Percutaneous transluminal coronary angioplasty in patients with cardiogenic shock.

In cardiogenic shock complicating acute myocardial infarction, percutaneous transluminal coronary angioplasty has been reported to significantly improve the modest survival benefits afforded by emergency surgical revascularization and thrombolytic therapy. The records of all patients who underwent angioplasty for acute myocardial infarction complicated by cardiogenic shock were retrospectively reviewed to determine whether coronary angioplasty improves survival. Of the 45 patients, 28 (group 1, 62%) had successful dilation of the infarct-related artery and 17 (group 2, 38%) had unsuccessful angioplasty. The groups were similar in extent of coronary artery disease, infarct location, incidence of multivessel disease and hemodynamic variables. The overall hospital survival rate was 56% (71% in group 1 and 29% in group 2). Group 1 patients had more left main coronary artery disease, and group 2 patients were older and had a higher incidence of prior myocardial infarction. Multivariate analysis showed that the survival advantage in patients with successful angioplasty was statistically significant (p = 0.014) when these factors were taken into account. At a mean follow-up interval of 2.3 years (range 1 month to 5.6 years), there were five deaths (four cardiac and one noncardiac), for a 2.3-year survival rate of 80% in patients surviving to hospital discharge. During the follow-up period, 36% of hospital survivors had repeat hospitalization for cardiac evaluation, 8% had myocardial infarction, 8% had coronary artery bypass surgery and 24% had angina.     

Catheter reperfusion for failed emergency coronary angioplasty without subsequent bypass surgery

A transluminal intracoronary reperfusion catheter was used in eight patients, seven with acute myocardial infarction and one with unstable angina after failed emergency coronary angioplasty. After placement of the reperfusion catheter across the occlusion, symptoms of ischemia resolved in each patient. Chest pain recurred 3 hr later in a single patient who underwent successful repeat angioplasty. The catheter was withdrawn within 6 hr after introduction. Control coronary angiography showed a patent vessel in all but one. Repeat angioplasty or bypass surgery was unnecessary. During 1 year mean follow-up time all patients remained free of symptoms. The reperfusion catheter is a safe and effective means of perfusing a coronary artery after failure of thrombolytic therapy and coronary angioplasty in cases where emergency bypass surgery is not performed because operative morbidity is expected to outweigh the benefit of myocardial salvage, or when it cannot be immediately organized.     

Comparison of angioplasty and bypass surgery in multivessel coronary artery disease

The role of coronary angioplasty in the treatment of patient with multivessel coronary artery disease has not been fully established. We compared immediate and 1-year follow-up results in 60 patients undergoing coronary angioplasty for multivessel coronary disease in 1982 with 41 patients anatomically suitable for angioplasty but who underwent elective coronary bypass surgery during the same time period. Baseline variables were similar in both groups except for number of vessels diseased which was higher in the surgical group. Angioplasty was initially successful in 70% of cases. There were no deaths. Mean initial hospital days were lower in the angioplasty group. At follow-up there were no significant differences in survival, functional class, occurrence of subsequent myocardial infarction or use of cardiac medications. However, 33% of the successfully dilated patients required either repeat dilatation or subsequent bypass surgery because of restenosis or inadequate initial revascularization. The statistical power of the study was limited due to the small sample sizes. While demonstrating that angioplasty can be successfully performed in patients with multivessel disease, definitive conclusions about the comparability of the two treatments are hampered by possible selection bias and small patient numbers. This issue could be better addressed by a multicenter prospective randomized trial.     

Results of coronary surgery after failed elective coronary angioplasty in patients with prior coronary surgery

The results of coronary artery bypass surgery after failed elective coronary angioplasty in patients who have undergone prior coronary surgery are unknown. Coronary angioplasty may be performed to relieve angina after surgery either to the native coronary vessels or to grafts. Failure of attempted coronary angioplasty may mandate repeat coronary surgery, often in the setting of acute ischemia. From 1980 to 1989, 1,263 patients with prior coronary bypass surgery underwent angioplasty; of these patients, 46 (3.6%) underwent reoperation for failed angioplasty during the same hospital stay. Of the 46 patients who underwent reoperation, 33 had and 13 did not have acute ischemia. In the group with ischemia, 3 patients (9.1%) died and 14 (42.4%) died or had a Q wave myocardial infarction in the hospital compared with no deaths (p = NS) and no deaths or Q wave myocardial infarction (p = 0.005) in the group without ischemia. At 3 years, the actuarial survival rate was 88 +/- 6% in the group with ischemia, whereas there were no deaths in the group without ischemia (p = NS), and freedom from death or myocardial infarction was 51 +/- 10% in the group with ischemia, versus no events in the group without ischemia (p = 0.006). In most patients with prior coronary bypass surgery, coronary angioplasty was performed without the need for repeat coronary bypass surgery. Should coronary angioplasty fail, reoperation in patients without acute ischemia can be performed with overall patient survival comparable to that of elective reoperative coronary bypass without coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Survival and cardiac event rates in the first year after emergency coronary angioplasty for acute myocardial infarction

One year survival and event-free survival rates were analyzed in 342 patients with acute myocardial infarction who were consecutively enrolled in a treatment protocol of early intravenous thrombolytic therapy followed by emergency coronary angioplasty. Ninety-four percent of the patients achieved successful reperfusion, including 4% with failed angioplasty whose perfusion was maintained by means of a reperfusion catheter before emergency bypass surgery. The procedural mortality rate was 1.2% and the total in-hospital mortality rate was 11%. Ninety-two percent of surviving nonsurgical patients who underwent repeat cardiac catheterization were discharged from the hospital with an open infarct-related artery. The related cumulative 1 year survival rate for all patients managed with this treatment strategy was 87%, and the cardiac event-free survival rate was 84%. The 1 year survival for hospital survivors was 98% and the infarct-free survival rate was 94%. Multivariable analysis identified the following factors as independent predictors of subsequent cardiovascular death: cardiogenic shock, greater age, lower ejection fraction, female gender and a closed infarct-related vessel on the initial coronary angiogram. Among patients with cardiogenic shock, despite a 42% in-hospital mortality rate, only 4% died during the first year after hospital discharge. Similarly, the in-hospital and 1 year postdischarge mortality rates were 19 and 4%, respectively, for patients with an initial ejection fraction less than 40, and 25 and 3%, respectively, for patients greater than 65 years. An aggressive treatment strategy including early thrombolytic therapy, emergency cardiac catheterization, coronary angioplasty and, when necessary, bypass surgery resulted in a high rate of infarct vessel patency.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous angioplasty of unprotected left main coronary disease with implantation of systematic stenting. Immediate and mid-term results

The authors report the immediate and medium term results of percutaneous angioplasty of unprotected left main coronary disease with systematic stenting. Between March 1994 and December 1998, out of 6,006 patients undergoing coronary angioplasty, 92 had significant unprotected left main stem disease. The majority of patients was male (74 men, 80%) with an average age of 74.3 +/- 8.1 years. Between March 1994 and October 1996, only patients with a surgical contraindication were treated by angioplasty (n = 39). After October 1996, the indications were extended to patients who did not have surgical contraindications (n = 53). During the hospital phase, 4 patients (4%) died (ventricular arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage: 1). No non-fatal infarction with or without Q waves were observed, and no emergency coronary bypass surgical procedures were required. The angiographic success rate was 100%. During follow-up (7.3 +/- 5.8 months), 6 other patients died, 13 required a repeat coronary angioplasty, 4 for restenosis of the left main coronary artery, and 2 underwent coronary bypass surgery. The actuarial survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years. Percutaneous angioplasty for unprotected left main coronary disease with systematic stenting was performed with acceptable hospital and medium term results.     

Percutaneous transluminal coronary angioplasty of the left main coronary artery in patients with rest angina

Left main coronary angioplasty may be a therapeutic revascularization procedure for a subset of patients with symptomatic coronary artery disease. The purpose of this study is to report procedural outcomes and long-term clinical follow-up of 15 patients who underwent either protected or unprotected left main angioplasty for rest angina. These patients represent a cohort of unstable angina patients who were considered high risk for coronary artery bypass surgery. Ten of 15 patients had Canadian Heart Class IV angina, and three patients were hemodynamically unstable. Balloon angioplasty was successful in 14 patients, and one patient was treated with directional atherectomy. Initial angiographic success was achieved in 14 of 15 patients (93%). Major complications (myocardial infarction, emergent coronary artery bypass graft, death) occurred in one patient (6%); 73% of the patients were asymptomatic or had stable exertional angina at 6 months follow-up. One year survival was 87% (13 of 15). During the follow-up period six patients had repeat catheterization for recurrent angina. Four of these patients had left main restenosis and underwent successful repeat left main angioplasty. No patient had coronary bypass surgery during follow-up. This report suggests that left main angioplasty can be a safe and effective revascularization procedure for critically ill patients with unstable angina who are at high risk for coronary bypass surgery. © Wiley-Liss, Inc.     

Results of percutaneous transluminal coronary angioplasty for unstable angina pectoris in patients 70 years of age and older

Between November 1980 and November 1985, 54 patients ages greater than or equal to 70 years underwent percutaneous transluminal coronary angioplasty for unstable angina, defined as recent-onset (less than 1 month) angina, new onset of rest angina (greater than or equal to 2 episodes) or accelerating class III or IV angina. In these 20 men and 34 women, disease was 1-vessel in 34 (63%) and multivessel in 20 (37%). The mean (+/- standard deviation) ejection fraction was 0.62 +/- 0.12. Angioplasty was successful in 43 patients (80%). In the 11 unsuccessful cases, emergency coronary artery bypass grafting for acute occlusion was performed in 3 and elective coronary artery bypass surgery in 8. There were no deaths. Two patients (4%) sustained Q-wave myocardial infarctions. The mean duration of follow-up for the total group was 37 months (6 to 73 months). Of the 43 patients with successful dilation, 4 died, 1 had an non-Q-wave myocardial infarction and 8 had symptomatic restenosis (4 underwent successful repeat angioplasty, 1 had repeat percutaneous transluminal coronary angioplasty and then bypass surgery, 1 had repeat bypass surgery alone and 2 had medical therapy). At last follow-up, 3 patients had stable class III or IV angina and 31 patients (72%) were angina-free.     

Our experience with percutaneous transluminal coronary angioplasty--two years follow-up study

The results of 130 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures carried out in 112 patients between November, 1986 and October, 1988 are reported. The follow-up period ranged from 1 month to 24 months. Eighty-four patients (75%) had single vessel disease, and 28 (25%) had multivessel disease. Two-vessel dilatation was done in 23 patients. The primary success rate was 92%. In successful cases, the diameter of stenosis was changed on an average from an initial 85% to 23%. Acute occlusion of the vessel occurred on 9 occasions (6.8%). Emergency coronary bypass surgery (CABG) was done in 3 (2.7%), 2 patients (1.8%) were subjected to immediate re-dilatation. One patient who underwent CABG died (case fatality 0.8%). Occlusion of the dilated vessels did not occur after the patients were discharged from hospital. Follow-up data revealed that long-term clinical success (class I status) was seen in 78 patients who had a successful primary dilatation. Of the 25 patients who were studied by a repeat coronary arteriography, 7 had developed restenosis. Five of these patients have been successfully redilated. It is concluded that PTCA is an effective and safe method of treatment in selected patients with coronary artery disease in our setting.     

Usefulness of coronary angioplasty in asymptomatic patients

Of 6,545 patients who had elective coronary angioplasty procedures performed over a 7.5-year period from June 1980 through December 1987, 114 (1.7%) never had symptoms of myocardial ischemia. Exercise-induced silent myocardial ischemia was documented before angioplasty in 94% of these asymptomatic patients. Angioplasty was successful in 87%, whereas emergency coronary artery bypass grafting was required in 4%, and a further 2% had myocardial infarctions after the procedures. The remaining 7% had unsuccessful angioplasty procedures but experienced no in-hospital cardiac events. The follow-up period after hospital discharge averaged 43 +/- 20 months (range 5 to 93). There were no deaths. In the group of 99 patients with initially successful angioplasty procedures the follow-up interval ranged from 5 to 92 months. During that period, 7 patients underwent coronary bypass surgery, 4 patients had myocardial infarction and 30 patients had repeat angioplasty procedures for restenosis. The cumulative probability of event-free survival over 5 years for the group with successful angioplasty was: 100% freedom from death, 95% freedom from myocardial infarction, 87% freedom from myocardial infarction or coronary bypass surgery and 61% freedom from myocardial infarction, coronary bypass surgery or repeat angioplasty. Thus, coronary angioplasty performed in 114 asymptomatic patients, most with exercise-induced silent myocardial ischemia, achieved very good primary success and was accompanied by low cardiac event rates and no deaths over several years of patient follow-up.     

Coronary perfusion during acute myocardial infarction with a combined therapy of coronary angioplasty and high-dose intravenous streptokinase

Two hundred and sixteen patients with acute myocardial infarction were treated with immediate infusion of high-dose (1.5 million units) intravenous streptokinase followed by emergency coronary angioplasty. The infarct lesion was crossed and dilated in 99% and persistent coronary perfusion after the procedure was achieved in 90% (including 3% with significant residual stenosis). Total in-hospital mortality was 12%. Multivariable analysis showed a higher hospital mortality with cardiogenic shock (41% vs 5% without shock), older age, lower left ventricular ejection fraction, and female sex. Final patency of the infarct-related vessel was determined by follow-up in-hospital cardiac catheterization. Coronary reocclusion occurred in 11% (symptomatic in 7%, treated with emergency angioplasty or bypass surgery; silent in 4%, treated medically). Of the surviving patients with successful initial establishment of infarct vessel patency, 94% were discharged from the hospital with an open infarct artery or a bypass graft to the infarct vessel. There was significant improvement in both ejection fraction (44% to 49%; p less than .0001) and regional wall motion in the infarct zone (-3.0 SD to -2.4 SD; p less than .0001) among patients with persistent coronary perfusion and insignificant residual stenosis at the time of the follow-up cardiac catheterization. Thus, a treatment strategy for acute myocardial infarction that includes immediate administration of streptokinase followed by emergency coronary angioplasty, and coronary bypass surgery when necessary, results in a high rate of early and sustained patency of the infarct-related vessel.     

Coronary angioplasty in emergency treatment of myocardial infarction in a community-hospital setting

From July 1986 through June 1988, 135 consecutive patients with myocardial infarction, including 23 in cardiogenic shock, were treated with percutaneous transluminal coronary angioplasty in a community-hospital setting. In 109 (81%) of the cases, angioplasty was successful, resulting in brisk anterograde flow and in residual stenosis of less than 50%. The success rate was 88% (99/112) for patients not in cardiogenic shock and 43% (10/23) for those in shock. During the term of hospitalization, clinically evident total reocclusion occurred in 5 (4%) patients not in shock on presentation (2 of these experienced anterior infarction, and 3 inferior infarction); repeat angioplasty was performed successfully in all 5. No clinical reocclusion was detected in the smaller group of patients admitted in shock. Eleven patients (8%) underwent emergency coronary artery bypass grafting following the coronary angioplasty procedure: 4 for failed angioplasty in the infarct-related artery, and the other 7 for severe triple-vessel disease. Hospital mortality was 0.9% (1/112) for patients not in cardiogenic shock and 52% (12/23) for those admitted in shock, for an overall rate of 10% (13/135). Among patients whose balloon angioplasty was successful, hospital mortality was 0% for those not in shock and 30% (3/10) for those in shock. Among patients whose angioplasty failed, however, mortality was 8% (1/13) for those not in shock and 69% (9/13) for those admitted in shock.     

Immediate and long-term outcome after angioplasty with stenting of the left main coronary artery

INTRODUCTION AND OBJECTIVES: Coronary artery bypass graft surgery is the treatment of choice for severe left main coronary artery stenosis. The results of a number of multicenter trials have suggested angioplasty with stenting as a possible alternative treatment. The aim of the present study was to analyze the immediate and long-term results of angioplasty with stenting of the left main coronary artery, and to identify factors predictive of death. PATIENTS AND METHOD: A total of 38 nonconsecutive patients (mean age 69 [8] years) with a severe lesion in the left main coronary artery were treated with angioplasty and stenting between November 1997 and March 2003. The procedure was elective in 27 patients and urgent in the remaining 11. In 23 patients (60.5%) the left main coronary artery was not protected by aortocoronary bypass. All patients underwent clinical follow-up examination at 25 (20) months. RESULTS: Angiographically documented success was obtained in all patients. However, one patient died from acute occlusion one hour after the operation. Four patients (10%) had a non-Q-wave myocardial infarction. In-hospital mortality was 15.8% (6/38 patients). Five of the 11 patients (45.4%) who underwent emergency angioplasty and stenting died in the hospital from acute myocardial infarction complicated by severe (Killip grade III-IV) heart failure. However, only one of 27 patients (3.7%) in the elective surgery group died (P=.007). Major clinical cardiac events during follow-up occurred in 5 patients (13%); 3 died and the other 2 had recurrent angina. All patients who died had an unprotected left main coronary artery. Cumulative survival rates for the elective group were 92 (0.5)% at 6 months, 88 (0.6)% at 1 year and 86 (0.7)% at 3 years, respectively. For the emergency surgery group cumulative survival rate was 54 (0.2)% at 6 months (P<.05). CONCLUSIONS: Elective angioplasty and stenting of the left main coronary artery in selected patients was associated with a high immediate success rate. In patients who underwent elective angioplasty and stenting, the incidence of major cardiac events during follow-up was relatively low. Emergency angioplasty and signs of left ventricular dysfunction were the main predictors of in-hospital mortality.     

LONG-TERM CLINICAL AND ANGIOGRAPHIC RESULTS FOLLOWING PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

The long-term results of percutaneous transluminal coronary angioplasty were evaluated in our first 42 patients, who had initial successful angioplasty and no restenosis on angiogram performed four months after angioplasty. Evaluation included repeat follow-up angiogram performed approximately two years after angioplasty in 22 of the 42 patients. All 42 patients had single vessel disease with severe angina pectoris refractory to medical treatment before angioplasty; at a mean follow-up of 28 months after angioplasty, 37 (88%) were asymptomatic. No patient died or underwent coronary artery bypass graft surgery during the follow-up period, although three patients (7%) suffered a myocardial infarction due to occlusion of a nondilated artery. In the 22 cases studied at a mean of 28 months after angioplasty, angiogram showed that successful coronary artery dilatation remained in all cases, with no deterioration of a dilated lesion between the four and 28 month angiograms. Progression of atherosclerosis, however, did occur in five of the 22 patients (23%), with development of either stenosis or occlusion of a non-dilated vessel. This study suggests that the development of restonsis between four and 28 months after percutaneous transluminal coronary angioplasty is unlikely. The results suggest an excellent long-term prognosis after angioplasty, in patients who have no evidence of restenosis at four months after an initially successful dilatation.     

左主干病变导致急性ST段抬高型心肌梗死的诊治体会

目的:总结左主干狭窄或闭塞导致急性ST段抬高型心肌梗死(AMI)患者的临床特点,并提出其早期诊断和治疗体会.方法:复习我院2年内246例AMI急诊经皮冠状动脉介入治疗(PCI)的临床资料,其中7例梗死相关血管为左主干,均为男性,年龄36～83岁,所有患者无论是否存在心源性休克,均立即行主动脉内球囊反搏术,并在其支持下尽早接受急诊造影检查.结果:7例患者心电图均存在aVR导联ST段抬高(≥0.05 mV),5例患者同时存在V1 -V6导联ST段抬高及新出现完全右束支传导阻滞,其中4例入院时即存在严重心源性休克,6例急诊置入支架,另1例仅行球囊扩张,并接受急诊冠状动脉旁路移植术,住院期间死亡3例(42.9％),存活患者4例均完成1年随访.其中2例于1月随访时对其LAD进行PCI,1例于3月随访时进行了LAD和LCX的冠状动脉旁路移植术.结论:左主干急性闭塞或严重狭窄所致的AM I患者急性期病死率高;根据心电图和临床特点早期识别梗死部位,早期评估,并且无论是否出现低血压或心源性休克早期行主动脉内球囊反搏术,并在其支持下尽早再灌注治疗,加强术后监护,提高随访质量,可以挽救部分患者的生命和改善预后.     

Primary PTCA in a Rural Hospital

The results of primary percutaneous transluminal coronary angioplasty (PTCA) to treat patients with acute myocardial infarction in a rural hospital were reviewed. Thirty-five patients presenting with acute myocardial infarction, including 40% considered high risk, were treated using the strategy of primary angioplasty. Following cardiac catheterization, two patients were found to have anatomy deemed unsuitable for primary angioplasty and subsequently underwent urgent coronary artery bypass graft (CABG) surgery. Thirty-three patients underwent primary angioplasty with a procedural success rate of 94%. Procedural success was defined as reduction of the infarct arteries stenosis to less then 50% and the establishment of TIMI-III flow. Six percent of these patients required urgent CABG surgery because of unsuccessful angioplasty. In-hospital cardiac mortality was 3%. Six month follow-up was achieved for all patients. There were no cardiac deaths following hospital discharge. Recurrent ischemia occurred in 17% of the patients. Favorable in-hospital and late results were achieved. This review indicates that the strategy of primary angioplasty to treat myocardial infarction may be successfully applied in a rural setting.     

Repeat coronary angioplasty for restenosis: results and predictors of follow-up clinical events

To determine the predictors of long-term outcome after repeat percutaneous transluminal coronary angioplasty (PTCA), we analyzed the immediate and follow-up results of 144 patients who underwent a second PTCA procedure for restenosis of a previously successfully dilated lesion. Clinical success was obtained in 94% of patients. Emergency coronary bypass graft surgery was required in two patients (1%). Of the 136 successfully treated patients, 126 were followed for a duration of 6 to 36 months (mean 16, median 12 months). The follow-up coronary events (mutually exclusive) included cardiac death (2%), nonfatal myocardial infarction (2%), coronary bypass surgery (15%), and third PTCA (9%). According to results of Cox regression analysis, the independent variables associated with an increased risk of recurrent coronary events after repeat PTCA were: dilatation of a proximal left anterior descending artery stenosis at both initial and second PTCA (p = 0.001), time interval between the initial and the second PTCA less than or equal to 3 months (p = 0.001), multiple versus single-lesion redilatation at the time of repeat PTCA (p = 0.002), and the presence of diabetes mellitus (p = 0.005). Thus repeat PTCA for restenosis is a safe and efficacious procedure, and it provides excellent long-term outcome in the majority of patients. Dilatation of a proximal left anterior descending artery lesion, a short time interval between the first and second PTCA procedures, diabetes mellitus, and redilatation of multiple lesions are predictors of recurrent clinical events after a second PTCA. Repeat PTCA should be considered carefully for patients falling within a high-risk profile for recurrent events after the procedure.     

Repeat coronary angioplasty: efficacy of a third angioplasty for a second restenosis

To determine the efficacy of repeat percutaneous transluminal coronary angioplasty, 74 patients were studied who underwent a third angioplasty for a second restenosis of one coronary artery segment. The procedure was successful in 93% of patients. Procedural complications included emergency bypass surgery (three patients) and in-hospital death (two patients). At late follow-up (mean 18 months, range 7 to 49), 30 patients (43%) had a third restenosis treated with either a fourth angioplasty (16 patients), coronary bypass surgery (11 patients) or medical management (1 patient). Thirty-nine patients (57%) had no restenosis on the basis of follow-up angiography or absence of symptoms previously attributed to restenosis. Factors associated with a third restenosis included a shorter time interval (less than 3 months) between previous angioplasty procedures and dilation of the left anterior descending coronary artery. Among the 16 patients undergoing a fourth angioplasty for a third restenosis, the procedural success rate was 94%. One patient required emergency bypass surgery. At late follow-up (mean 16 months, range 7 to 38), eight patients (53%) had a fourth restenosis treated with either a fifth angioplasty (one patient), bypass surgery (five patients) or medical management (two patients). Considering all 74 patients undergoing a third angioplasty for a second restenosis, 27% had bypass surgery, 5% died, 4% were managed medically and 64% were free of angina at late follow-up after either a third, fourth or fifth angioplasty. Restenosis rates after a third or fourth angioplasty procedure for recurrent restenosis are higher than those for the initial procedures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty in the setting of large intracoronary thrombi

A cohort of 112 consecutive patients with angiographically defined intracoronary thrombi was treated with percutaneous transluminal coronary angioplasty and followed prospectively to determine early and late outcomes. Coronary angioplasty using a treatment modality of intravenous and intracoronary heparin, antiplatelet agents and prolonged inflations with oversized balloons (balloon:vessel ratio, 1.2:1) resulted in clinical success in 103 patients (92%) at hospital discharge. No periprocedural thrombolytic therapy was used and prolonged pretreatment with heparin was not routinely used. Four patients (3.5%) required elective coronary bypass surgery, and 4 patients (3.5%) required emergency coronary artery bypass grafting because of abrupt closure. Late clinical follow-up (mean 7 months) was available in 99 of the 103 successfully treated patients (96%). Seventy-three percent of patients were asymptomatic at follow-up, and 27% had class I or II angina. No patients had a late myocardial infarction. Elective coronary artery bypass surgery was required in 3 patients (3%) and repeat coronary angioplasty in 17 patients (17%). There were 2 late cardiac deaths at 7 months. Ninety-four patients (95%) had an event free follow-up defined as absence of coronary artery bypass surgery, myocardial infarction or death. In conclusion, coronary angioplasty alone, using intracoronary heparin and prolonged balloon inflations with relatively oversized balloons may be helpful to achieve a high initial success rate, low incidence of in-hospital complications and excellent long-term results in patients with intracoronary thrombus.     

Left main intervention revisited: Early and late outcome of PTCA and stenting

We reviewed our experience with 28 unselected, consecutive patients undergoing left main coronary artery (LMCA) angioplasty who had been considered unsuitable for coronary artery bypass graft surgery (CABG). Fourteen patients (50%) had a protected LMCA circulation. Balloon angioplasty was performed in 11 patients (39.3%), and stents were implanted in 17 patients (60.7%). The procedure was elective in 22 patients (78.6%) and acute in the setting of myocardial infarction/cardiogenic shock in (21.4%). The mean follow-up duration was 15.9 ± 12 months. There were 5 early (before hospital discharge) and 4 late deaths (total 32.1%), 1 myocardial infarction (3.6%), 6 repeat angioplasties (21.4%), and 3 subsequent CABG (10.7%). All 5 early deaths occurred in patients with cardiogenic shock and unprotected circulation. The results of our study suggest that when patients have prohibitive surgical risks, elective LMCA angioplasty and/or stenting may be undertaken with a high procedural success rate. However, our data do not support intervention in the presence of acute myocardial infarction/cardiogenic shock. Cathet. Cardiovasc. Diagn. 41:21–29, 1997. © 1997 Wiley-Liss, Inc.