New Trends in Coronary Revascularization: Neoangiogenesis by Human Growth Factors

This article is a report of our clinical experience with the human growth factor FGF as applied to the ischemic human myocardium. After the completion of extensive preliminary animal experiments, the growth factor FGF, obtained from genetically manipulated Escherichia coli bacteria and highly purified, was introduced into aortocoronary bypass surgery as an additional therapeutic agent. A double-blind study was carried out on 40 patients with coronary heart disease, separated into "growth factor" and control groups, each containing 20 members. All patients were treated for coronary three-vessel vascular disease, in each case with an IMA bypass for the LAD and single venous bypasses for the RCX and or RCA. To bridge over additional peripheral stenoses in the LAD or one of its branches, human growth factor FGF was injected into the myocardium of those in the growth factor group. Twelve weeks later, the IMA bypasses were selectively demonstrated by intraarterial DSA. These angiographs were then quantitatively evaluated. In all patients of the growth factor group, the formation of new vessels could be demonstrated in the region where FGF had been administered in a manner strictly reminiscent of our experimental results. A capillary net sprouting from the coronary artery and making further connection with this vessel could be demonstrated, and the computer-supported evaluation of the angiographs showed a significant increase in the blood supply of the region of the myocardium injected. The use of FGF may be the appropriate treatment for patients with peripheral stenosis or diffuse coronary arteriosclerosis who cannot be treated surgically. However, large randomized studies are required to confirm these results.     

Evaluation of Fusion Beat Detection with a New Ventricular Automatic Capture Algorithm in ICDs

This study evaluated a newly developed automatic capture verification scheme for implantable cardioverter defibrillators (ICDs) regarding discrimination of capture, fusion, and noncapture beats, with an emphasis on fusion detection. The algorithm uses evoked response detection based on a sensing vector from right ventricular shocking coil to Can. Patients undergoing ICD implant or replacement were enrolled in this study. An external system was used for pacing and data acquisition. To provoke ventricular fusion beats, VVI patients were paced close to the rate of their intrinsic rhythm and DDD patients were paced close at their intrinsic PR interval. Surface ECG and wideband filtered intracardiac electrograms were recorded for off-line analysis. Each paced beat was independently classified visually by surface ECG and by the automatic detection algorithm. The algorithm performance was then evaluated by comparing the classification results. Twenty-seven patients (22 males, 5 females; 63.8 ± 12.5 years) were analyzed. Device and lead demographics were: 18 DDD/9 VVI; 16 dedicated bipolar, 11 integrated bipolar leads; 18 acute, 9 chronic (3.7 ± 2.0 years) leads. In total, 2064 beats were analyzed, including 1,477 fusion beats and 587 capture beats. Fusion detection sensitivity and specificity were 99.5% and 99.0%, respectively. Seven true-fusion beats (0.5%) were classified as capture and 6 capture beats (1.0%) were identified as fusions. Capture or fusion beats were never detected as non-capture beats. It is concluded that the algorithm was effective in detecting fusion beats. It could potentially be used in ICD applications that need accurate fusion detection.     

Evaluation of Autosensing as an Automatic Means of Maintaining a 2:1 Sensing Safety Margin in an Implanted Pacemaker

As intracardiac signal amplitudes fluctuate due to patient activity, drug intake, and other factors, it is imperative that an adequate sensing safety margin in an implanted pacemaker be used to compensate. We studied an investigational autosensing feature that automatically adjusts the device's sensitivity. Data were collected from 55 patients, with Intermedics model 292–03 or 294–03 pacemakers, upon inclusion of the study (Visit 1); 1 month postinclusion (Visit 2); 1 month, 1 day postinclusion (Visit 3); then 1 month, 2 days postinclusion (Visit 4). Atrial (N = 45) and/or ventricular (N = 54) thresholds were assessed at each visit; during Visit 2, myopotential tests were performed at two sensitivity settings. Autosensing was activated following Visit 1, then programmed on randomly at Visit 2 or Visit 3. From Visit 2 - Visit 4, patients were monitored during daily activities (D), exercise (E), and sleep (S) with 24-hour Holter. With Autosensing on, atrial undersensing episodes were D = 33 (p > 0.2), and S = 28 (p < 0.05); ventricular undersensing episodes were D = 6 (p > 0.5). Ventricular oversensing episodes were S = 2; atrial oversensing episodes were S = 34 (p > 0.5), D = 2, and E = 3. Comparing Autosensing adjusted sensitivity with the recommended 2:1 safety margin, 4 patients (p = 0.15) experienced atrial myopotential oversensing, and 2 patients (p = 0.15) ventricular. No unanticipated clinical events occurred. Compared with the recommended 2:1 sensing safety margin, the Autosensing feature performed equal to manual programming in preventing episodes of under/oversensing, and was better for atrial undersensing during sleep. Autosensing obviates the need for periodic reprogramming of a fixed sensitivity value.     

Intracoronary Beta-Radiation Therapy for In-stent Restenosis: Long-Term Success Rate and Prediction of Failure

Objective: The following retrospective observational study assesses the long-term results of intracoronary beta-radiation therapy for patients with in-stent restenosis.
Background: Beta-radiation has been used to treat patients with coronary in-stent restenosis. However, long-term clinical success using this technique has not at this time been established.
Methods: Two-hundred and thirteen consecutive patients received intracoronary brachytherapy (noncentered beta-emitter, Novoste BetaCath™) for in-stent restenosis and were followed up over a period of 39.1 ± 18.4 months. The combined end-point was defined as a major adverse clinical event (MACE) and comprised mortality, acute myocardial infarction, or target vessel revascularization (TVR).
Results: MACE occurred in 110 patients (51.6%): death in 27 patients (12.7%), acute myocardial infarction in 8 patients (3.8%), TVR in 90 patients (42.3%). TVR comprised percutaneous coronary reinterventions in 76 patients (35.7%) and coronary bypass surgery in 24 patients (11.3%). Secondary end-point was determined as target vessel failure and occurred in 93 patients (43.7%). Of note, the frequency of at least two previous target lesion interventions as well as impairment of left ventricular function was associated with reduced success rate, whereas other clinical parameters did not indicate outcome after treatment with intracoronary radiation therapy.
Conclusion: During the mean, a period of 3 years, more than half of the patients receiving intracoronary radiation therapy reached primary end-point, representing, in the main, TVR. During this period a mortality rate of nearly 13% was documented. These results signify a delayed, though continued, restenotic process after index procedure. (J Interven Cardiol 2010;23:60–65)     

Favorable Long-Term Survival in Patients Undergoing Stent PCI of Unprotected Left Main Coronary Artery Compared to Predicted Short-Term Prognosis of CABG Estimated by EuroSCORE: Clinical Determinants of Long-Term Outcome

Aims/Methods: The long-term outcome of patients (pts) undergoing percutaneous coronary intervention (PCI) of unprotected left main coronary artery (LMCA) is unclear so far . We prospectively investigated the outcome of 102 consecutive patients who underwent stent PCI of unprotected LMCA. Patients were divided according to clinical indication for PCI: stable coronary artery disease (CAD) (N = 60), NSTEMI (N = 18), STEMI (N = 24). Expected in-hospital mortality of coronary artery bypass grafting (CABG) was calculated using the European System for Cardiac Operative Risk Evaluation ( EuroSCORE ) and compared to the observed survival rate during long-term follow-up (mean 1.8 ± 1.2 years).
Results: The observed 30-day mortality was 1.7% (1/60 pts) in patients with stable CAD, 11% (2/18 pts) in NSTEMI patients, and 13% (3/24 pts) in STEMI patients. The observed mortality was lower than the predicted mortality of CABG as calculated by the logistic EuroSCORE. Using receiver-operator characteristics curves (ROC), EuroSCORE demonstrated a high predictive value for both 30-day mortality as well as 1-year mortality (AUC > 0.8; P < 0.01). Prognostically relevant patient related factors (P < 0.01) included severely reduced left ventricular ejection fraction (HR 3.24), ACS (HR 3.18), STEMI (HR: 3.01), Killip class IV (HR 7.69), occurrence of neoplastic disease (HR 3.97), and elevated CRP (HR 3.86).
Conclusions: LMCA-PCI was associated with lower long-term mortality rates compared to the estimated mortality of CABG. This prospective observational study suggests that DES-PCI of unprotected LMCA in "all-comers" can be carried out with reasonable risk .     

Management of Lower Lid Ectropion

BACKGROUND: Ectropion repair is a challenge in plastic surgery. Depending on the etiology of the underlying problem, a variety of surgical techniques are available. The etiology, operative management, and recurrence rate are presented. OBJECTIVE: An improvement of the deformity or, in the ideal case, a functional and aesthetic restoration should be accomplished. MATERIALS AND METHODS: In this study, 58 patients with ectropion treated from June 2002 until March 2004 were analyzed, 33 with scar contractures, 13 with a tumor of the lid margin, 8 with facial paralysis, and 4 with senile ectropion. Surgical procedures included lateral or medial canthopexy, lateral tarsorrhaphy, wedge excision, skin graft, local flaps, cartilage graft, fascial slings, and combined procedures in one-third of the patients. RESULTS: Postoperative complications included incomplete correction and others in 18.9% of the patients. Eight patients (13.8%) had to be reoperated. CONCLUSION: Correction of the lower lid area including restoration of the lid margin in terms of shape and position is the surgical end point. The preoperative analysis is mandatory for a surgical solution to this severe problem, which is associated with a high incidence of recurrence, especially in difficult reconstructive cases. An individual sophisticated strategy combined with experience in the variety of surgical techniques is mandatory. Frequently, multiple procedures are necessary.