Short and long term results of coronary angioplasty in patients over 75 years

Aims: This report reviews the outcome of percutaneous transluminal coronary angioplasty (PTCA) on patients aged 75 years or over at this institution, in order to provide statistics that may be useful in managing elderly patients. Methods: All elderly patients undergoing PTCA between January 1984 and December 1990 were included. Data concerning the PTCA procedure and short term (hospital stay) outcome were compared to those of all patients less than 75 years who underwent PTCA during the same period. Long term outcome was obtained for all surviving elderly patients. Results: One hundred and eleven procedures were performed on patients over 75 years, compared to 3183 procedures on patients under 75. The incidence of PTCA in the elderly increased to 6.7% of all procedures in 1990. Elderly patients were more symptomatic (97% vs 79% in patients under 75 years had Canadian Cardiovascular Society grade 3 or 4 angina), more frequently had the procedure performed urgently (39% vs 14%) and often (67%) had risk factors for PTCA (3 vessel disease, significant left ventricular dysfunction, or a complicating medical illness). Primary success rates (86%vs 90% in patients under 75 years), urgent coronary artery bypass grafting (1.8%vs 1.9%) and Q wave infarction (1.8%vs 1.0%) were similar in the two age groups. In the elderly, procedural difficulties requiring non standard equipment were common (61%), and in-hospital mortality was increased (4.5%vs 0.7%). Additionally, three patients died after discharge resulting in a 30 day mortality of 7.2%. A favourable long term outcome was obtained in 50% of patients at a mean follow up of 20 months. Unfavourable or neutral outcome was due to one or more of the following; death (16%), coronary artery bypass grafting (19%), acute myocardial infarction (7.5%) or significant residual angina (17%). Conclusions: Highly symptomatic patients over 75 years constitute a high risk group for PTCA, with approximately half obtaining a favourable long term outcome.     

Holmium laser-assisted coronary angioplasty in acute ischemic syndromes

Background and hypothesis: Initial studies have shown holmium laser to be effective in ablation of coronary atheromam, and small studies suggest that it may be helpful in ablation of thrombotic stenoses. Therefore, holmium laser-assisted coronary angioplasty was studied in 85 consecutive patients with acute ischemia syndromes. Methods: Indications for therapy were acute myocardial infarction (MI) in 7 patients (8%), post-MI ischemic in 32 patients (38%), and crescendo angina pectoris in 46 patients (54%). Coronary morphology characteristics by multivessel angioplasty prognosis group criteria were Type A in 9 (10%), Type B1 in 15 (18%), Type B2 in 44 (52%), Type C in 17 patients (20%). Results: Angiographic evidence of thrombus was seen in 37 (44%) of patients. The laser successfully crossed the total length of the coronary narrowing in 76 patients (89%). Procedure/clinical success was 92% for the total study population, 100% for patients with acute MI, 94% for post-MI ischemia patients, and 89% for patients with crescendo angina. Lesions with and without thrombus had identical procedure succes rates. Major complication rate was 3.5%, (deaths 0%, Q-wave MI 0%, and emergent bypass surgery 3.5%). Six-month angiographic restenosis rate (>50% stenosis) was 45%. Conclusion: Holmium laser-assisted balloon angioplasty appears promising in the treatment of acute ischemic syndromes and thrombotic coronary lesions.     

Acute closure during coronary excimer laser angioplasty and conventional balloon dilatation: a comparison of management outcome and prediction

Of 523 consecutive patients undergoing elective percutaneoustransluminal coronary angioplasty (PTCA) and 83 patients treatedwith coronary excimer laser angioplasty (ELCA), 17 (3.3%) hadin-laboratory occlusion following PTCA and 25 (30%)followingELCA; they were enrolled into a prospective study. Successfulmanagement (reopened vessel, patency at repeat angiography within24 h, no death, no myocardial infarction (MI), no emergencybypass surgery) including repeat lasing, subsequent PTCA, useof intracoronary nitroglycerin or streptokinase was achievedin 24 (96%) of the 25 patients with acute occlusion during ELCA.An anterior MI occurred in one patient of the laser group. Repeatballoon dilatation was successfully performed in seven of the17 patients (41%) with acute closure during PTCA. Among the10 patients with persistent occlusion after PTCA, five developeda limited myocardial infarction (35%). One patient requiredemergency CABG, and died peri-operatively. Severe spasm priorto occlusion defined by a new coronary flow depression withoutevidence of dissection or thrombus showed a significant positiveassociation with acute occlusion during ELCA (P =0.0008). Thus, in contrast to occlusion during PTCA, subsequent balloondilatation was successfully performed in the majority of patientswith acute occlusion during ELCA, implying that different underlyingmechanisms are responsible for this complication. In this limitedpatient group, occlusion after excimer laser angioplasty wasmuch more frequent than closure during PTCA, but was infrequentlyassociated with major events such as myocardial infarction ordeath.     

Directional coronary atherectomy for lesions of the proximal left anterior descending artery: initial clinical results, complications and histopathological findings

Background: Directional coronary atherectomy is a percutaneous technique which extends the role of balloon angioplasty to bulky eccentric coronary lesions. Aims: To report the early experience, clinical results, complications and histopathological findings of directional coronary atherectomy (DCA) in proximal left anterior descending artery (LAD) stenosis. Methods: Study of 25 lesions in 24 patients on whom directional atherectomy was performed on the proximal LAD artery with the Simpson coronary atherectomy device. Results: Twenty-five procedures were performed on 24 patients with stenosis in the proximal LAD artery. There were 21 males and three females with a mean age of 56.5 years. Sixteen patients presented with stable angina and eight with unstable angina. Eight patients had previous myocardial infarction (MI). Angiographic success was obtained in 24 of 25 lesions (96%). The mean lesion length was 13.1 ± 3.7 mm and the mean LAD artery diameter was 3.6 ± 0.5 mm. Minimal luminal diameter improved from 0.9 ± 0.4 mm to 3.0 ± 0.5 mm and the percentage diameter stenosis reduced from 75 ± 12% to 16 ± 9%. Complications included acute occlusion in one patient, non-Q MI in three patients, local vascular complications in one patient and side-branch loss in one patient. Histology demonstrated fibrous cap of atherosclerotic plaque in 100%, media and internal elastic lamina in 28% and intimal hyperplasia in 100% of restenotic lesions and 27% of native lesions. Restenosis rates in angiographically restudied patients was 27%. The mean minimal luminal diameter at follow-up was 2.3 ± 0.9 mm and the mean percentage diameter stenosis was 35 ±21%. Conclusion: From this initial study, we conclude that DCA is an effective and safe procedure for the treatment of large proximal LAD lesions. DCA provides a large luminal diameter and a ‘smoother’ angiographic appearance compared to coronary angioplasty. Acute complication rates are low and restenosis rates were comparable with percutaneous transluminal coronary balloon angioplasty.     

Value and limits of balloon laser-assisted angioplasty in the treatment of acute obstruction during percutaneous transluminal coronary angioplasty]

One of the problems of percutaneous transluminal coronary angioplasty is acute occlusion during the procedure, the main cause of serious complications and emergency coronary bypass surgery. Acute occlusion is generally related to severe intimal dissection and/or thrombosis. In animal experiments, it is possible to treat intimal dissection and dessicate thrombi by balloon laser angioplasty. Using this method, a programmed laser energy may be delivered to the arterial wall via a fiber optic system linked to a Nd:Yag laser during classical balloon inflation. This has been proposed for the treatment of acute coronary occlusion. Between September 1989 and August 1990, 923 patients underwent coronary angioplasty at the Centre Cardiologique du Nord. Peroperative acute occlusions occurred 52 times (3.9%) in 52 patients. Sixteen patients who were "candidates" for emergency coronary bypass surgery (residual stenosis > or = 75%; delayed flow; myocardial ischaemia) were treated by laser balloon angioplasty, 14 with success (87%). Two patients had to be operated as an emergency. There were no hospital deaths. The average follow-up was 4.7 months for the 14 non-operated patients. Systematic control coronary angiography was refused by 2 asymptomatic patients. In the other 12 patients investigated 1 to 17 months after the procedure, there were 10 restenoses (76%), 6 of which were treated by repeat angioplasty and 3 by coronary bypass surgery. These results show that balloon laser angioplasty is very effective in the treatment of peroperative acute occlusions, enabling emergency coronary bypass surgery to be avoided in 87% of cases, but it is associated with a very high restenosis rate which is difficult to accept.     

Feasibility of primary clot extraction prior to percutaneous coronary intervention in acute myocardial infarction

Objectives : To test the feasibility, safety, and in‐hospital outcomes of utilizing the FilterWire EZ to extract clot prior to percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (MI). Background : PCI in patients with acute MI is associated with a higher incidence of distal embolization, no‐reflow, or slow flow partly due to the presence of clot burden. Methods : The authors describe the feasibility, safety, and outcomes of using a FilterWire EZ distal protection device as a clot extraction device in patients who presented with acute MI and documented clot on coronary angiography. Results : Fifteen consecutive male patients with a mean age of 54 ± 8 years presented with acute MI (60% ST elevation MI). MI involved left anterior descending artery (n = 4), circumflex artery (n = 3), and right coronary artery (n = 8). Clot extraction followed by PCI reduced the percent diameter stenosis from 94 ± 12 to 65 ± 11 (P < 0.001) and restored TIMI 3 flow in all patients without distal embolization. The angiographic, procedural, and clinical success rates were 100%. The mean left ventricular ejection fraction (LVEF) was 52 ± 8% (range 30–62%) with only three patients (15%) who had an LVEF <50% and five patients (33%) without apparent wall motion abnormalities on echocardiography. Conclusions : Clot extraction before PCI during acute MI in native coronaries is feasible, safe, and effective in restoring TIMI 3 flow without distal embolization. Whether this approach results in better outcomes and improved LV function compared with standard therapy alone requires further investigation. © 2008 Wiley‐Liss, Inc.     

Periprocedural myocardial infarction in patients undergoing complex versus noncomplex percutaneous coronary intervention

Background

Limited data are available on the risk of periprocedural myocardial infarction (MI) in patients undergoing complex versus noncomplex percutaneous coronary intervention (PCI).

Methods

We assessed the risk of periprocedural MI according to the fourth Universal definition of myocardial infarction (UDMI) and several other criteria among patients undergoing elective PCI in a prospective, single-center registry. Complex PCI included at least one of the following: 3 coronary vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, treatment of chronic total occlusion, and use of rotational atherectomy.

Results

Between 2017 and 2021, we included 1010 patients with chronic coronary syndrome, of whom 226 underwent complex PCI (22.4%). The rate of periprocedural MI according to the fourth UDMI was significantly higher in complex compared to noncomplex PCI patients (26.5% vs. 14.5%, p < 0.001). Additionally, periprocedural MI was higher in the complex PCI group using SCAI (4% vs. 1.1%, p = 0.009), ARC-2 (13.7% vs. 8.0%, p = 0.013), ISCHEMIA (5.8% vs. 1.7%, p = 0.002), and EXCEL criteria (4.9% vs. 2.0%, p = 0.032). SYNTAX periprocedural MI occurred at low rates in both groups (0.9% vs. 0.6%, p = 0.657). Complex PCI was an independent predictor of the fourth UDMI periprocedural MI (odds ratio [OR] 1.54, 95% confidence interval [CI]: 1.04–2.27, p = 0.031).

Conclusions

In patients with chronic coronary syndrome undergoing elective PCI, complex PCI is associated with a significantly higher risk of periprocedural MI using multiple definitions. These findings highlight the importance of considering upfront this risk in the planning of complex PCI procedures.     

Use of vibrational angioplasty for the treatment of chronic total coronary occlusions: Preliminary results

The aim of the study was to investigate the feasibility and clinical safety of vibrational angioplasty in the treatment of chronic total coronary occlusions and evaluate the clinical and angiographic factors that are predictive of the procedural success and complications of the procedure. Seventy-eight patients with chronic total occlusions (>3 months) resistant to conventional techniques were treated by vibrational angioplasty using a variety of conventional guidewires. Lesions were successfully crossed in 67 (85.9%) cases and antegrade flow was achieved in 59 (75.5%). Major complications (myocardial infarction and tamponade) occurred in two (2.5%) patients, but no fatalities ensued. Angiographically detectable dissections were seen in 23 (29.5%) patients but only resulted in vessel compromise and reclosure in 5 cases. Multiple stepwise logistic regression analysis identified the duration (<6 months, P = 0.008) and the length of the occlusion (<15 mm, P = 0.03) as independent predictors of final success and the age of the patient (<55 years, P = 0.006) as the only independent predictor of procedural complications. Vibrational angioplasty is a safe technique useful in the treatment of chronic coronary occlusive disease. Patients in whom the procedure is likely to prove most successful may be easily identified by clinical and angiographic features (duration and length of occlusion).Cathet. Cardiovasc. Intervent. 46:98–104, 1999. © 1999 Wiley-Liss, Inc.     

Comparison of the histopathology of culprit lesions in chronic stable angina,unstable angina,and myocardial infarction

Background: The etiology of unstable angina (UA) and myocardial infarction (MI) both involve rupture of an atherosclerotic plaque in a coronary artery. It has been suggested that the two syndromes differ because MI results if a red occlusive permanent thrombus occurs and UA occurs only if a nonocclusive platelet (white) thrombus occurs. Hypothesis: The purpose of this study was to determine the differences between coronary lesion pathology in MI and UA and compare them with lesions of chronic stable angina (CSA). Methods: We reviewed the pathologic specimens of culprit lesions obtained by directional coronary atherectomy in 27 patients with MI, 29 patients with UA, and 16 patients with CSA. Results: The incidence of ruptured plaque was high and identical in patients with MI (77.8%), and UA (75.8%), and significantly lower in patients with CSA (25.0%) (p « 0.001). Similarly, the incidence of red thrombus was the same in MI (92.6%) and UA (82.7%), and significantly less in CSA (p “0.001). Conclusions: The underlying pathophysiology of both UA and MI appears to be the same, with red thrombus playing an important role in both syndromes. The only difference is in the degree of occlusiveness of the red thrombus on the ruptured plaque and whether the occlusion is transient (UA) or persistent (MI). The balance between thrombosis and endogenous clot lysis determines which syndrome occurs. Lytic therapy is not effective in UA, probably because the clot is not occlusive or because endogenous lysis has already achieved the degree of coronary opening that eventuates from tissue plasminogen activator or streptokinase administration. Prompt catheterization and revascularization may be as indicated in patients with MI if there remains viable myocardium as in patients with UA.     

Rheolytic thrombectomy with AngioJet catheter during transluminal coronary revascularization in patients with acute myocardial infarction

BACKGROUND: Although balloon angioplasty and stenting are effective in the treatment of acute myocardial infarction (M1), reduced coronary flow and distal embolization frequently complicate interventions when thrombus is present. Adjunctive treatment with mechanical thrombectomy devices was suggested to reduce these complications. METHODS: We evaluated immediate angiographic, in-hospital and 30-day follow-up clinical outcomes of 185 patients with acute MI and angiographically evident thrombus who were treated with AngioJet rheolytic thrombectomy followed by immediate definitive treatment. RESULTS: Procedural success (residual diameter stenosis <50% and thrombolysis in myocardial infarction [TIMI] flow >2 after final treatment) was 97%. Rheolytic thrombectomy success was achieved in 7% of patients. Subsequent definitive treatment included stenting in 67% and balloon angioplasty alone in 26% of patients. Final TIMI 3 flow was achieved in 89%. AngioJet treatment resulted in mean thrombus area reduction from 69.6 mm(2) at baseline to 17.3 mm(2) post-thrombectomy (p<0.001). Procedural complications included distal embolization (7.6%) and perforation (1.1%). Clinical success (procedure success without major in-hospital cardiac events) rate was 88%, in-hospital mortality - 7.0%. There were no further major adverse events during 30-day follow-up. CONCLUSION: Rheolytic thrombectomy can be performed safely and effectively in patients with acute MI, allowing for immediate definitive treatment of thrombus-containing lesions.     

Do patients with heart failure appropriately undergo invasive procedures post‐myocardial infarction? Results from a prospective multicentre study

Background: The degree of adherence to guideline recommendations that patients following myocardial infarction (MI) with congestive heart failure (CHF) undergo early angiography, and angioplasty if indicated, is unknown. Methods: We prospectively evaluated the use of invasive procedures in patients with segment‐elevation myocardial infarction (STEMI), non‐STEMI and CHF, admitted in 1 month to 16 Australian hospitals. Results: Of 475 post‐MI patients (248 (52.2%) with STEMI), 112 (23.6%) had CHF, (57 (23.0%) with STEMI). Patients with CHF, compared with those without CHF, were older (67.8 vs 63.2 years; P = 0.002) and were more often women (34 vs 24%, P = 0.03), but had similar rates of other risk factors. Compared with post‐MI patients without CHF, patients with CHF had fewer invasive procedures: angiography 72.3% versus 85.1% (P = 0.002) and angioplasty 33.9% versus 52.9% (P < 0.001) (12 (2.5%) patients underwent coronary surgery in‐hospital); and among STEMI patients (angiography 72.3% CHF vs 89.5% no CHF [P < 0.001]; angioplasty 50.9% CHF vs 69.1% no CHF [P = 0.011]); these differences remained significant after adjustment for clinical covariates. Of the 121 (25.5%) post‐MI patients aged ≥75 years, compared with those <75 years, the frequencies of angiography and angioplasty procedures were 66.1% versus 87.6% (P < 0.001) and 33.9% versus 53.4% (P < 0.001), respectively; 66% of the elderly with, and without, CHF had angiography. Conclusion: The presence of CHF post‐MI resulted in lower rates of use of angiography and angioplasty, which was not explained by lower procedure rates in the elderly. As these guideline‐recommended procedures may improve survival in patients with CHF post‐MI, future strategies should aim to enhance their use.     

Late coronary artery reperfusion has additive beneficial effects on infarct expansion when combined with early angiotensin converting enzyme inhibitor therapy post myocardial infarction

Background: Individually, late coronary artery reperfusion and early angiotensin converting enzyme (ACE) inhibitor therapy prevent infarct expansion post myocardial infarction (MI). Objectives: To examine the effect of late reperfusion on infarct expansion when added to early ACE inhibitor therapy post MI. Methods: Rats were randomized into two groups: Reperfusion group: rats underwent coronary artery occlusion followed by reperfusion 2 hours after MI, a time too late to reduce infarct size. A control group: rats underwent permanent coronary artery occlusion followed by a sham operation 2 hours after MI. All rats received enalapril (2.0 ± 0.2 mg/kg) daily in drinking water, started immediately after the second operation. Rats were sacrificed 2 weeks after coronary occlusion. Hearts were arrested and fixed at a constant pressure, then sectioned and photographed for morphometric analysis. Results: Infarct size was similar in the reperfusion and control groups (23 ± 2 vs 26 ± 2%, p = NS). Septal thickness was also similar in both groups (1.8 ± 0.1 vs 1.8 ± 0.1 mm, p = NS). There was a trend towards thicker infarcts in the reperfusion group compared to the control group (0.84 ± 0.06 vs 0.72 ± 0.05 mm, p = 0.1). Compared to early ACE inhibition alone, late reperfusion combined with early ACE inhibition limited infarct expansion (expansion index, 1.13 ± 0.12 vs 1.44 ± 0.14, p < 0.05), prevented left ventricular (LV) dilation (LV volume, 0.30 ± 0.02 vs 0.39 ± 0.03 ml, p < 0.01) and prevented LV hypertrophy (LV weight, 0.71 ± 0.18 vs 0.77 ± 0.20 gm, p < 0.05). Conclusions: Late coronary artery reperfusion prevents infarct expansion, LV dilation and hypertrophy even when added to early ACE inhibitor therapy post MI. This suggests that late reperfusion may be beneficial in patients with acute MI treated with early ACE inhibitor therapy.     

Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience

Objectives. The purpose of the present study was to assess the effect of bridging collateral vessels on the success of coronary angioplasty of chronic total occlusions in the context of state of the art technology and operator skill.Background. Coronary angioplasty of chronic total occlusions has been associated with relatively low success rates. Because the presence of bridging collateral vessels in chronic total occlusion has been reported to be the major predictive factor in procedural failure, angioplasty is often not recommended in patients with such vessels.Methods. Three hundred ninety-seven consecutive patients undergoing coronary angioplasty for chronic total occlusion were classified into two groups. Patients in group I had chronic total occlusion with bridging collateral vessels (97 patients, 109 total occlusions), and patients in group II had chronic total occlusion without such vessels (300 patients, 324 total occlusions).Results. The mean ± SD duration of occlusion was 46 ± 66 months (range 2 to 170) in group I and 27 ± 39 months (range 2 to 112) in group II (p < 0.05, high power value 0.83, group I vs. group II). Angioplasty for single-vessel disease was performed in a smaller proportion of patients in group I than in group II (22% vs. 36%, p < 0.05; power value 0.77). Procedural success was achieved in 82 chronic total occlusions in group I and 270 chronic total occlusions in group II (75% vs. 83%, p = 0.07; power value 0.53). The rates of restenosis and reocclusion were 54% and 16%, respectively, for group I and 56% and 13%, respectively, for group II (p = 0.76, 0.46; power value 0.51, 0.47). Complications were minor with no Q wave infarction or requirement for urgent bypass surgery in either group. Of 81 patients with unsuccessful coronary angioplasty, 1 patient from group I (1%) and 3 patients from group II (1%) required pericardiocentesis because of cardiac tamponade. Guide wire manipulation did not impair the flow of bridging collateral channels in group I.Conclusions. Coronary angioplasty can open chronic total occlusions, with or without bridging collateral channels, for safe and effective recanalization without major complications.     

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

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.     

Quantitative assessment of peripheral and coronary artery lesions before and after balloon angioplasty: A comparison of intravascular ultrasound and angiography

Summary Intravascular ultrasound and conventional angiography were used to determine the degree of stenosis before and after angioplasty in 25 consecutive patients with peripheral arterial occlusive disease and 15 selected patients with coronary artery disease. Angiographic determinations of the luminal area and percent stenosis were made with the help of an automatic detection system, and the same parameters were evaluated planimetrically in the ultrasound studies. Following angioplasty of peripheral lesions, angiography demonstrated a significantly greater increase in mean luminal area (10.8 ± 7.8mm² vs 5.8 ± 4.0 mm²;P < 0.05) and a greater reduction in degree of stenosis (26% ± 16%vs 14% ± 11%;P < 0.05) than did the ultrasonic investigation. There was a significant but moderate correlation between values for the luminal area determined by angiography and ultrasound before angioplasty (r = 0.75; SEE = 4.8mm²) and in normal proximal segments of coronary arteries (r = 0.79; SEE 4.1 mm²). Following angioplasty there was no significant correlation between angiographic findings and those determined by intravascular ultrasound in peripheral or coronary lesions. These results suggest that angiography and intravascular ultrasound are fundamentally different imaging and analysis techniques. Following angioplasty, conventional angiography rarely demonstrated dissection or intraluminal filling defects, while intravascular ultrasound detected plaque rupture and the presence of intraluminal atheroma in almost all cases. Quantitative determinations of luminal area and degree of stenosis rely on indirect measures with conventional angiography, while these parameters are determined directly by intravascular ultrasound. Additional studies and clinical experience should demonstrate whether intravascular ultrasound will play a significant role in the planning and management of vascular interventions.Presented in part at the 1993 European Congress of Cardiology in Nice, France.     

Changes in patient treatment after abrupt closure complicating percutaneous transluminal coronary angioplasty: A historic perspective

This study compares the incidence and management of acute closure complicating coronary angioplasty in three historic populations of patients having undergone the procedure at the same center: group 1 (n = 146 of 881) (“early years” of angioplasty, 1980 to 1986), group 2 (n = 133 of 1781) (bailout stenting learning curve, 1990 to 1992), and group 3 (n = 34 of 525) (1993). The incidence of acute closure decreased from group 1 (146 [17%] of 881) to groups 2 and 3 (147 [6%] of 2306); (p < 0.001). Management of the occlusion changed over the years, with less emergency coronary bypass surgery ([36%] 52 of 146, 15 [13%] 113, and 3 [9%] of 34), respectively, p < 0.01) and more repeat angioplasty (70 [48%] of 146; 87 [78%], of 113, and 30 [88%] of 34, p < 0.001). The use of prolonged inflations (>10 minutes) and stenting increased from group 2 (15 [13%] of 113 and 16 [14%] of 113, respectively) to group 3 (12 [35%] of 34, and 10 [30%] of 34, respectively). In-hospital death occurred in 18 (12%) of 146, 7 (6%) of 113), and (2 (6%) of 34) patients in the three groups. Acute myocardial infarction decreased from 64% to 46% and 27%, respectively (p < 0.01). Overall, the number of patients free of events at hospital discharge increased from 38 (26%) of 146 to 53 (47%) of 113 (p < 0.001) and to 23 (68%) of 34 (p < 0.001). In group 3, 80% of the patients treated with prolonged balloon inflations or stenting were free of events compared with 50% of the others (p = 0.07). Improvement in the management of acute occlusion complicating coronary angioplasty results from increased experience in this difficult setting and also from the use of new angioplasty techniques such as bailout stenting or prolonged balloon inflations.     

Short and long term outcome of percutaneous transluminal coronary angioplasty in unstable versus stable angina pectoris: A report of the 1985–1986 nhlbi ptca registry

In a cohort of 1,720 consecutive patients from the National Heart, Lung, and Blood Institute, Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry (August 1985–May 1986), we compared 768 patients (45%) with stable angina and 952 patients (55%) with unstable angina pectoris. Unstable angina patients exhibited at least one of the following characteristics: new onset angina, rapidly progressing angina, angina at rest, angina refractory to medication, variant angina, acute coronary insufficiency, or angina recurring shortly after an acute myocardial infarct. The distribution of single- and multi-vessel disease was similar among stable and unstable angina patients; multi-vessel disease predominated. Average severity of stenosis and incidence of tubular and diffuse stenosis morphology were higher among patients with unstable angina (both p<0.001). Patient success rates were similar in stable and unstable patients. However, on a per lesion basis, overall angiographic success rate and average reduction of severity of stenosis in successfully dilated lesions were significantly higher among patients with unstable angina (both p<0.001). Incidence of major patient complications (p<0.01) and of emergency coronary bypass surgery (p<0.05) were also higher in patients with unstable angina but consistent with their more precarious clinical condition and stenosis morphology. During a two year follow-up, the cumulative distributions of death, myocardial infarct, repeat PTCA, and coronary bypass surgery were not significantly different in patients with stable angina compared to patients with unstable angina. Comparison of the current PTCA Registry cohort with the cases reported in the 1979–1982 Registry revealed a 19% higher success rate for both stable and unstable angina patients. Major complication rates decreased between time periods for stable but not for unstable angina patients. Incidence of emergency bypass surgery decreased more for stable than for unstable angina patients. Coronary angioplasty is indicated in properly selected patients with unstable angina and both single-and-multi-vessel coronary disease.     

Staphylococcal bacteraemia: the hospital or the home? A review of Staphylococcus aureus bacteraemia at Concord Hospital in 1993

Aims: To examine the risk factors for, and the complications and mortality of, Staphylococcus aureus bacteraemia. Methods: A retrospective case review of patients with S. aureus bacteraemia in 1993 diagnosed at the Concord Repatriation General Hospital, Sydney. Results: Of 104 cases reviewed, 32 were due to methicillin resistant S. aureus (MRSA), 73 were due to methicillin sensitive S. aureus (MSSA) and one was a dual infection. Twenty-eight of the bacteraemias were community-acquired, including one case of MRSA, and 76 were hospital-acquired; 38% had an implanted prosthetic device or graft. The average age (68 years), incidence of underlying diseases and hospitalisation in the past month (26%) did not differ between MRSA and MSSA groups. MRSA was more likely in patients with recent broad-spectrum antibiotic use (53%vs 0, p<.01). Vascular access was the commonest source of sepsis (61 %) but in community-acquired cases the source was unknown in 50%. Use of central line access was more predictive of MRSA infection (75%vs 49%, p=.018). In hospital-acquired infection, MRSA sepsis occurred later in the course of the admission (26 days vs eight days, p<.01). Directly attributable mortality was highest in MRSA and community-acquired MSSA infection (9% and 11%) compared with hospital-acquired MSSA infection (1%). Conclusions: Nosocomial S. aureus bacteraemia, particularly MRSA, is a major source of preventable morbidity, which could be addressed by improved infection control of MRSA, antibiotic use and attention to central line catheter use.     

Acute renal failure following cardiac surgery: incidence, outcomes and risk factors

Background: Acute renal failure (ARF) is a recognised complication following cardiac surgery, but the incidence varies widely in the published literature and there are no Australian data available to help predict the risks of ARF in patients with pre-existing renal disease. Aim: To determine the incidence, outcome and risk factors for ARF following cardiac surgery. Methods: A retrospective case control analysis of 903 consecutive patients who had cardiac surgery (795 CABG, 68 valve/septal surgery, 40 combined valve/CABG) in 1992-93. ARF was defined as doubling of serum creatinine concentration (Cr) to >0.13mmol/L if serum Cr was <0.13 mmol/L pre-operatively, or else a rise in serum Cr of 2:0.10 mmol/L after cardiac surgery. For each subject with ARF, two case control subjects were matched for date of surgery, surgeon, age, sex, type of surgery and pre-operative serum Cr to permit analysis of the influence of preoperative factors (hypertension, diabetes mellitus, left ventricular systolic dysfunction) and for the comparison of cardiopulmonary bypass time upon the development of ARF. Subsidiary endpoints were mortality, need for dialysis and length of hospital stay. Results: ARF developed in only 1.1% of patients with ‘normal’ pre-operative renal function (creatinine 0.13 mmol/L) and none required dialysis. ARF developed in 16%of those with impaired pre-operative renal function, 20% of whom required dialysis. Mortality from ARF was 13%. The risk of ARF rose from 10.4% in those with pre-operative serum Cr 0.14-0.20 mmol/L to 36.8% if the serum Cr was >0.20 mmol/L (p< 0.01). Mortality was higher (4.2%vs 0.7%, p< 0.01) and length of hospital stay longer (14.5 vs nine days [median], p< 0.001) in those with impaired pre-operative renal function. ARF was more likely in those over 65 years, if valve surgery was included and where there was prolonged cardiopulmonary bypass time. Conclusions: These data confirm that ARF following cardiac surgery is uncommon without preoperative impairment of renal function but currently carries a mortality rate of 13%. Impaired renal function alone is associated with higher mortality and prolonged hospital stay. Studies to prevent ARF in this setting should focus on the high risk subsets described in this study.     

Immediate and one-year outcome in patients with coronary bifurcation lesions in the modern era (NHLBI dynamic registry)

Balloon angioplasty of bifurcation lesions has been associated with lower success and higher complication rates than most other lesion types. The development of alternative strategies such as debulking and stenting, either alone or in combination, are currently used relatively often. The relative role of these newer approaches in improving acute or long-term outcome, however, remains uncertain. Of the total of 2,436 patients treated between July 1997 to February 1998 in the National Heart, Lung, and Blood Institute Dynamic Registry, there were 321 patients (group 1) with bifurcation lesions and 2,115 patients without any bifurcation lesions attempted (group 2). Treatment strategies in terms of major devices used were significantly different between the 2 groups (group 1 vs 2): balloon angioplasty alone (23.1% vs 26.5%), balloon angioplasty and rotational atherectomy (6.9% vs 4.4%), balloon angioplasty and stent (55.8% vs 59.9%), and balloon angioplasty, rotational atherectomy, and stent (10.3% vs 7%) with p <0.01. There were no significant differences between the groups in terms of age, gender, and frequency of prior myocardial infarction (MI) or coronary artery bypass graft surgery (CABG). Complete angiographic success was achieved in only 86% of bifurcation lesions versus 93.5% of nonbifurcation lesions (p <0.001). In-hospital complication rates were increased in patients with bifurcation lesions compared with the nonbifurcation group: MI, 3.7% versus 2.6%; CABG, 2.2% versus 1.1%; side branch occlusion, 7.3% versus 2.3% (p <0.001); and the composite of death, MI, and any CABG, 7.2% versus 5.0%. At 1-year follow-up, major adverse cardiac events were 25% higher in group 1 than in group 2 (32.1% vs 25.7%, p <0.05). We conclude that despite the widespread use of newer percutaneous devices, treatment of bifurcation lesions remains difficult and is associated with decreased success and increased complication rates compared with nonbifurcation lesions.