medicine to Kendall, Reichstein and Hench in 1950. Therapy using endogenous and synthetic corticosteroids was thought to be a miracle cure for several illnesses. We now recognize the many short- and long-term side effects of glucocorticoid therapy in neonates, children and adults, including growth retardation, insulin resistance, metabolic disturbances, cognitive and psychological problems, rapidly-progressing and profound osteoporosis, and iatrogenic Cushing's syndrome. Significant attention is now being paid to the long-term consequences of glucocorticoid therapy in premature and full-term neonates.     

Effect of Ebstein's anomaly on short- and long-term outcome of surgically treated patients with Wolff-Parkinson-White syndrome.

BACKGROUND. Ebstein's anomaly is the most commonly occurring congenital abnormality associated with the Wolff-Parkinson-White (WPW) syndrome. However, the effects of Ebstein's anomaly on the risks and benefits of surgical ablation of accessory pathways in patients with WPW syndrome are unknown. METHODS AND RESULTS. This study compared the long-term outcome of 38 WPW patients with Ebstein's anomaly undergoing accessory pathway ablation to a reference population of 384 similarly treated patients without the anomaly. Ebstein's anomaly was mild in 21 patients (55%) and moderate-to-severe in 17 patients (45%). Sixteen patients (42%) required tricuspid valve surgery, and 23 (61%) had an atrial septal defect or patent foramen ovale repaired. Baseline clinical characteristics and preoperative clinical arrhythmias were similar in both groups. Ten-year survival was 92.4% and 91.2% for patients with and without Ebstein's anomaly, respectively (p = NS). During a mean follow-up of 6.2 +/- 3.8 and 5.3 +/- 3.6 years, 82% of patients with and 90% without Ebstein's anomaly had either clinically insignificant or no arrhythmias, and 18% versus 10% reported symptoms suggesting arrhythmias lasting longer than 1 minute, respectively. Atrial fibrillation was reduced postoperatively to 9% (p less than 0.001) in patients with and to 4% (p less than 0.001) in those without the anomaly. Fewer hospitalizations were reported postoperatively by 90% versus 96% of patients with and without Ebstein's anomaly; 9.4% versus 6.0% of patients were disabled at follow-up, respectively (p = NS). CONCLUSIONS. Patients with Ebstein's anomaly are improved significantly after accessory pathway ablation. The presence of this anomaly should not preclude accessory pathway ablation in these patients.     

雷帕霉素洗脱支架对糖尿病患者经皮冠状动脉介入治疗的远期影响

目的分析雷帕霉素洗脱支架(SES)对糖尿病患经皮冠状动脉介入治疗后的远期影响。方法采用回顾性研究方法,在1004．例接受冠状动脉内支架术治疗的冠心病患中,84例糖尿病和250例非糖尿病患置入SES;168例糖尿病和502例非糖尿病患置入普通支架。记录并比较一般临床资料、冠状动脉造影及冠状动脉内支架术情况、远期心脏事件发生率和1年无心脏事件生存率。结果随访期间(平均16．2个月),SES组中糖尿病亚组和非糖尿病亚组的远期心脏事件发生率为4．8％比3．6％,P=0．744;1年无心脏事件生存率为95．0％比96．7％,P=0．602,两亚组差异均无统计学意义。但BMS组中,糖尿病亚组的远期心脏事件发生率显高于非糖尿病组(31.0%比21．7％,P=0．015);两亚组的1年无心脏事件生存率分别为74．2％比86．8％(P=0．001)。结论SES能显改善糖尿病患冠状动脉支架术的远期疗效,降低靶病变再狭窄和远期心脏事件的发生率,提高1年无心脏事件生存率。     

17-alpha-hydroxylase deficiency in three siblings: short- and long-term studies.

We have studied a family (12 members) with 3 patients (2 adult females and 1 pubertal-aged genotypic male) affected by congenital adrenal hyperplasia due to 17-alpha-hydroxylase deficiency, all of whom presented as phenotypically female subjects with lack of sexual development and with hypokalemic hypertension. The baseline hormonal pattern revealed low glucocorticoid levels (17-hydroxyprogesterone, plasma and urinary cortisol, cortisol secretion rate), as well as androgen (testosterone and dehydroepiandrosterone sulfate) and estrogen (17-beta-estradiol) levels, since the defect is present at both adrenal and gonadal levels. As a consequence ACTH, LH, and FSH concentrations were high. Otherwise steroids not requiring 17-alpha-hydroxylation, such as deoxycorticosterone, corticosterone and their 18-hydroxylated compounds, were secreted in excess with the exception of aldosterone whose levels were undetectable; baseline plasma renin activity levels were suppressed. Short-term dexamethasone treatment normalized potassium and reduced blood pressure and the abnormal mineralocorticoid levels. During chronic ACTH suppression with low doses of glucocorticoids (8 years), electrolyte disturbances were corrected, blood pressure was normalized in 2 cases but only reduced in the third; plasma renin activity returned to normal range within four years in all the patients, while urinary aldosterone was normalized only after 8 years of therapy and became partially responsive to posture, ACTH, angiotensin II, and furosemide. The other mineralocorticoids were reduced but remained above the normal range. The HLA-genotyping in all the family members revealed that the gene responsible for 17-alpha-hydroxylase deficiency was not linked to the HLA system. Measurement of plasma steroids (deoxycorticosterone, corticosterone, aldosterone) in this family revealed that the heterozygotes were different from the control population only in their ACTH-stimulated corticosterone levels.     

Impact of total pancreatectomy: short- and long-term assessment

Background

The aim was to assess the outcome of a total pancreatectomy (TP).

Methods

From 1993 to 2010, 56 patients underwent an elective TP for intraductal papillary mucinous neoplasia (n = 42), endocrine tumours (n = 6), adenocarcinoma (n = 5), metastases (n = 2) and chronic pancreatitis (n = 1). Morbidity and survival were analysed. Long-term survivors were assessed prospectively using quality-of-life (QoL) questionnaires.

Results

Five patients developed gastric venous congestion intra-operatively. Post-operative morbidity and mortality rates were 45% and 3.6%, respectively. An anastomotic ulcer occurred in seven patients, but none after proton pump inhibitor therapy. There were five inappropriate TPs according to definitive pathological examination. Overall 3- and 5-year survival rates were 62% and 55% respectively; five deaths were related to TP (two postoperative deaths, one hypoglycaemia, one ketoacidosis and one anastomotic ulcer). Prospective evaluation of 25 patients found that 14 had been readmitted for diabetes and that all had hypoglycaemia within the past month. The glycated haemoglobin (HbA1c) was 7.8% (6.3–10.3). Fifteen patients experienced weight loss. The QLQ-C30 questionnaire showed a decrease in QoL predominantly because of fatigue and diarrhoea, and the QLQ-PAN26 showed an impact on bowel habit, flatulence and eating-related items.

Discussion

Morbidity and mortality rates of TP are acceptable, although diabetes- and TP-related mortality still occurs. Endocrine and exocrine insufficiency impacts on the long-term quality of life.     

Effect of anemia on short- and long-term outcome in patients hospitalized for acute coronary syndromes

Anemia is common in hospitalized cardiac patients and is associated with adverse outcomes. The aim of this study was to identify the association of anemia with early and long-term outcomes in patients with acute coronary syndromes (ACSs). Included were 5,304 consecutive patients (73% men, 61 ± 12 years of age) admitted to a coronary care unit from 1985 through 2008 for ACS. According to the World Health Organization, anemia was defined as serum hemoglobin levels <13 g/dl for men and <12 g/dl for women. Anemia was divided into tertiles to compare mild, moderate, and severe anemia to nonanemia. For trend analyses the study population was categorized in 3 groups: 1985 to 1990, 1991 to 2000, and 2001 to 2008. Outcome measurements were all-cause mortality at 30-days and 20 years. Anemia was present in 2,016 patients (38%), of whom 655 had mild anemia, 717 moderate anemia, and 646 severe anemia. Median follow-up duration was 10 years (range 2 to 25). Compared to nonanemia, adjusted hazard ratios (HRs) for mortality at 30 days were 1.40 for moderate anemia (95% confidence interval [CI] 1.04 to 1.87) and 1.67 for severe anemia (95% CI 1.25 to 2.24). At 20 years HRs were 1.13 for moderate anemia (95% CI 1.01 to 1.27) and 1.39 for severe anemia (95% CI 1.23 to 1.56). In addition, survival during hospitalization improved over time. Compared to 1985 to 1990 adjusted HRs were 0.52 for 1991 to 2000 (95% CI 0.41 to 0.66) and 0.36 for 2001 to 2008 (95% CI 0.25 to 0.51). In conclusion, presence and severity of anemia is an important predictor of higher in-hospital and long-term mortality after ACS. In addition, since the 1980s in-hospital outcome of patients with ACS and anemia has improved.     

Influence of diabetes mellitus on short- and long-term outcome in patients with active infective endocarditis

BACKGROUND AND AIM OF THE STUDY: The incidence and severity of certain infections appear to be increased in patients with diabetes mellitus (DM). The study aim was to evaluate the effect of DM on short- and long-term outcome in patients with active infective endocarditis (IE). METHODS: A total of 151 patients with IE was included and followed up for a mean of 3.1 years. Of these patients, 13 (9%) were diabetics. The outcome of patients with or without DM was compared at short-term (in-hospital) and long-term follow up. RESULTS: Patients with DM were older (66 +/- 11 versus 50 +/- 19 years, p < 0.01) and had a lower frequency of intravenous drug abuse (0 versus 30%, p <0.01) and tricuspid valve involvement (0 versus 20%, p = 0.02) than non-DM patients. Mortality was higher in DM patients both in hospital (31% versus 15%, p = NS) and at a mean follow up of 3.1 years (54% versus 31%, p = 0.002). DM patients also had a significantly higher rate of cardiac failure (69% versus 38%, p = 0.03) and renal failure (62% versus 20%, p <0.01) during hospitalization. Incidences of anatomic complications (abscess, pseudoaneurysm) (15.4% versus 20.3%), valve rupture or perforation (7.7% versus 16.7%) and need for surgical repair (46.2% versus 45.7%) were similar in both DM and non-DM patients. DM, without secondary pathology like renal failure, did not appear to be an independent risk factor for mortality at either short- or long-term follow up. CONCLUSION: Although mortality and morbidity in IE were greater in DM than in non-DM patients, diabetes itself does not constitute an independent risk factor.     

Congenital hypothyroidism: long-term outcome.

Although mental retardation associated with congenital hypothyroidism (CH) is prevented by newborn screening and early treatment, affected children still undergo a brief period of thyroid hormone deficiency reflecting etiology of thyroid disease, illness severity, and treatment factors. Because thyroid hormone is essential for normal brain development and because some processes require thyroid hormone in the period when thyroid hormone was lacking, children with CH treated early may still have subtle neurocognitive deficits. As the period when thyroid hormone is needed differs for different brain regions, there may be different types of deficits depending on when thyroid hormone levels were insufficient. Since 1980, we have been following a large cohort of Toronto-based children with congenital hypothyroidism identified by newborn screening from infancy to adolescence. Early findings revealed a 5-10-point decline in IQ, poorer visuomotor and visuospatial abilities, delayed speech and language development, selective neuromotor deficiencies, and poorer attention and memory skills, which were correlated with different disease and treatment factors. Now a comparison between 48 subjects at adolescence and matched controls indicates that deficits persist in visuospatial, memory, and attention domains and these are correlated with severity of early hypothyroidism. Negative relationships between attention indices and thyroxine (T4) elevations at time of testing also suggest a role for thyroid hormone in the regulation of attention.     

Short- and long-term outcome of balloon angioplasty for compromised side branches after intracoronary stent deployment

During coronary stent deployment there is a risk of compromising side branches, which can result in chest pain. Compromised side branches can be reopened by balloon angioplasty through the side of the stent. In a consecutive series of 10 patients with side-branch compromise and chest pain, balloon angioplasty through the side of the stent resolved the ischemia in all cases. The stented segment showed no deterioration following side-branch angioplasty. Six-month follow-up angiography showed a restenosis in the branch vessel of eight patients. The stented parent vessel restenosed in four patients. Therefore, side-branch balloon angioplasty after coronary stenting for ongoing ischemia is technically feasible and immediately effective. Restenosis of the branch occurs in most cases. Cathet. Cardiovasc. Intervent. 46:421–424, 1999. © 1999 Wiley-Liss, Inc.     

Self-management reduces both short- and long-term hospitalisation in COPD.

The aim of the present study was to assess the long-term impact on hospitalisation of a self-management programme for chronic obstructive pulmonary disease (COPD) patients. A multicentre, randomised clinical trial was carried out involving 191 COPD patients from seven hospitals. Patients who had one or more hospitalisations in the year preceding study enrolment were assigned to a self-management programme "Living Well with COPD(TM)" or to standard care. Hospitalisations from all causes were the primary outcome and were documented from the provincial hospitalisation database; emergency visits were recorded from the provincial health insurance database. Most patients were elderly, not highly educated, had advanced COPD (reflected by a mean forced expiratory volume in one second of 1 L), and almost half reported a dyspnoea score of 5/5 (modified Medical Research Council). At 2 years, there was a statistically significant and clinically relevant reduction in all-cause hospitalisations of 26.9% and in all-cause emergency visits of 21.1% in the intervention group as compared to the standard-care group. After adjustment for the self-management intervention effect, the predictive factors for reduced hospitalisations included younger age, sex (female), higher education, increased health status and exercise capacity. In conclusion, in this study, patients with chronic obstructive pulmonary disease who received educational intervention with supervision and support based on disease-specific self-management maintained a significant reduction in hospitalisations after a 2-year period.     

Prodromal unstable angina in acute myocardial infarction: prognostic value of short- and long-term outcome and predictor of infarct size

BACKGROUND: An estimated 50% of patients with myocardial infarction have prodromal unstable angina. There is controversy over whether prodromal unstable angina identifies a group of patients at lower risk of short- and long-term death and the clinical importance of recording this event. METHODS: Of 207 patients enrolled at a single Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) site, 196 survived the 24 hours after presentation, achieved peak creatine kinase MB concentrations, and were classified as having either abrupt symptom onset or prodromal unstable angina in the 2 weeks before myocardial infarction. Creatine kinase MB peak was used to categorize infarct size as aborted myocardial infarction, minor myocardial damage, or extensive myocardial injury. Follow-up was performed at 24 hours, 30 days, 1 year, and 5 years. Multiple variables, including prodromal unstable angina, time to treatment, age, sex, previous infarction and infarct location, were analyzed for predicting infarct size. Also, these variables plus peak creatine kinase MB level and a combined variable of prodromal unstable angina and peak creatine kinase MB level were examined for predicting survival. RESULTS: Mortality rate was 2.5% within 24 hours, 9.0% at 30 days, 13.5% at 1 year, and 27.1% at 5 years. Patients categorized as either aborted infarction or minor myocardial damage were significantly more likely to have prodromal unstable symptoms (81.3% vs 51.2%, P <.001) and better survival at each follow-up period. Prodromal presentation was the most significant predictor of infarct size category (P =.001). Five-year survival was predicted by age (P <.0001), peak creatine kinase MB level (P =.007), infarct location (P =.009), the combined variables (P =.029), and prodromal unstable angina (P =.017). Prodromal unstable angina had the highest odds ratio for 5-year survival at 3.83 (95% confidence interval 1.27-11.47). CONCLUSIONS: Prodromal unstable angina is a strong predictor of infarct size and survival. Recognizing prodromal unstable angina is important for clinically assessing prognosis.     

Determinants of short- and long-term outcome in patients with respiratory failure caused by AIDS-related Pneumocystis carinii pneumonia

OBJECTIVES: To determine (1) predictors of in-hospital mortality and long-term survival in patients with acute respiratory failure (ARF) caused by acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia (PCP) and (2) long-term survival for patients with ARF relative to those without ARF. METHODS: A retrospective medical chart review was conducted of all cases of PCP-related ARF for which the patient was admitted to the intensive care unit of a single tertiary care institution between 1991 and 1996. Data were extracted regarding physiologic scores, relevant laboratory values, and duration of previous maximal therapy with combined anti-PCP agents and corticosteroids at entry to the intensive care unit. Duration of survival was determined by Kaplan-Meier methods from date of first hospital admission and compared for patients with and without ARF. RESULTS: There were 41 admissions to the intensive care unit among 39 patients, with 56.4% in-hospital mortality. Higher physiologic scores (Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Lung Injury, and modified Multisystem Organ Failure scores) were predictive of in-hospital mortality. Duration of previous maximal therapy also predicted in-hospital mortality (45% for patients with <5 days of previous maximal therapy vs 88% for those with > or =5 days of previous maximal therapy; P = .03). Combining physiologic scores and duration of previous maximal therapy enhanced prediction of in-hospital mortality. There was no difference in long-term survival between patients with PCP with ARF and those without ARF (P = .80), and baseline characteristics did not predict long-term survival. CONCLUSIONS: In-hospital mortality of patients with acquired immunodeficiency syndrome-related PCP and ARF is predicted by duration of previous maximal therapy and physiologic scores, and their combination enhances predictive accuracy. Long-term survival of patients with ARF caused by PCP is comparable to that of patients with PCP who do not develop ARF, and determinants of in-hospital mortality do not predict long-term survival.     

Comparison of allogeneic T cell-depleted peripheral blood stem cell and bone marrow transplantation: effect of stem cell source on short- and long-term outcome.

We report the results of a retrospective single-center study comparing engraftment, acute and chronic GVHD, relapse and survival in patients with malignant hematological disorders transplanted with allogeneic peripheral blood stem cells (alloPBSCT, n = 40) or bone marrow cells (alloBMT, n = 42). All transplants were T cell depleted by in vitro incubation with the Campath-1 monoclonal antibody. Primary graft failure occurred in none of the patients receiving an alloPBSCT compared with 3/42 of the recipients of an alloBMT. In addition, two patients in the alloBMT group showed no platelet engraftment. Recipients of PBSC had a more rapid recovery of neutrophils (median 14 days) compared to BM transplant recipients (median 32 days). Platelet recovery was also accelerated in PBSC recipients compared to BM recipients (11 vs 38 days). There was an increase in the incidence of grade II acute GVHD and chronic GVHD in patients after alloPBSCT (18% and 23%, respectively) compared to patients receiving alloBMT (5% and 8%, respectively). The 2-year cumulative incidence of relapse was similar in both groups (47%). At 6 months after transplantation, transplant-related mortality (TRM) was lower in PBSCT recipients than in BMT recipients. However, at a follow-up of 3 years TRM was similar in both groups. The disease-free survival rate at 3 years after transplantation did not differ between the groups (42% for PBSCT and 41% for BMT recipients). Our results indicate that T cell-depleted alloPBSCT compared to alloBMT is associated with a more rapid hematopoietic reconstitution and a decreased TRM at 6 months follow-up after transplantation. However, at a follow-up of 3 years, no sustained survival benefits were observed.