Delayed coronary occlusion following primary successful angioplasty: Management and outcome

Summary The treatment of delayed coronary occlusion after primary successful percutaneous transluminal coronary angioplasty (PTCA) is more difficult because surgical standby is often not available. The purpose of this study was to assess the therapeutic approaches and outcome of patients with delayed coronary occlusion from 30 to 180 minutes after successful PTCA. A delayed occlusion occurred in 18 (0.9%) (61±11 years; malen=14, femalen=4) out of 2065 consecutive patients after PTCA. In 11 patients the dilated stenoses were located in the left descending artery, while seven patients had the stenosis in the right coronary artery. Twelve patients had unstable or postinfarction angina. The time interval between completion of PTCA and the onset of chest pain was 64±39 minutes. Immediate i.v. nitroglycerin resulted in no relief of the symptoms in any patient. One patient was operated upon at once, and one was given i.v. thrombolysis resulting in pain relief and reversal of ECG changes. The remaining 16 patients returned initially to the catheterization laboratory, where the occluded vessels were opened by mechanical recanalization. Three of them remained in stable condition. Due to impending reocclusion surgery was necessary in four patients and thrombolysis was performed in nine. After thrombolysis the vessel remained open in four patients. The other five needed bypass surgery on the day of PTCA. Myocardial infarction developed in nine patients (maximal CK 673±488 units/l). In conclusion, delayed occlusion after successful PTCA is a rare complication occurring primarily in patients with unstable angina. Mechanical recanalization opened the occluded vessel in most patients, and myocardial infarction was prevented in 50%.Abbreviations PTCA percutaneous transluminal coronary angioplasty - CK creatine kinase - ECG electrocardiogramm - SD standard deviation     

Percutaneous transluminal coronary angioplasty of focal coronary lesions after cardiac transplantation

Summary Transplant coronary artery disease is the greatest impediment to long-term survival beyond the first year after cardiac transplantation. Transplant coronary artery disease shows a heterogeneous angiographic appearance, but focal stenoses can occur alone or at least predominate. Based on an angiographic indication 35 critical focal lesions causing narrowing by 75% or more were treated by PTCA during 23 procedures in seven patients 18–84 months after cardiac transplantation. Three patients each underwent only one procedure and four underwent repeated procedures [2, 3, 4 and 11, respectively]. Primary success was achieved without any complication in 35 of 35 lesions (100%). The mean degree of stenosis was reduced from 86±9% to 28±17% (P<0.001). The rate of restenosis was 18/29 (62%) at a mean of 4 months after angioplasty. Four patients are alive and free of adverse effects (symptoms, myocardial infarction, repeated percutaneous transluminal coronary angioplasty, retransplantation) 16±10 months after their last angioplasty. One patient underwent a successful second heart transplantation 26 months after the first angioplasty. Two patients died, 1 and 31 months after the last angioplasty. In conclusion, percutaneous transluminal coronary angioplasty can be performed safely with an excellent primary success rate in critical focal transplant coronary artery disease. The rate of restenosis is higher than in native coronary artery disease. Long-term follow-up depends on the individually variable accelerated nature of graft atherosclerosis.Abbreviations PTCA percutaneous transluminal coronary angioplasty - TxCAD transplant coronary artery disease - HTX heart transplantation - LAD left anterior decending artery - CFX circumflex artery - RCA right coronary artery     

Changes in N-terminal pro B-type natriuretic peptide concentration: comparative study of percutaneous transluminal coronary angioplasty and off-pump coronary artery bypass graft

The goal of this study was to compare the effects of different reperfusion methods on N-terminal B-type natriuretic peptide (NT-proBNP) in percutaneous transluminal coronary angioplasty (PTCA) or off-pump coronary artery bypass (OPCAB) patients. Fifty subjects were enrolled in the study, 32 patients received PTCA and 18 OPCAB. An NT-proBNP measurement was performed before intervention and at 1, 3, and 7 days after the procedures. NT-proBNP levels were not significantly different before intervention (PTCA group 297+/-147.3 vs. OPCAB group 235+/-167.8 pg/mL, p>0.05). However, 1 day after the procedures, NT-proBNP levels were higher in the OPCAB group (PTCA 375+/-256.4 vs. OPCAB 1,415+/-737.6 pg/mL, p<0.05), after 3 days NT-proBNP reached peak levels (PTCA 480+/-363.0 vs. OPCAB 2,119+/-818.4 pg/mL, p<0.05), and levels were reduced after 7 days (PTCA 292+/-243.7 vs. OPCAB 522+/-334.0 pg/mL, p>0.05). PTCA induced a mild and transient increase in NT-proBNP concentration, but OPCAB caused sustained high NT-proBNP levels during the 7 day postoperatively. However, differences between NT-proBNP levels associated with these two modalities showed a tendency to decrease rapidly postoperatively.     

Percutaneous transluminal coronary angioplasty in a child with Kawasaki disease.

A successful attempt at percutaneous transluminanl coronary angioplasty (PTCA) to relieve stenosis of the mid-portion of the left anterior descending artery was achieved in a 6-year 9-month old boy who had multiple coronary aneurysms and stenosis due to Kawasaki disease. Despite the progression of coronary stenosis he had been well except for the perfusion defect of the anterior wall of myocardium on 99mTc-MIBI SPECT with dipyridamole infusion until PTCA was carried out after 4-year 4-months of the onset of illness. The area of stenosis was 70% before PTCA and 20% after PTCA. No restenosis at the site of PTCA was observed on follow-up angiography at 26 months after PTCA. This successful attempt may indicate that this procedure should be considered early in subclinical stenosis to prevent ischemic cardiac damage.     

Serial changes in QT interval during the course of acute ischemic episode: with special reference to intracoronary electrograms

The change in electrocardiogram (ECG) during percutaneous transluminal coronary angioplasty (PTCA) was investigated by recording both standard 12 lead ECG (surface ECG) and intracoronary electrogram (ic-ECG) before, during and after PTCA with right atrium pacing (80/min). During the ischemia induced by PTCA, the amplitude of QRS complex revealed an initial decrease in amplitude and later increase in ic-ECG, however, it only showed an initial decrease in surface ECG up to 5 minutes, while the QRS interval showed a significant decrease in only in ic-ECG (77 +/- 14 vs 75 +/- 13 msec). The QT interval became shorter with the increase in the duration of ischemia, the difference being statistically significant even for the initial 20 seconds of ischemia in both ic-ECG (398 +/- 27 vs 370 +/- 22) and surface ECG. In the case of acute myocardial infarction, the direction of T wave and QT interval seemed to depend on the degree of reperfusion. Hence, in patients who underwent successful reperfusion therapy the QT interval was lengthened initially and later shortened, cardiac function preserved and T wave normalized in anteroseptal myocardial infarction, while in those who had unsuccessful reperfusion the QT interval was progressively lengthened, cardiac function was not preserved well and T wave was not normalized. Therefore, in patients with a positive T wave the QT interval was shorter (382.4 +/- 42.6 vs 448.7 +/- 29.7 msec), with better fractional shortening (4.24 +/- 2.2 vs 1.95 +/- 1.2) and better left ventricular ejection fraction (68.1 +/- 6.1 vs 52.9 +/- 14.7%) than in the patients with negative T wave in lead V2 in the chronic stage.(ABSTRACT TRUNCATED AT 250 WORDS)     

微创球囊堵闭法建立猪心肌梗死模型及其手术并发症的预防和处理

目的 探讨运用微创冠状动脉球囊堵闭法建立猪急性心肌梗死模型的实验方法及其手术过程中并发症的处理.方法 猪麻醉后经右侧股动脉置入冠状动脉球囊导管至左前降支远端堵闭120 min,直至心电图证实心肌梗死形成.结果21只苏中幼猪均完成了冠状动脉造影及球囊封堵术,1只因术中失血过多在术后饲养过程中死亡,2只因封堵结束撤管时出现缓慢性心律失常和呼吸骤停,经抢救无效死亡.心电图监护显示典型急性心肌梗死图形演变过程,血清肌钙蛋白明显升高且呈动态变化,4周后病理标本显示疤痕形成,切片显示典型心肌梗死病理改变.结论 微创球囊冠状动脉堵闭法为一种简单安全的建立心肌梗死模型的方法,术中并发症的预防及处理是保证存活率的关键.     

Characterization of the nonlinear content of the heart rate dynamics during myocardial ischemia

We develop a method to quantify the changes in heart rate dynamics during local myocardial ischemia induced by a percutaneous transluminal coronary angioplasty procedure (PTCA). The method introduces an index measuring the nonlinear content of the beat-to-beat (RR) time series by using nonlinear time series techniques such as surrogate data analysis and average mutual information.The index is applied to RR data from 67 subjects obtained before, during, and after the ischemic period and shows an increase in the nonlinearity of the cardiac control dynamics during ischemic and reperfusion stages. The nonlinear index is also used to characterize the effects of performing the coronary occlusion at different arteries and distances. We observe that the effect of ischemia becomes larger as the occlusion distance is reduced, and that most of the changes in the nonlinear content of the dynamics occur at long time scales typically related to sympathetic modulation of the cardiac rhythm (6–25 s).     

冠脉成形术缺血性刺激前后血清IL-6、TNF-α水平的变化

目的:冠脉成形术(PTCA)引起的炎症反应始于术后早期。白细胞介素6(IL-6)、肿瘤坏死因子α(TNF-α)是主要的炎性细胞因子。本实验拟通过对比有或没有侧支循环病人PTCA前后IL-6、TNF-α水平的变化,探讨PTCA引起早期炎性反应的机制。方法:参照Leaman冠脉积分系统,对PTCA球囊阻断引起的缺血强度进行量化。计算正常对照组与冠心病组PTCA手术前后的IL-6、TNF-α水平变化,并进行相关性分析。结果:缺血性剌激前IL-6和TNF-α分别为(9.592±1.847)ng/L和(26.959±1.967)ng/L。在剌激后4h分别为(27.423±1.882)ng/L和(78.542±1.573)ng/L,呈显著差异。结论:IL-6、TNF-α是反映PTCA术后早期炎性反应的敏感指标。缺血积分可作为反映PTCA术中缺血/再灌注损伤程度的量化指标。侧支循环可减轻PTCA术后早期炎症反应。     

A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.

BACKGROUND. Despite the widespread use of percutaneous transluminal coronary angioplasty (PTCA), only a few prospective trials have assessed its efficacy. We compared the effects of PTCA with those of medical therapy on angina and exercise tolerance in patients with stable single-vessel coronary artery disease. METHODS. Patients with 70 to 99 percent stenosis of one epicardial coronary artery and with exercise-induced myocardial ischemia were randomly assigned either to undergo PTCA or to receive medical therapy and were evaluated monthly. The patients assigned to PTCA were urged to have repeat angioplasty if their symptoms suggested restenosis. After six months, all the patients had repeat exercise testing and coronary angiography. RESULTS. A total of 107 patients were randomly assigned to medical therapy and 105 to PTCA. PTCA was clinically successful in 80 of the 100 patients who actually had the procedure, with an initial reduction in mean percent stenosis from 76 to 36 percent. Two patients in the PTCA group required emergency coronary-artery bypass surgery. By six months after the procedure, 16 patients had had repeat PTCA. Myocardial infarction occurred in five patients assigned to PTCA and in three patients assigned to medical therapy. At six months 64 percent of the patients in the PTCA group (61 of 96) were free of angina, as compared with 46 percent of the medically treated patients (47 of 102; P less than 0.01). The patients in the PTCA group were able to increase their total duration of exercise more than the medical patients (2.1 vs. 0.5 minutes, P less than 0.0001) and were able to exercise longer without angina on treadmill testing (P less than 0.01). CONCLUSIONS. For patients with single-vessel coronary artery disease, PTCA offers earlier and more complete relief of angina than medical therapy and is associated with better performance on the exercise test. However, PTCA initially costs more than medical treatment and is associated with a higher frequency of complications.     

冠状动脉内放射治疗防止血管成形术后再狭窄的研究进展

再狭窄已经成为经皮冠状动脉腔内成形术(ＰＴＣＡ)广泛应用的最大障碍 ,约 4 0 %～ 60 %的患者在成功的完成ＰＴＣＡ术之后数月内发生再狭窄[1] 。再狭窄的机制非常复杂 ,目前多认为包括以下几方面 :术后血管弹性回缩 ;血管的重塑、平滑肌细胞迁移、增殖、细胞外基质形成新生内膜 ;局部血栓的形成与机化 ;许多细胞因子和生长因子的分泌参与再狭窄的过程[2 ,3] 。针对再狭窄的发生机制 ,许多研究试图通过各种药物进行预防 ,包括肝素和血小板ＧＰＩＩｂ -ＩＩＩａ受体拮抗剂在内的所有药物在临床实践中并未明显降低再狭窄率。支架置入术能够减…     

Cognitive adaptation as a predictor of new coronary events after percutaneous transluminal coronary angioplasty.

OBJECTIVE: We tested whether the psychological components of cognitive adaptation theory would predict new coronary events after a first percutaneous transluminal coronary angioplasty (PTCA). METHODS: A consecutive sample of patients treated successfully with PTCA were enrolled in the study. Of 343 patients approached, 303 (88%) agreed to participate and were interviewed shortly before hospital discharge. We measured the components of cognitive adaptation theory (optimism, self-esteem, and mastery) during the interview. Five patients were excluded from the analysis because of early, in-hospital reocclusion. New cardiac events (coronary artery bypass grafting, PTCA, myocardial infarction, or disease progression) were examined within 6 months of the first PTCA. We obtained 6-month follow-up data on 98% of patients. RESULTS: The cognitive adaptation index predicted new cardiac events, even when demographic variables and medical variables thought to predict restenosis were statistically controlled (p = .02). CONCLUSIONS: These results suggest that persons who respond to their illness by perceiving control over their futures, by having positive expectations about their futures, and by holding a positive view of themselves seem to be at less risk for a new cardiac event after a first PTCA.     

T lymphocyte activation and restenosis after percutaneous transluminal coronary angioplasty.

We investigated the relation between the activation of T lymphocytes and the occurrence of restenosis after percutaneous transluminal coronary angioplasty (PTCA) in 10 stable angina patients. Recent studies have suggested that PTCA causes an inflammatory response, which may affect restenosis after angioplasty. Soluble interleukin-2 receptor (sIL-2R) is a useful marker to evaluate the activation of T lymphocytes. sIL-2R was measured before and 2 h after successful PTCA, and 3-month follow-up coronary angiography was done to observe restenosis. Four of 10 patients showed restenosis. The restenosis group of 4 patients had a higher level of sIL-2R after PTCA than the no-restenosis group of 6 patients (495 vs. 274 U/ml, p < 0.01). This study suggests that sIL-2R may offer prognostic information after elective PTCA and identify a subgroup of patients at high risk for clinical restenosis in a few months.     

Application of the ARMA method to acoustic detection of coronary artery disease

To further explore the application of advanced signal processing techniques to the noninvasive detection of coronary artery disease, 30 patients (10 angioplasty and 20 normal or abnormal) were tested using autoregressive moving average (ARMA) modelling of the disastolic heart sound data. It is during diastole that coronary blood flow is maximum and sounds associated with turbulent blood flow through partially occluded coronary arteries would be loudest. Model parameters (the power spectral density (PSD) functions and the poles of the ARMA method) were used to separate the normal patients from the abnormal patients in the normal/ abnormal study, or to decide whether the recordings were made before or after angioplasty in the angioplasty study. The decisions were made ‘blind’, without knowledge of the actual disease states of the patients for the normal/abnormal study and without prior knowledge of whether a given recording was made before or after angioplasty for the angioplasty study. Results from the angioplasty and the normal/abnormal studies showed that pre- and post-angioplasty records were correctly distinguished in 8 out of 10 cases, and normal and abnormal records were correctly distinguished in 17 of 20 cases. These results also confirmed that high frequency energy above 400 Hz is probably associated with coronary stenosis.     

Effect of angioplasty and grafting on porcine vascular nerves: a potential neurotropic role for endothelin-1

The most commonly performed procedure for treating coronary artery stenosis is percutaneous transluminal coronary angioplasty (PTCA) and, where the vessel lumen is severely narrowed, coronary artery bypass grafting (CABG). In PTCA, regions of atherosclerotic plaques are disrupted, and the vessel lumen increased by inflating a balloon catheter. In CABG an autologous saphenous vein into coronary artery interposition graft is performed in order to bypass occluded regions of epicardial coronary arteries. Both interventions cause varying degrees of vascular damage and the long-term efficacy of these procedures is limited by a high incidence of neointimal formation and subsequent vascular restenosis (Bach et al. 1994; Bryan & Angelini, 1994).
The endothelium-derived constrictor peptide, endothelin-1 (ET-1) (Yanagisawa et al. 1988), also possesses mitogenic activity on vascular smooth muscle cells (Hirata et al. 1989) and has been suggested as playing a role in atherosclerosis (Dashwood et al. 1993; Zeiher et al. 1994) and intimal hyperplasia (Dashwood et al. 1993; Douglas et al. 1994).     

Percutaneous transluminal coronary angioplasty without thrombolytic therapy in acute myocardial infarction

Percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI) was performed in 42 patients (37 males, 5 females, average age 53 years). Recanalization of the stenosed or occluded infarction-related coronary artery was achieved within the first 14 to 50 min from the start of catheterization in 95% of cases. Three patients were transferred for emergency coronary bypass graft surgery (CABG) because of major multiple coronary lesions, immediately after angiographically successful PTCA. One of the patients died in cardiogenic shock. Four patients died between days 5 to 15 of hospitalization. Repeat coronary angiography was done in 27 of the 37 survivors at a mean interval of 2.5 months after AMI. Total reocclusion was found in 6 patients. The recanalized coronary artery had prevented its patency in 78% of the cases; restenosis was found in 5 patients, and was successfully dealt with renewed angioplasty in 3 patients. While the ejection fraction (EF) had remained largely unchanged, there was some improving tendency of left ventricular segmental kinetics, particularly in case of anterior wall infarction. PTCA without thrombolytic therapy seems to provide an effective and relatively prompt recanalizing procedure in the complex management of AMI.     

Technology in interventional cardiology: percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is now capable of providing myocardial revascularization in a majority of patients, but significant problems with the technique remain. It is unsuitable for dealing with diffuse coronary artery disease, chronically occluded vessels may be impossible to disobliterate, and disease of the distal coronary vessel may be difficult to reach with a balloon. Approximately 5 percent of all procedures may be complicated by acute occlusion of the target vessel, usually by dissection of the arterial intima, often resulting in a need for emergency coronary artery bypass surgery (CABG). Furthermore, there is recurrence of the dilated lesion--'restenosis'--in approximately 30 percent of cases in the first 3 to 6 months after PTCA. Advances in this technique, since its introduction in the mid 1970s, have been directed at making initial success more likely, obviating the need for emergency CABG, and reducing the incidence of restenosis.     

Application of adaptive FTF/FAEST zero tracking filters to noninvasive characterization of the sound pattern caused by coronary artery stenosis before and after angioplasty

This article presents a new signal processing application that can be used for acoustical detection of coronary artery disease before and after angioplasty. The adaptive Autoregressive (AR) method based on the FTF/FAEST (Fast transversal filters/Fasta posteriori error sequential techniques) is used to track acoustical behavior associated with coronary occlusions. Using the amplitude trajectory of the second pole pair of this method, 9 out of 10 angioplasty patients were correctly identified using a blind protocol without prior knowledge of whether a given recording was made before and after angioplasty. These results were obtained from signals located between 200 and 300 msec after the end of the second heart sound during the diastolic period.     

冠心病患者介入治疗后血浆新型气体信号分子硫化氢及一氧化氮变化的临床研究

目的研究新型气体信号分子硫化氢（H2S）及一氧化氮（NO）在冠心病患者和冠脉造影正常者血浆中含量的差异及介入治疗对其的影响,探讨其在冠心病发病及介入治疗中的病理生理意义。方法冠心病组40例,造影正常组17例,采用硫敏感法测定术前血浆H2S含量并用Greiss法测定血浆中NO含量,动态监测冠心病患者冠状动脉造影前后、介入治疗后即刻、术后24h和72h血浆H2S、NO含量,分析冠心病组和造影正常组患者血浆H2S、NO含量的差异及介入治疗后血浆H2S和NO的变化。结果冠心病患者血浆H2S、NO含量远低于造影正常组（P均〈0.01）;冠脉双支和多支病变组血浆H2S含量差异无统计学意义（P〉0.05）,但均明显低于单支病变组（P〈0.05和P〈0.01）。不同支数病变冠心病患者血浆NO含量差异无统计学意义。冠脉血管有闭塞组其血浆H2S、NO含量明显低于单纯狭窄组（P均〈0.05）;支架植入术后复查狭窄者NO含量明显低于无狭窄者（P〈0.05）,H2S含量也低于无狭窄者,但差异无统计学意义（P〉0.05）。冠状动脉造影术对血浆H2S、NO含量无影响,但PCI治疗术后即刻H2S、NO含量显著降低;H2S含量术后24h恢复至术前水平,NO含量术后24h降至最低水平,72h仍未恢复至术前水平。结论 H2S和NO可能参与了冠心病的发病过程及介入治疗后急性血管闭塞及再狭窄的发生,血浆H2S含量的高低与冠脉血管病变严重程度相关。     

基于小波变换的心电信号基线矫正方法

本文介绍一种基于小波变换的心电信号基线漂移去除方法。该方法利用小波变换多分辨分析的特性,将含噪声及基线漂移心电信号进行多尺度分解,结果表明,某尺度下的分解信号较好地反映了心电信号基线漂移,在重构过程中可直接将其去除。     

冠心病患者CGA、NT-proBNP和Hs-CRP水平变化及临床应用分析

探讨血清CGA、NT-proBNP、Hs-CRP水平和冠心病发病机制及不稳定性心绞痛(UAP)治疗前后与其相关性;用CL-ELISA及RIA法测定冠心病组和UAP经皮冠状动脉形成术(PTCA)治疗前后及对照组血清CGA、NT-proBNP和Hs-CRP水平并进行分析.结果表明冠心病组NT-proBNP水平与对照组比较有...