Effect of percutaneous transluminal coronary angioplasty on arrhythmias complicating angina.

Four patients who had stenosis of a single major coronary artery which was treated by percutaneous transluminal coronary angioplasty are described. Three had exercise induced myocardial ischaemia complicated by ventricular tachycardia, fibrillation, and sinus bradycardia, respectively. Asystole developed in a fourth patient who had spontaneous chest pain. After successful percutaneous transluminal coronary angioplasty these arrhythmias did not recur spontaneously or on treadmill exercise testing. Percutaneous coronary angioplasty can be effective in preventing arrhythmias complicating acute myocardial ischaemia secondary to stenosis of a single major coronary artery.     

Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

Left main stem coronary stenosis is now uniformly treated with coronary artery bypass grafting. The advent of percutaneous transluminal coronary angioplasty has permitted a non-operative improvement in myocardial blood flow in many cases of single- and multi-vessel coronary atherosclerosis. The use of percutaneous transluminal coronary angioplasty in left main stem coronary stenosis has been sporadic and controversial. Twenty percutaneous transluminal coronary angioplasties were attempted in 19 patients as the treatment of choice for left main stem coronary stenosis in the past 66 months. The primary success rate was 95% (19/20 patients). The emergency surgery was performed only once (5%), and no death occurred secondary to percutaneous transluminal coronary angioplasty itself. In the follow-up (mean 41 months) period, 12 patients (63%) remained in satisfactory condition with no further need for surgical intervention. Seven patients (37%) ultimately required coronary artery bypass grafting. Although coronary artery bypass grafting will remain the fundamental treatment for left main stem coronary stenosis, this series delineates those anatomic and clinical exceptions wherein percutaneous transluminal coronary angioplasty may be utilized as the primary therapy for left main stem coronary stenosis.     

Contraindications for percutaneous transluminal coronary angioplasty in treatment of unstable angina pectoris

In recent years, the indications for percutaneous transluminal coronary angioplasty have expanded to include multivessel disease, unstable angina pectoris, stenosis of coronary bypass grafts, and recent total coronary occlusion. To evaluate our experience in using percutaneous transluminal coronary angioplasty to treat unstable angina, we reviewed the records of the patients who underwent this procedure at our hospital between January 1983 and December 1986. Of the 689 patients who underwent balloon angioplasty during the study period, 454 had stable angina and 235 had unstable angina; of the latter group, 34 (14.5%) required emergency coronary artery bypass grafting after balloon angioplasty failed. This outcome was associated with 2 risk factors: previous myocardial infarction and triple-vessel disease. Our data suggest that, in cases of unstable angina pectoris, percutaneous transluminal coronary angioplasty should be reserved for patients with single-vessel disease and no evidence of previous myocardial infarction. They also lend credence to the conclusion that the disease process in unstable angina is different from that in stable angina, and that therapy should be directed towards reducing platelet aggregation and correcting global ischemia, rather than towards balloon angioplasty of "culprit lesions."     

Abolition of exercise induced positive U-wave after coronary angioplasty: clinical implication

OBJECTIVE: We prospectively studied the course of exercise induced positive U-wave before and after percutaneous transluminal coronary angioplasty (angioplasty). BACKGROUND: Negative U-wave in ECG is known to be associated with the myocardial ischemia in the territory of the left anterior descending artery. Positive U-wave needs further evaluation to prove its diagnostic value in localization of coronary artery disease. METHOD: Twenty patients demonstrated exercise induced positive U-wave from a cohort of 730 patients referred because of chest pain. Exercise was carried to > or =90% of target heart rate. They underwent angiography and subsequent angioplasty for stenosis of 70% or greater. The exercise test was repeated post angioplasty. Careful screening for clinical endpoints and presence of ST segment depression and positive U-wave was done during exercise and the first 3 min of the recovery phase. RESULTS: Fifteen patients had isolated exercise induced U-wave and five had additional ST segment depression of > or =1 mm. Significant stenosis (>70% diameter reduction) of the circumflex artery was seen in 11 (55%) and of the right coronary artery in 9 (45%) patients. Coronary artery stenosis was reduced from 90+/-2% to 13+/-1% (mean+/-S.D.) P<0.001. On repeat of the exercise test U-wave and ST depression disappeared in all 20 individuals. Effort tolerance was improved after angioplasty for a mean duration of 3 min and 38 s, P<0.001. CONCLUSION: Exercise induced positive U-wave is an infrequent but specific marker of significant single coronary (circumflex or right) artery stenosis. It may lend itself to the detection of restenosis.     

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.     

Primary angioplasty for cardiogenic shock complicating acute myocardial infarction.

To evaluate the role of primary percutaneous transluminal coronary angioplasty in cardiogenic shock, 53 patients admitted with the diagnosis of acute myocardial infarction and cardiogenic shock were studied. Thirty-five (66.0%) patients received intravenous thrombolytic therapy (streptokinase 15 lac units) and 18 (34.0%) underwent primary percutaneous transluminal coronary angioplasty. There was no significant difference in the mean age, risk factor profile, presence of prior myocardial infarction, site of myocardial infarction and cardiac enzyme levels at presentation between the two groups. More male patients were present in the group undergoing primary percutaneous transluminal coronary angioplasty (94.44% vs 68.57%; p = 0.04). The time delay between the onset of symptoms and presentation to the hospital did not differ significantly between the two groups (318.9 vs 320.0 minutes; p = NS). In the primary percutaneous transluminal coronary angioplasty group, 17 patients had a single infarct-related artery and one had both left anterior descending and right coronary artery occlusion. Thus in 18 patients, 19 vessels were attempted. Angiographic success (< 50% residual stenosis) was achieved in 15 (78.94%) vessels of which TIMI III flow was achieved in 10 (52.63%) vessels and TIMI II flow in five (26.31%). Intra-aortic balloon pump was needed in five (27.77%) patients undergoing coronary angioplasty. In-hospital mortality was 27.77 percent in patients undergoing primary percutaneous transluminal coronary angioplasty and 57.14 percent in patients receiving intravenous thrombolytic therapy (p = 0.04). In the thrombolytic therapy group, mortality was higher (85.91%) in patients presenting six hours or later after the onset of symptoms as compared to those presenting in less than six hours of the onset of symptoms (50%). In primary percutaneous transluminal coronary angioplasty group, mortality was 21.42 percent in patients with successful and 50 percent in patients with failed angioplasty. Thus, in patients with acute myocardial infarction and cardiogenic shock, an aggressive invasive strategy with primary percutaneous transluminal coronary angioplasty, as compared to intravenous thrombolytic therapy, is helpful in reducing in-hospital mortality.     

Iatrogenic coronary stenosis after angioplasty

Restenosis is the usual mechanism of recurrent myocardial ischaemia in the months following successful percutaneous transluminal coronary angioplasty (PTCA). Control coronary arteriography may occasionally show another cause: the constitution of a new stenosis near the dilated segment or in the left main coronary stem after angioplasty in a branch of this artery. The authors report 4 cases of patients who developed new coronary stenoses within a few weeks of PTCA, interpreted as traumatic complications of the initial procedure due to a lesion of the intima with a secondary fibrotic reaction and luminal narrowing. The guiding catheter was probably responsible for the trauma to the left main coronary stem whereas the tips of either the balloon catheter or the guide wire were thought to have been responsible for the endothelial effraction of the dilated vessels.     

Experience of percutaneous transluminal coronary angioplasty in orthotopic cardiac transplant recipients.

We evaluated the role of percutaneous transluminal coronary angioplasty (PTCA) in a series of orthotopic cardiac transplant recipients with severe epicardial coronary occlusive disease. Ten orthotopic cardiac transplant patients treated by PTCA up to March 1990 were reviewed. All had significant epicardial coronary artery lesions (greater than 70% stenosis compared with the adjacent healthy artery) and exercise electrocardiogram or isotope perfusion evidence of myocardial ischaemia in the relevant region. Primary angiographic PTCA success was achieved in 12 of the 16 lesions attempted (75%). Mean stenosis improvement was from 80% of adjacent healthy artery (range 70-90%) to 12% (range 0-20%). Median angiographic follow-up of 9 months (2-25 months) is available for all patients. The mean recurrence rate is 33% (4 of 12 successfully treated lesions) defined as greater than 50% reduction in the original gain at the PTCA. We have shown that PTCA is technically possible in a series of cardiac transplant recipients. The primary success and recurrence rates are comparable to the use of PTCA in conventional atherosclerotic coronary disease.     

Prevention of subsequent exercise-induced periinfarct ischemia by emergency coronary angioplasty in acute myocardial infarction: comparison with intracoronary streptokinase

To compare the efficacy of emergency percutaneous transluminal coronary angioplasty and intracoronary streptokinase in preventing exercise-induced periinfarct ischemia, 28 patients presenting within 12 hours of the onset of symptoms of acute myocardial infarction were prospectively randomized. Of these, 14 patients were treated with emergency angioplasty and 14 patients received intracoronary streptokinase. Recatheterization and submaximal exercise thallium-201 single photon emission computed tomography were performed before hospital discharge. Periinfarct ischemia was defined as a reversible thallium defect adjacent to a fixed defect assessed qualitatively. Successful reperfusion was achieved in 86% of patients treated with emergency angioplasty and 86% of patients treated with intracoronary streptokinase (p = NS). Residual stenosis of the infarct-related coronary artery shown at predischarge angiography was 43.8 +/- 31.4% for the angioplasty group and 75.0 +/- 15.6% for the streptokinase group (p less than 0.05). Of the angioplasty group, 9% developed exercise-induced periinfarct ischemia compared with 60% of the streptokinase group (p less than 0.05). Thus, patients with acute myocardial infarction treated with emergency angioplasty had significantly less severe residual coronary stenosis and exercise-induced periinfarct ischemia than did those treated with intracoronary streptokinase. These results suggest further application of coronary angioplasty in the management of acute myocardial infarction.     

Ten year follow up of patients with single vessel coronary artery disease that was suitable for percutaneous transluminal coronary angioplasty

The 10 year outcome of patients with single vessel coronary artery disease who underwent coronary angiography more than 10 years before and who would have been potential candidates for percutaneous transluminal coronary angioplasty had it been available then is reported. Long term follow up data were obtained in 96 (91 men, five women; mean age 48 years) of 105 consecutive patients with single vessel coronary artery disease (greater than 70% stenosis), judged suitable for coronary angioplasty. Fifty patients had coronary bypass surgery within six months of catheterisation (surgical group) and 46 were treated medically (medical group). At entry to the study more patients in the surgical group had unstable angina, but fewer had a previous history of myocardial infarction. Ten year survival was 91% and remained excellent in all the subsets analysed. Moreover, the quality of life of these patients was good. Over the 10 year follow up, 16 (36%) of the patients treated medically and 13 (26%) in the surgical group were admitted to hospital because of cardiovascular events (including late coronary surgery in four of the patients treated medically). Lastly, 54/69 (78%) of the patients who were employed before catheterisation resumed work and 29 (42%) were still employed 10 years later. Although these data must be interpreted with care because of the limitations inherent in all retrospective studies, it appears that the long term results of conventional medical or surgical treatment are excellent in patients with single vessel coronary artery disease in whom percutaneous transluminal coronary angioplasty is now an option.     

Ten year follow up of patients with single vessel coronary artery disease that was suitable for percutaneous transluminal coronary angioplasty.

The 10 year outcome of patients with single vessel coronary artery disease who underwent coronary angiography more than 10 years before and who would have been potential candidates for percutaneous transluminal coronary angioplasty had it been available then is reported. Long term follow up data were obtained in 96 (91 men, five women; mean age 48 years) of 105 consecutive patients with single vessel coronary artery disease (greater than 70% stenosis), judged suitable for coronary angioplasty. Fifty patients had coronary bypass surgery within six months of catheterisation (surgical group) and 46 were treated medically (medical group). At entry to the study more patients in the surgical group had unstable angina, but fewer had a previous history of myocardial infarction. Ten year survival was 91% and remained excellent in all the subsets analysed. Moreover, the quality of life of these patients was good. Over the 10 year follow up, 16 (36%) of the patients treated medically and 13 (26%) in the surgical group were admitted to hospital because of cardiovascular events (including late coronary surgery in four of the patients treated medically). Lastly, 54/69 (78%) of the patients who were employed before catheterisation resumed work and 29 (42%) were still employed 10 years later. Although these data must be interpreted with care because of the limitations inherent in all retrospective studies, it appears that the long term results of conventional medical or surgical treatment are excellent in patients with single vessel coronary artery disease in whom percutaneous transluminal coronary angioplasty is now an option.     

Visualisation of exercise-induced ischaemia of the right ventricle by thallium-201 single photon emission computed tomography.

OBJECTIVE: Exercise thallium-201 (201T1) single photon emission computed tomography (SPECT) has been used to detect potential ischaemia in the left ventricular myocardium but not in the right ventricle. The purpose of this study was to establish the clinical usefulness of a right ventricular polar map of 201T1 SPECT for visualisation of exercise-induced right ventricular ischaemia. METHODS: Myocardial 201T1 SPECT was obtained immediately after treadmill exercise in 97 patients with suspected coronary artery disease. A region of interest was placed over the right ventricle (RV) on post-stress transaxial images. Short axis images of this region were generated and reconstructed as a bull's eye polar map. Normal ranges of RV 201T1 uptake were determined in 12 patients with normal coronary arteries. Scintigraphic criteria for identifying RV perfusion abnormality were derived from 25 patients with right coronary artery (RCA) stenosis greater than 75%. These criteria were applied to 60 consecutive patients with suspected coronary artery disease. RESULTS: Perfusion defects in the RV were larger in patients with proximal RCA stenosis than in those with distal RCA stenosis (mean (SD) 28 (16)% v 6 (5)%, P < 0.001). The sensitivity and specificity of the RV polar map for the detection of proximal RCA stenosis were 67% (8/12) and 98% (47/48), respectively. RV perfusion defects became undetectable in 9 patients who had successful percutaneous transluminal coronary angioplasty to a proximal RCA lesion. CONCLUSIONS: A right ventricular polar map display was useful for visualising exercise-induced right ventricular ischaemia.     

The spectrum of pathology associated with percutaneous transluminal coronary angioplasty during acute myocardial infarction

The purpose of this study was to determine at necropsy the morphologic consequences of percutaneous transluminal coronary angioplasty performed during acute myocardial infarction. The heart was examined in four patients who died between 6 hours and 4 days after coronary angioplasty. The patients had angioplasty of the left main coronary artery (one patient), left anterior descending coronary artery (two patients) and left circumflex coronary artery (one patient). Necropsy revealed residual stenosis, intimal hemorrhage and plaque disruption in all four patients. Also noted were distal embolization of plaque elements (two patients) and thrombotic occlusion of the coronary artery (one patient). In conclusion, the morphologic changes after angioplasty are varied. These changes illustrate the mechanisms of angioplasty and some of the complications that can be expected in a small number of cases. The morphologic changes associated with coronary angioplasty are similar in patients undergoing elective or emergency angioplasty although medial dissection was not observed in these patients with an evolving myocardial infarction.     

Unprotected left main stenting in acute myocardial infarction

Left main stenosis is a rare cause of acute myocardial infarction. Emergent percutaneous transluminal coronary angioplasty (PTCA) of the left main coronary artery has been shown to have greatly increased procedural and short-term mortality. Stenting decreases the incidence of abrupt closure and has a lower restenosis rate after PTCA. We present a case of a patient presenting in cardiogenic shock due to an acute anterior myocardial infarction who underwent emergent left main coronary artery stenting.     

Percutaneous transluminal coronary angioplasty: Its potential impact on surgery for coronary artery disease

The potential impact of percutaneous transluminal coronary angioplasty on surgery for angina pectoris was evaluated in 500 consecutive patients referred because of intractable symptoms. A positive lesion, that is, one appropriate for percutaneous transluminal coronary angioplasty, was defined as proximal, discrete, segmental, subtotal, noncalcific and stenotic. Significant disease was observed in 1,079 major coronary arteries, of which 9.4 percent were not appropriate for bypass surgery. Positive lesions were observed in 115 arteries (10.7 percent); these were in the left anterior descending artery in 60; in the right coronary artery in 37 and in the left circumflex artery in 18 cases. Main left coronary artery disease was present in 31 patients with six lesions appropriate for coronary angioplasty. Of these six patients none had isolated left main coronary artery disease. Operable coronary lesions were noted in 474 patients of whom 105 (22 percent) had positive lesions appropriate for angioplasty. The age of patients with such lesions was not significantly different from that of the remaining patients. However, the duration of clinical heart disease was significantly (p <0.01) shorter in those with positive lesions, with the frequency of such lesions inversely related to duration of disease, and myocardial infarction was less frequent in those with angioplastic lesions (28.6 versus 43.5 percent, p <0.01). An ideal patient for percutaneous transluminal coronary angioplasty was defined as one with a positive lesion in all operable coronary arteries. Thus, 40 patients were considered ideal for this procedure and represented 8.4 percent of operable candidates. Thirty patients had single vessel disease (of the left anterior descending artery in 19, the right coronary artery in 8 and the circumflex artery in 3) and 10 had disease of two vessels. No patient with triple or left main coronary artery disease was ideally suited for percutaneous transluminal coronary angioplasty. The only factor that distinguished the patient ideally suited for angioplasty from the remaining patients was a shorter duration (2.0 versus 4.1 years) of clinical disease (p <0.01) and a lesser frequency (15 versus 43 percent) of myocardial infarction (p <0.01). Seven additional patients were noted as being less ideal for coronary angioplasty, but still potential candidates. It is concluded that percutaneous transluminal coronary angioplasty may play a role in only 8 to 10 percent of patients with angina pectoris.     

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less.

OBJECTIVE--To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians. SETTING--A tertiary referral cardiac centre. PATIENTS--57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient. RESULTS--The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival. CONCLUSIONS--In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.     

The importance of electrocardiographic changes at rest during exercise in deciding to perform immediate ("ad hoc") percutaneous transluminal coronary angioplasty

In 100 patients (75 men and 25 women, mean age 53 years) who had "ad hoc" percutaneous transluminal coronary angioplasty (PTCA) on one or two vessels retrospectively the ECG records were evaluated (signs of necrosis or ischaemia) at rest and/or after exercise and compared with the finding of major obstruction (complete occlusion, stenosis > 50%) on coronarography. In obstruction of the ramus interventricularis anterior the positive ECG finding was consistent with the area of the impaired blood supply in 87%, in case of obstruction of the right coronary artery in 79%, in obstruction of the ramus circumflexus in 90%. In concurrent obstruction of two coronaries despite a 100% positive ECG no close topical correlation was found between coronarography and ECG. On the whole no reliable consistency was found between ECG and kinetic disorders detected by echocardiography. The results indicate that topical analysis of ECG ischaemic findings in patients with coronary arterial disease before planned coronarography contributes to the decision to make "ad hoc" PTCA in affections of one artery. In affections of two arteries ECG is of no particular value.     

Subacute left main coronary stenosis: an unusual but serious complication of percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is a proven nonoperative method of direct myocardial revascularization. Acute complications occurring during PTCA center primarily around acute disruption at the site of dilatation, arrhythmias, or vascular problems at the site of guide catheter access. Late complications include restenosis or aneurysm formation at the site of dilatation. Subacute stenosis of the left main coronary artery occurred in three of 440 patients who had PTCA performed between September 1980 and December 1983 and may be an infrequent but potentially critical complication of PTCA. The serious clinical course of patients with left main coronary stenosis requires prompt recognition and intervention.     

Blood velocity measurements during selective coronary angiography before and after percutaneous transluminal coronary angioplasty

The velocity of blood flowing down a coronary artery may provide an index of myocardial perfusion, independent of the need for measuring the amount of myocardium supplied by a vessel. The velocity of the leading edge of contrast material was therefore measured before and after percutaneous transluminal coronary angioplasty in 15 patients utilizing digitized images from routine coronary angiography. The velocity (mean +/- SD) before percutaneous transluminal coronary angioplasty in the 15 patients was 11.9 +/- 6.0 cm/s, increasing to 21.7 +/- 8.7 cm/s after (P less than 0.01). There was a correlation between the percent change in velocity and the change in percent stenosis before and after percutaneous transluminal coronary angioplasty (r = 0.65; P less than 0.001). The mean absolute interobserver and intraobserver variabilities for the velocity measurements were 2.1 and 1.8 cm/s, respectively. Measurement of coronary flow velocity from data obtained at the time of routine coronary angiography is an easily performed reproducible technique, which may be used to assess the results of an intervention such as percutaneous transluminal coronary angioplasty.     

Percutaneous transluminal coronary angioplasty as alternative treatment to coronary artery bypass surgery in iatrogenic stenosis of the left main coronary artery

The present report describes three patients with iatrogenic left main coronary artery after aortic valve replacement. All three patients were successfully treated by percutaneous transluminal coronary angioplasty. No clinical or angiographic signs of restenosis were seen during the long-term follow-up (4, 6, and 11 years). These patients show the feasibility of percutaneous transluminal coronary angioplasty in iatrogenic left main coronary artery stenosis as alternative of coronary artery bypass surgery. However, it should be only considered in patients who would otherwise be deemed inoperable, refused reoperation, and are willing to take the risk involved.