Impact of drug-eluting stent generation on patient- and stent-related adverse events of diabetic patients treated by percutaneous coronary intervention

AIM

Aim of the present study was to assess stent- and patient-related outcomes of the first- vs. second-generation drug-eluting stents (DES) in diabetics, according to the insulin requirement status.

METHODS

Data were obtained from a prospective, single-center registry of 816 consecutive patients with diabetes mellitus (23% insulin-requiring) who underwent percutaneous coronary intervention (PCI) between April 2003 and May 2012 with first- (N.=534) or second-generation DES (N.=282) at our Institution, with at least 12 months of follow-up. We assessed the occurrence of stent-related outcome, including cardiac death, target vessel-related myocardial infarction and target lesion revascularization, versus patient-related outcome, including any cause death, any myocardial infarction and any coronary revascularization.

RESULTS

Patients treated with second-generation DES were older and had more complex lesions than patients treated with first-generation DES. Both among patients treated with first-generation DES and those treated with second generation DES, patient-related events were almost double than stent-related events. No interactions were observed between the DES generation type and insulin requirement status.

CONCLUSION

In this observational study, first- and second-generation DES were equally safe and efficacious in diabetic patients undergoing PCI, regardless of insulin requirements. The greater number of patient-related than stent-related events in patients with complex clinical and lesion characteristics emphasizes that the optimization of secondary prevention is at least as important as the selection of which new generation DES to implant in a specific lesion.

Ventricular assist devices

Despite major advances in the treatment of heart failure over the past two decades, improving the natural history of this condition, heart failure continues to be a major source of morbidity and mortality. Although availability of heart donor for transplantation has declined over the past several years, innovations in ventricular assist device (VAD) technology has provided an alternative therapeutic option for patients with advanced heart failure. Initiated as a mechanical option to "bridge" critically ill patients awaiting transplantation, VADs are being increasingly deployed as "destination" devices to provide long-term support. With technical advances resulting in improved mechanical reliability, reduced postoperative morbidity and greater likelihood of patient acceptance, there is interest in expanding the applicability of VAD beyond the current indication, as destination therapy for severely ill patients who are not candidates for transplant. This review examines the rational as well as the technical details of the different generation of VADs for mechanical cardiac support, implanted either surgical or percutaneously. These devices are at various stages of development and clinical investigation. One or more of these newer devices is likely to emerge as an important development in the treatment of patients with advanced heart failure.

Percutaneous revascularization of coexisting severe carotid and coronary artery disease: a case report

Following the NASCET and ACAS trials, the use of carotid endarterectomy for the treatment of carotid artery stenosis has become widespread. However, in high-risk patients, the perioperative morbidity and mortality have reached 18%. In such populations, a percutaneous approach including coronary angioplasty and stenting of the carotid lesion could be an option worth exploring. In this report we discuss a case that is representative of our experience with the simultaneous treatment of critical carotid and coronary stenosis. A 74-year-old patient with advanced coronary artery disease and severe bilateral carotid pathology was submitted to coronary angioplasty and stenting of the carotid lesions.

Angiographic presentation of coronary artery spasm in heart transplant recipients

We describe the angiographic characteristics of coronary artery spasm observed in 12 out of 247 (4.9%) patients who underwent 808 coronary angiographies after heart transplantation. Coronary artery spasm was diagnosed when localized and reversible narrowing of the coronary lumen was identified. After coronary artery spasm identification all patients were followed-up clinically for a mean period of 5.1 years. Coronary artery spasm was documented 1-3 years after heart transplant. Coronary artery spasm affected 1 main coronary artery in 10 patients and 2 in 2 patients; in 3 patients 1 or more secondary branches were also affected. The right coronary artery was affected by coronary artery spasm in 8 patients and the anterior descending coronary artery in 6 patients. In 6 patients coronary artery spasm was mechanically induced by the catheter tip. The degree of luminal narrowing due to coronary artery spasm ranged from mild to almost complete occlusion. Coronary artery spasm appeared as a single tubular smooth and concentric stenosis in 8 patients, was discrete in 2 patients and multiple on the same vessel in 2 patients. In 1 patient coronary artery spasm was erroneously interpreted as an organic lesion and percutaneous transluminal coronary angioplasty was planned. During follow-up 3 patients out of 4 who had shown multiple coronary artery spasm died and 2 patients developed critical organic stenosis. In conclusion coronary artery spasm after heart transplant is less rare than commonly believed. Although it usually has a peculiar appearance, it can be misinterpreted as an organic lesion. Multiple coronary artery spasm appears to carry a poor prognosis.

Analytical expression of effective afterload in aortic and mitral regurgitation

Effective arterial elastance (Ea) is the coupling parameter between the left ventricle and peripheral circulation in normal subjects. If left ventricular end systolic pressure (Pes), contractility (Es) and Ea are known, left ventricular end diastolic volume (LVEDV) and ejection fraction of the ventricle are completely determined. The aim of this study was to give an analytical expression for Ea in patients with mitral and aortic regurgitation, and predict both LVEDV and the effect of vasodilator therapy on LVEDV. Twenty-three subjects with atypical chest pain, 15 patients with mitral insufficiency and 11 with aortic insufficiency underwent diagnostic cardiac catheterization, coronary angiography, and left ventricular cineangiography, which was analyzed quantitatively. Ea was 2.05 +/- 0.63 in normal subjects, while it was 1.28 +/- 0.71 and 1.57 +/- 0.87 in patients with mitral and aortic insufficiency, respectively. All these groups differed with ANOVA test (p = 0.0031). We tested the ability of the analytical expressions for Ea in normal subjects, and patients with mitral insufficiency or aortic insufficiency to predict measured Ea and LVEDV. Ea and LVEDV were predicted rather accurately in every case (p < 0.0001). We used published data to test the effect of resistance modulation on LVEDV. Predicted and measured LVEDV were linearly correlated both in aortic (p < 0.0001) and mitral insufficiency (p = 0.027). Moreover, in some cases a left ventricular enlargement after vasodilator therapy could be anticipated because of an unbalanced decrease in resistance and heart rate. Ea seems to be the coupling parameter between the left ventricle and the peripheral circulation not only in normal subjects, but also in patients with mitral or aortic regurgitation; its measurement before administering vasodilating drugs may be useful in order to predict the effects on LVEDV, and achieve an optimal ventriculoarterial coupling.

[Immediate and long-term results of treatment of focal lesions with aortocoronary venous bypass with a stent implant]

Patients with recurrent angina after coronary artery bypass graft surgery pose a problem. Stent implantation has been advocated in an effort to avoid repeat operation and to address the limitations of balloon angioplasty. Aim of the present study was to determine the in-hospital and long-term results of stent deployment in focal, de novo lesions of vein grafts. Thirty-five focal, de novo lesions of vein grafts in 31 patients were treated with stent deployment. Twenty-four patients (77%) had three vessels, 6 (20%) two vessels and 1 (3%) single vessel disease. Saphenous vein grafts aged 9.7 +/- 4.2 years (range 1-19 years). Twenty-two lesions (63%) were located within the body of the saphenous graft, 8 (23%) at the graft/coronary artery anastomosis and 5 (14%) at the aorta/graft anastomosis. The indications for stent deployment included: suboptimal result from balloon angioplasty (defined as > or = 50% post-angioplasty residual stenosis) in 29/35 lesions (83%); post-angioplasty coronary dissection with threatening occlusion in 4/35 (11%); abrupt closure in 2/35 (6%). Patients were screened for death, myocardial infarction, bypass surgery and repeat angioplasty during in-hospital stay and after a follow-up of 12 +/- 8 months. Even-free survival curve was constructed by the Kaplan-Meier method. Stent deployment was successful in all patients. One stent was deployed in 24/35 lesions (69%), half Palmaz-Schatz stent in 6/35 (17%) and 2 or more stents in 5/35 (14%). The balloon/vessel ratio resulted of 1.0 +/- 0.1 Minimal lumen diameter increased from 0.8 +/- 0.4 to 3.8 +/- 0.6 mm, with a mean gain of 1.8 +/- 0.6 mm (range 1.8-4.0 mm). During the in-hospital period 1 patient (3.2%) died and 1 (3.2%) had a non Q wave myocardial infarction. Therefore, the clinical success rate, was 94%. During the follow-up period, 2 patients died (6.9%), 2 (6.9%) developed a non Q wave myocardial infarction, 1 (3.4%) underwent bypass surgery and 3 (10.3%) underwent repeat angioplasty. The estimated 2-year event-free survival rate (free from myocardial infarction, repeat surgery and repeat angioplasty) was 62%. In conclusion, Palmaz-Schatz stent deployment in focal, de novo vein grafts presents a high rate of procedural success, a low rate of acute complications and good long-term results.

Intracoronary stenting for thrombus-containing lesions in the setting of acute ischemic syndromes

AIM

The presence of intracoronary thrombus was considered a contraindication for stent deployment. Recently, many investigators have demonstrated that the use of stents for thrombus-laden lesions under both elective and bail-out conditions is effective and safe, even in the setting of acute myocardial infarction (AMI).

METHODS AND RESULTS

In this study Palmaz-Schatz stents were implanted to treat suboptimal results and complications of percutaneous transluminal coronary angioplasty (PTCA) in 41 thrombus-containing lesions. Clinical presentation was unstable angina in 24 and AMI in 17 patients. Stents were deployed because of suboptimal result (n = 27), coronary dissection with threatening occlusion (n = 13) or abrupt closure (n = 1). An angiographic successful deployment was obtained in all but one lesions (98%). Four patients (9.8%) suffered from in-hospital complications: three developed a non fatal non-Q wave AMI and one died. There was no need for emergency coronary artery bypass graft surgery, repeat PTCA or blood transfusion for vascular complications. At six-months follow-up one patient (2.6%) developed a non-Q wave AMI and two (5.1%) underwent a repeat coronary angioplasty.

CONCLUSIONS

Our experience confirms that adequately dilated Palmaz-Schatz stent might be safe and effective for thrombus-containing lesions in the setting of acute ischemic syndromes.

[Coronary angioplasty in acute myocardial infarction]

Primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) allows to obtain a higher reperfusion rate in the culprit vessel than thrombolytic therapy, reducing the incidence of death, non fatal reinfarction and recurrent ischemia. The aim of this study was to test the in-hospital and mid-term results of an early invasive strategy with PTCA in patients with AMI. Thirty-four patients with AMI underwent coronary angiography within 3 hours from the onset of symptoms. Twenty-four patients had anterior AMI and 3 were in cardiogenic shock. Three patients, 1 without significant lesions and 2 with multivessel diffuse coronary disease, were left out of the procedure, and 31 patients underwent PTCA. Twenty-six lesions were total occlusions with TIMI flow 0.A TIMI flow 1 was present in the other 5 vessels. Stent deployment was decided for 16 lesions (52%). Primary success (TIMI flow 3 with mean residual stenosis of 15 +/- 20%) was obtained in 30 patients (97%). In 1 patient recanalization of the anterior descending coronary artery was not possible due to tortuosity of the abdominal and thoracic aorta. At pre-discharge angiography a good result was confirmed in 24/25 patients. After 6 months only 1 patient (3%) underwent a new PTCA for recurrent angina. In conclusion, primary PTCA for AMI within 3 hours of symptom onset allows good in-hospital and mid-term results with a low rate of complications.

Troponin T, creatine kinase MB mass, and creatine kinase MB isoform ratio in the detection of myocardial damage during non-surgical coronary revascularization

The presence of myocardial injury during non-surgical coronary revascularization has been evaluated by means of highly specific and sensitive biochemical markers. Troponin T, creatine kinase-MB isoenzyme mass concentration, and creatine kinase MB2/MB1 isoform ratio have been determined in 80 patients who underwent coronary revascularization with percutaneous transluminal coronary angioplasty (PTCA). Forty-five patients underwent balloon angioplasty, 15 rotational atherectomy, 10 directional atherectomy, and 10 elective coronary stenting. Serum concentration of the evaluated markers did not increase significantly after 57 uncomplicated revascularization procedures, including 15 rotablation procedures, nor after 8 PTCAs complicated by localized coronary type B and C dissections. Significant elevation of all markers above the upper limits of the reference interval (P < 0.05) was detected after occlusion of small side branches (< 0.5 mm diameter) in 5 patients. Creatine kinase MB2/MB1 isoform ratio was the earliest marker to increase. After recanalization of occluded vessels in 8/10 patients with 6-60 days old myocardial infarction only troponin T concentrations increased from a baseline of 0.28 microgram/l to a median peak of 0.80 microgram/l. This increase was statistically not significant (P = 0.12). In conclusion, myocardial damage was not detected following uncomplicated non-surgical revascularization obtained with different techniques. Markers of myocardial injury provide high sensitivity after small side branch occlusion.

[Percutaneous mitral valvuloplasty in mitral restinosis after surgical commissurotomy]

The frequency of mitral restenosis after surgical commissurotomy has been estimated between 10 and 30% up to 10 years and 85% up to 28 years. Aim of this study was to analyze the results of balloon mitral valvuloplasty (BMV) in a series of patients with previous surgical commissurotomy.

METHODS

Between December 1988 and December 1995 432 patients underwent BMV. Of these patients, 30 (6.9%; 10 men, 20 women, aged 53 +/- 12 years) had recurrent mitral stenosis after surgical commissurotomy. Contraindications to BMV were the evidence of left atrial thrombi at transesophageal echocardiography and/or of mitral insufficiency > 2+/4+. The Inoue's single balloon catheter was used for all the procedures.

RESULTS

BMV resulted in a decrease in mean mitral gradient from 12.6 +/- 3.8 to 6.1 +/- 2.9 mmHg, and an increase in mitral valve area from 1.03 +/- 0.19 cm2 to 1.95 +/- 0.40 cm2. A mitral insufficiency > or = 3+/4+ occurred in 4/30 BMV (13%). At follow-up (mean 27 +/- 18 months) 20/26 patients (77%) remained clinically improved: 54% were in NYHA class I and 23% in class II.

CONCLUSIONS

BMV is an effective short- and long-term procedure for patients with previous surgical commissurotomy, with a low additional risk of complications. Thus, BMV can be considered the treatment of choice in these patients.

Percutaneous transluminal coronary angioplasty in refractory unstable angina pectoris: are new devices useful?

This study was undertaken to assess if the introduction of new angioplasty devices (autoperfusion balloon catheters, stent and atherectomy) could ameliorate early and late results of prompt percutaneous transluminal coronary angioplasty (PTCA) in patients with refractory unstable angina. From January 1993 to June 1995, 59 of 278 patients (14 female, 45 male; mean age: 61 +/- 10 years; range: 38-78) admitted to our Coronary Care Unit with the diagnosis of unstable angina had more than one episode of chest pain at rest with dynamic electrocardiographic ST-T changes and without signs of cardiac necrosis while on medical therapy including oxygen, aspirin, heparin, nitroglycerin and either a beta-blocker or a calcium-antagonist. Coronary angiography was performed within 48 h from the last ischemic attack and a culprilesion technically suitable for PTCA was identified. PTCA was performed in 73 lesions. Elective stent implantation was considered for 16 type B or C lesions in 14 patients. The procedure was initially successful in 52/59 patients (88%), uncomplicated unsuccessful in 4/59 (7%) and complicated in 3/59 (5%). Elective stent insertions were all successful (16/16, 100%). All successfully treated patients were followed up for a mean of 12 +/- 7 months (range: 6-27): 2/52 patients (3.8%) suffered from non-transmural myocardial infarction, 14/52 (26.9%) had a recurrence of angina and 2/52 (3.8%), asymptomatic, had a positive stress test. We conclude that prompt PTCA in refractory unstable angina using 1990s 'state of the art' equipment compares favorably to previous study and that stent delivery might become the elective treatment of complex lesions in this subset of patients.

Acute changes in left ventricular function after percutaneous transluminal mitral valvuloplasty

Percutaneous balloon mitral valvuloplasty (PBMV) has been shown to induce an immediate increase in the left ventricular end-diastolic volume, which increase, in turn, has been attributed to an increase in left ventricular compliance. We studied 51 patients, 41 women and 10 men, who underwent PBMV, and were in sinus rhythm before and after the procedure. Heart rate did not vary significantly. There were increases in left ventricular end-diastolic volume (97.5 +/- 25.6 vs 112.7 +/- 25.7 ml/m2, P < 0.001), left ventricular end-diastolic pressure (8.7 +/- 3.0 vs 9.7 +/- 4.3 mmHg, P = 0.04), and both left ventricular systolic pressure and stress (118 +/- 20.5 vs 123 +/- 23.2 mmHg and 468 +/- 129 vs 580 +/- 164 mmHg; P = 0.04 and P < 0.001, respectively). The elastic stiffness constant did not vary (16.2 +/- 1.9 vs 15.7 +/- 1.9 (dimensionless units), P = 0.2). The increase in volume seemed to be particularly important when the ventricle appeared to be "shrunken" before PBMV. This increase was still present after a 1 year follow up. Thus, PBMV determines an increase in both end-diastolic volume and pressure, so that the left ventricle appears to move along a single pressure-volume curve. This enlargement evokes the Frank Starling mechanism, and improves systolic performance. Since it is still evident after a 1 year follow up, some concern may arise when a simultaneous volume overload is present, as in aortic insufficiency.

[Rotational atherectomy and PTCA in complex coronary lesions (B2 and C): the immediate and long-term results]

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA) in complex coronary lesions (type B2 and C of the modified AHA/ACC classification) presents a lower primary success rate and higher risk of dissection than type A and B1 lesions. An alternative approach to this lesions is coronary rotational ablation (Rotablator, Heart Technology) with complementary PTCA using low inflation pressures ("facilitated angioplasty").

MATERIALS AND METHODS

Twenty-six type B2 and C lesions in 24 patients (pts) (8 female, 16 male, age 37-80 years) were treated with coronary rotational ablation and complementary PTCA between January 1993 and December 1994 (4.7% of all interventional coronary procedures performed in this period in our laboratory). Eleven pts had stable effort angina and 13 pts had unstable, class IB, IIB, and IIC, angina. The treated vessel was the LAD in 15 cases, CX in 5, RCA in 5, and an intermediate branch in one case. Coronary rotational ablation was proposed because of the presence of two or more risk factors for uneffective or complicated PTCA: eccentricity, calcified lesions, bifurcation stenosis, lesion length > 10 mm, severe stenosis (90-99%), ostial location and bend location (45-60 degrees). No lesion showed coronary thrombus, considered as absolute contraindication to coronary rotational ablation. We used small burrs (burr/artery ratio < 0.75), and complementary PTCA was performed using low inflation pressure (< 8 atm) and long balloons for long lesions (> 10 mm) in order to minimize the risk of dissection.

RESULTS

Coronary rotational ablation was successfully performed in all but two cases (24/26; 92.3%), with a reduction of the stenosis from 88 +/- 9% to 45 +/- 10% (range 30-60%). In two pts (7.7%) the procedure was complicated by acute occlusion: both pts underwent effective salvage PTCA with 30% residual stenosis. Small type A and B dissections occurred in 4/26 cases (15.4%). All but one lesions complicated by acute occlusion or dissection following coronary rotational ablation were not or only slightly calcified. Complementary PTCA was performed in all but two pts who already presented 30% residual stenosis after rotational ablation. A further reduction of stenosis to 20 +/- 9% (range 5-30%) was achieved. After complementary PTCA four pts (15.4%) developed type A and B dissections; in one of these a Palmaz-Schatz stent was implanted, whereas the remaining three pts presented a residual stenosis below 30% and no further procedures were undertaken. Overall success rate of rotational atherectomy plus salvage or complementary PTCA or stenting was 100%, and no major complications (Q-wave myocardial infarction, emergency bypass surgery or death) occurred. Three pts showed delayed coronary run-off (slow reflow) after rotational ablation, and two of these released a small amount of cardiac specific enzymes (CK MB) without ECG changes and wall motion alteration on echocardiographic examination. Clinical restenosis, defined as recurrent angina and/or positive exercise stress test, developed in 45.8% (11 pts); in all these pts restenosis was angiographically evidenced (75-99%).

CONCLUSIONS

Our experience suggests that coronary rotational ablation along with complementary PTCA using low inflation pressure and long balloons is safe and effective in type B2 and C lesions if calcifications are present; however, restenosis rate remains high.

[Percutaneous mitral valvuloplasty: the immediate and long-term results]

BACKGROUND

Between December 1988 and December 1992, 235 patients (pts) underwent percutaneous balloon mitral valvuloplasty (PBMV).

METHODS AND RESULTS

There were 55 men (23%) aged 49 +/- 13 years and 180 women (77%) aged 51 +/- 13 years. Previous surgical commissurotomy (PSC) had been performed in 22 pts. Procedure was successful (area > 1.5 cm2 or area increase > or = 50% without mitral regurgitation > 2+) in 91.9% of pts, with increase in mitral valve area from 1.05 +/- 0.2 to 2.26 +/- 0.6 cm2, decrease of transvalvular mean pressure gradient from 14.4 +/- 5.5 to 6.05 +/- 4.91 mm Hg and increase of cardiac index from 2.79 +/- 0.75 to 3.17 +/- 0.9 l/m'/m2 (p < 0.001). Insufficient increase in valve area occurred in 3.8% of pts. Major complications included 5 pts with 3+ mitral regulation (MR) requiring mitral valve replacement (MVR), 2 TIA's (0.85%) and 1 pericardiocentesis (0.42%). At follow-up (mean 18.9 months) clinical improvement was achieved in 93.8% of pts (NYHA class from 2.4 to 1.3); mitral valve area was 1.9 +/- 0.4 cm2 and mean mitral valve gradient 5.3 +/- 2.3 mm Hg. Restenosis (area < 1.5 cm2 or > or = 50% loss of initial gain) occurred in 24 pts (10.16%). Six pts required MVR; 1 pt underwent a second successful PBMV. Multivariate study (logistic regression) identified as independent factors of severe MR NYHA class and PSC; echo score, age and basal mean mitral valve gradient were independent factors for restenosis.

CONCLUSIONS

In conclusion, PBMV is a safe technique and stable clinical improvement can be obtained in the majority of pts.

Measurement of systemic resistances in aortic regurgitation

Peripheral resistance is usually measured by dividing mean aortic pressure by mean aortic flow. This statement holds true as long as resistance is constant throughout the heart cycle. This is not the case in aortic regurgitation, because during diastole, but not in systole, a conduit is opened to blood flow through the regurgitating valve. Peripheral resistance was measured in 11 patients with aortic regurgitation and in 23 normal subjects by solving for Ri in the "windkessel" equation. We compared this resistance (R1) with that measured by standard methods (RES). In normal subjects, R1 and RES are almost identical [R1 = 0.96 (RES) +/- 0.12, r = .95], while in aortic regurgitation there is no correlation [R1 = 0.64 (RES) +/- 1.4, r = 0.2]. RES in normal subjects is increased with respect to RES in aortic regurgitation (32 vs 22, p = 0.0019), while R1 in aortic regurgitation is decreased compared to both R1 and RES in normal subjects (13.5 vs 21 and 22, p = 0.0063). The difference between R1 and RES in aortic regurgitation is related to the regurgitating volume. Compliance, calculated by assuming a monoexponential diastolic aortic pressure decay, is markedly decreased in aortic insufficiency, while it is increased if it is calculated by dividing the time constant of aortic pressure decay by R1. Thus, in severe aortic regurgitation peripheral resistance is usually less than normal, and standard methods of measurement fail to detect this fact. Correct evaluation of resistance and compliance may be useful to evaluate ventriculoarterial coupling and to titrate vasodilator therapy in this disease.

[Regression of pulmonary hypertension in mitral stenosis: an echo-hemodynamic study in patients who underwent mitral balloon valvuloplasty]

BACKGROUND

Reversibility of pulmonary hypertension in patients affected by mitral stenosis is still under question.

METHODS

We selected 80 patients (mean age 48 +/- 14) who underwent successful percutaneous mitral valvuloplasty (PMV) for hemodynamic significant mitral stenosis (area < 1.5 cm2) with pulmonary hypertension (mean artery pulmonary pressure--PPM > 25 mm Hg), producing significant increase in mitral valve area (area before PMV = 0.99 +/- 0.23 cm2 vs 2.08 +/- 0.32 cm2 after PMV--p < 0.001) without hemodynamic complications (mitral insufficiency and/or interatrial shunt). Cardiac index, pulmonary arterial pressures, and pulmonary arteriolar resistances were invasively evaluated before and immediately after valvuloplasty. Systolic pulmonary pressure was indirectly monitored by Doppler method in a period from 1 to 3 months after percutaneous mitral valvuloplasty.

RESULTS

In general (70 pts.) there was an immediate significant reduction of pulmonary pressure after percutaneous mitral valvuloplasty (mean pulmonary pressure before PMV was 33.9 +/- 7.9 mm Hg vs 26.8 +/- 9.5 mm Hg after PMV, p < 0.01; systolic pulmonary pressure before PMV was 51.5 +/- 10.9 mm Hg vs 43.15 +/- 13.5 mm Hg after PMV--p < 0.01). A small subgroup of 10 pts., older in age (mean 59 +/- 15), manifested no reduction of pulmonary pressure immediately after procedure (mean pulmonary pressure before PMV = 35.2 +/- 8.37 mm Hg vs 36.5 +/- 6 mm Hg after PMV, p: ns; systolic pulmonary pressure before PMV = 58.2 +/- 10.6 mm Hg vs 59.2 +/- 9.6 mm Hg. after PMV, p: ns) and 4 of them (mean age 65 +/- 15) persisting pulmonary hypertension at 1-3 months follow-up (systolic pulmonary pressure before PMV = 58.75 +/- 14 mm Hg, immediately after PMV = 57.8 +/- 12.5 mm Hg, and 1-3 months after PMV = 62.5 +/- 9 mm Hg--p: ns).

CONCLUSIONS

Neither severe pulmonary hypertension, nor pulmonary arteriolar resistances but only age seems to be a predictive factor of persisting pulmonary hypertension after percutaneous mitral valvuloplasty in mitral stenosis.

[Monovascular coronary disease in the pre-angioplasty era]

Single-vessel coronary disease has been considered so far a benign condition, for which the medical therapy may represent the optimal treatment. In order to assess the effectiveness of this approach, we studied 323 patients who had come to our attention for ischemic heart disease and resulted affected by single-vessel coronary artery disease. From our data it appears that single-vessel coronary artery disease is frequently associated with myocardial infarction and post-infarction aneurysm. Coronary angiography indicated that left anterior descending coronary artery is the most frequently affected vessel, and that its involvement is often associated with lethal outcome. Forty-two out of the 323 patients underwent coronary artery bypass surgery; the remaining patients were medically treated. Surgical patients showed a better improvement respect to the medical group, while survival was not statistically different. An unexpected result was the relatively high risk in circumflex artery lesion. These data may justify a broader utilization of invasive therapy in recent onset angina, in light of the excellent results recently obtained with percutaneous transluminal coronary angioplasty.

[Morphofunctional correlations in dilated cardiomyopathies]

The aim of this study was to state whether in patients with dilated cardiomyopathy indices of left ventricular function (i.e. left ventricular end-diastolic and end-systolic volumes, ejection fraction, end-systolic pressure to end-systolic volume ratio, mass to volume ratio, elastic stiffness constant) are related to histologic findings, namely percentage of myocytes, of fibrosis and of interstitium. We have studied 26 patients (18 males and 8 females) aged 13-65 years, who underwent right and left heart catheterization, quantitative angiography, coronary angiogram, and in whom a diagnosis of dilated cardiomyopathy was established. All of them had a biopsy specimen taken from the right aspect of interventricular septum, following the technique of King's College. Histology was automatically evaluated with a computerized system for the percent content of myocytes, of fibrous tissue and interstitium. Correlation with hemodynamic parameters was calculated with the least square method. A significant correlation was found between percentage of fibrosis, left and right ventricular ejection fraction and preload index, and between percent myocytes and right ventricular ejection fraction and duration of disease. Thus, left ventricular function indices do not correlate with percent myocytes, as previously shown: this could be due to the fact that alterations in contractile machinery are due primarily to alterations in cell biochemistry. Moreover, the inverse relationship between myocyte content and duration of the disease may reflect those mechanisms, which tend to perpetuate failure in a dilated heart by increasing subendocardial fibrosis. However, the correlation found between myocyte content and right ventricular ejection fraction may be due to the fact that biopsy specimens were taken from the right ventricle.

Haemodynamic effects of nisoldipine by oral route

The aim of this study is to investigate the acute haemodynamic effect of orally administered nisoldipine. Eight patients with stable angina and normal overall ventricular function were submitted to cardiac catheterization and angiography before and one hour after administration of nisoldipine 20 mg per os. Cardiac output increased, peripheral resistance decreased and aortic compliance increased, determining a marked decrease in overall peripheral impedance. Left ventricular ejection fraction hardly increased and contractility did not vary. Left ventricular end diastolic pressure decreased, owing to a decrease in left ventricular wall stiffness. Thus nisoldipine acts as a peripheral dilating agent, decreasing arteriolar tone and, possible, venous tone, and increasing left ventricular muscle distensibility.

Value and limitations of transesophageal echocardiographic monitoring during percutaneous balloon mitral valvotomy

To determine the utility of transesophageal echocardiographic monitoring during percutaneous balloon mitral valvotomy, we analyzed data from 40 consecutive patients who had been randomly assigned to undergo balloon mitral valvotomy under transesophageal echocardiographic guidance or without echo. All procedures were carried out under general anaesthesia. The completion rate (100% vs 73%), the procedure time (108 +/- 28 min vs 65 +/- 18 min), the X-ray exposure time (62 +/- 13 vs 33 +/- 12 min), resulted significantly (P less than 0.001) more favorable in the echo-monitored patients. Moreover, a lower rate of major complications (cardiac tamponade, large residual atrial shunting, and severe mitral regurgitation) was noted in the echo-monitored patients. The achieved final area of the mitral valve did not differ significantly between the two groups. From an evaluation of results as a whole, 96% of the echo-monitored procedures were successful, whereas only 40% of the procedures conducted without echocardiographic control achieved a satisfactory final result in absence of major complications. We conclude that transesophageal echocardiography is a safe, effective, and valuable tool to monitor each step of balloon mitral valvotomy in order to shorten the time of the procedure, and to improve the results of this complex interventional catheterization technique.

[Short- and mid-term results of percutaneous aortic valvuloplasty for calcific aortic stenosis in elderly patients]

In order to evaluate the short and mid-term results of percutaneous aortic balloon valvuloplasty, 40 consecutive elderly patients with symptomatic severe calcific aortic stenosis, underwent the procedure consecutively, with follow-up by clinical evaluation and Doppler echocardiography. Over a mean follow-up period of 11.2 months there were 5 deaths, and 12 patients underwent subsequent aortic valve replacement. Doppler echocardiography revealed an increase in aortic valve area from 0.62 +/- 0.20 cm2 to 0.91 +/- 0.23 cm2 after the procedure, but there was a significant trend toward restenosis by 12 months follow-up in 23 of 32 patients (72%). Restenosis was accompanied by symptomatic deterioration in 18 of 23 patients (78%). Although balloon valvuloplasty may often improve haemodynamics and relieve symptoms, these benefits seem to be short-lived in most cases. Restenosis has a high rate of occurrence. Aortic balloon valvuloplasty should be reserved for truly inoperable cases and for haemodynamically-unstable patients, who may later undergo surgery.

Mitral valve disruption following percutaneous balloon valvuloplasty

Two cases of massive mitral regurgitation due to mitral valve disruption following percutaneous balloon valvuloplasty are reported. This severe complication occurred in two elderly women with recurrent mitral stenosis after previous surgical commissurotomy. Due to their unstable hemodynamic and clinical condition, both patients underwent emergency valve replacement. At surgery, the commissures appeared fused and heavily calcified; the chordae tendineae thickened, shortened, and fused; and the leaflets presented a large tear with sheared edges. Because the technical aspects of both procedures were unremarkable, the anatomic features of the mitral valve seemed to affect the occurrence of severe mitral regurgitation. Percutaneous balloon valvuloplasty should be therefore applied carefully to patients with prior surgical valvotomy, in whom the structural alterations of the mitral apparatus may predispose to severe valvular damage.

Short-lasting hemodynamic and clinical benefits from percutaneous balloon valvuloplasty for calcific aortic stenosis

In order to evaluate the short- and mid-term results of percutaneous aortic balloon valvuloplasty, 40 consecutive elderly patients, who had undergone balloon valvuloplasty for calcific aortic stenosis, were prospectively followed up by means of clinical and echo-Doppler examinations. Although valvuloplasty often dramatically improves hemodynamics and relieves symptoms, these benefits seem to be short-lived in most cases. Restenosis, defined as a loss of 50% or more of the increase in aortic valve area obtained by the dilatation, has a very high rate of occurrence. Aortic balloon valvuloplasty should therefore be reserved for truly inoperable cases and can be performed in hemodynamically unstable patients, who may later undergo surgery.

[Results of emergency aortocoronary bypass in complicated coronary angioplasty]

Sixteen out of 293 (5.4%) procedures for percutaneous transluminal coronary angioplasty, performed between 1985 and 1988, were complicated by acute closure and required emergency revascularization surgery. The injured vessel was the left anterior descending artery in 14 cases and the right coronary artery in 2 cases. All patients had persistent chest pain associated with ST-segment elevation in 14 cases and ST-segment depression in 2 cases. Two patients developed cardiogenic shock and were in cardiac arrest at the beginning of operation; one of these died immediately after the operation. Thus the overall mortality rate was 6.2%. Enzyme evidence of myocardial infarction (CPK-MB greater than 40 UI/I) occurred postoperatively in 8 patients (50%), but only the 6 patients (37.5%) with electrocardiographic evidence of myocardial necrosis (new Q-waves or loss of R-wave voltage) showed akinesis of the myocardium perfused by the occluded vessel at the echocardiographic examination performed two weeks after the operation. The occurrence of myocardial infarction was correlated with the degree of preoperative ischemia and hemodynamic deterioration. A collateral flow was present in 3 cases and none of these showed evidence of myocardial necrosis after the operation. Our results show that emergency bypass surgery for failed coronary angioplasty is less satisfactory than elective surgery, and has a higher mortality and myocardial infarction rate. Thus, the risk of emergency operation for complicated dilation must be considered when selecting of candidates for coronary angioplasty.

[Aortic valvuloplasty associated with coronary angioplasty. Description of a case]

The authors report the case of a 57 year-old man with severe calcific aortic stenosis and single vessel coronary artery disease, symptomatic of angina pectoris, who refused surgical therapy and was treated with combined percutaneous aortic valvuloplasty and coronary angioplasty as a single procedure. Valvuloplasty was performed initially, and the calculated aortic valve area increased from 0.75 to 1.27 cm2. Subsequently, a 75% proximal right coronary artery stenosis was dilated to 20%. Two months later, at follow-up the patient was asymptomatic and the Doppler-determined aortic valve area was 1.01 cm2.

Left ventricular size and function in double inlet left ventricle

Using quantitative cineangiography we studied left ventricular size and function in 15 patients (aged 1 day to 15 years) with double inlet left ventricle. Our purpose was to assess how ventricular volume and performance change with age and palliative surgery in patients with and without restriction to pulmonary flow. Ventricular volumes were calculated using Simpson's rule method; end-diastolic volume was also stated as a percentage of predicted total (combined right and left) ventricular volume. Ejection fraction and systolic pressure to end-systolic volume ratio were calculated as indexes of ventricular function. Our results suggest that ventricular size is inadequate for a septation procedure in patients with restriction to pulmonary flow but increases after shunting operation. In patients without restriction to pulmonary flow, ventricular volume is adequate for a septation procedure during the first months of life, but it tends towards reduction, along with obstruction of the interventricular communication, after pulmonary artery banding. Ejection fraction is slightly lower than in left ventricle of heart with biventricular atrioventricular connexion, but it does not decrease with age, at least during the first 15 years of life. Systolic pressure to end-systolic volume ratio also does not decrease with age, but it is lower in patients with excessive pulmonary flow or atrioventricular valvar regurgitation.

[Coronary angioplasty in unstable angina. Immediate and short-term results]

We report the results of percutaneous transluminal coronary angioplasty (PTCA) in 67 consecutive patients with unstable angina. Twenty patients had new onset (less than 2 months) angina, 33 patients had crescendo angina and 14 had early postinfarction angina. Fifty-one patients had one-vessel disease, 12 patients had two-vessel disease and two patients had three-vessel disease; two patients had a stenosis of a venous graft. In cases with multivessel disease, we performed only the dilatation of the ischaemia-related vessel identified by morphologic features of coronary lesion and electrocardiographic changes during chest pain. The procedure was successful in 54 cases (80.6%). Seven patients (10.4%) had major complications. Emergency coronary artery bypass graft surgery was performed in 6 cases (8.9%) because of occlusion of the left anterior descending artery; despite emergency operation one patient died and two patients sustained a myocardial infarction. One patient had occlusion of the right coronary artery and inferior myocardial infarction. In all patients in whom angioplasty was successful unstable angina disappeared. At 6 months follow-up there were no infarctions or deaths but 14 of 42 patients (33%) had recurrent angina. Restenosis occurred in 16 of 33 patients (48%) who had repeat coronary angiography. Four patients with recurrence of unstable angina had repeat angioplasty; it was successful in 3 cases. One patient died of refractory cardiac arrest. The mortality rate of 71 procedures performed in 67 patients was 2.8% (2/71) and the overall myocardial infarction rate was 4.2% (3/71).(ABSTRACT TRUNCATED AT 250 WORDS)

[Origin of the right pulmonary branch from the ascending aorta]

The AA report a case of newborn admitted to the hospital at the age of 12 days because of severe congestive heart failure, with electrocardiographical and radiological findings of right ventricular overload and increased pulmonary blood flow. Cardiac catheterization showed the origin of the right pulmonary artery from the ascending aorta in the presence of an intact ventricular septum. Surgical repair was performed on an emergency basis by deconnecting the anomalous right pulmonary artery from the aorta and reattaching it to the main pulmonary artery. Postoperative angiographic study, performed 12 months later, revealed excellent anatomical and functional result.

[Double outlet right ventricle. Angiographic study]

Cineangiographic study in 41 patients with double outlet right ventricle was performed. Segmental approach was utilized to describe the anatomical features. Atrial situs was inversus in 5 cases, ambiguous in 3 and solitus in the other cases. Atrio-ventricular (a-v) connections were biventricular in 34 and univentricular in 7. A common a-v valve was found in 2 cases. Mitral valve was imperforated in 1 and straddling in 1. The most frequent relationship between aorta and pulmonary artery was side by side (41.1%). Ventricular septal defect was subaortic in 14, subpulmonary in 9, double committed in 5 and non committed in 6. In 27 cases a double infundibulum was present; in 7 patients we described a subpulmonary conus only. Some nosological aspects of this congenital heart disease are discussed particularly in conformity with the surgical needs.

Ventricular development and function in complete transposition: angiocardiographic evaluation

We studied 50 left ventricular cineangiograms and 41 right ventricular cineangiograms of 40 patients with usual atrial arrangement (situs solitus) together with concordant atrioventricular and discordant ventriculo-arterial connexions (complete transposition), catheterized between 1 day and 12 months of age. Our purpose was to evaluate ventricular development and function. The patients were subdivided on the basis of associated lesions into groups with intact ventricular septum; with ventricular septal defect; with ventricular septal defect together with pulmonary stenosis and with pulmonary stenosis in isolation. Each group was further separated according to age into those patients below and above 60 days. Ventricular volumes, ejection fraction and the ratio between systolic pressure and end-systolic volume were evaluated for both ventricles. The left ventricular mass, stress, and the ratio of stress to end-systolic volume were also calculated. A volume overload leads to increased left ventricular volume even at birth. With an intact ventricular septum, the left ventricle in patients with complete transposition is normal at birth and also during the first weeks of life. Myocardial mass, however, does not increase proportionately with increase in volume as the patient grows and it remains inadequate by the age of one year. The left ventricular mass is also inadequate in patients with associated anomalies when the left ventricular pressure is less than 60 mm Hg. Moreover, the left ventricle in presence of an intact ventricular septum presents a decrease in contractility during the first year of life despite the finding of a satisfactory arterial oxygen saturation. The right ventricle has a normal volume at birth which increases during the first year due to a greater diastolic filling following atrial septostomy. We noted a progressive decrease in ejection fraction, however, which is related to various factors including a reduction in contractility.

[Heart rupture as a complication of myocardial infarct in the acute stage. Case contributions and clinical course of survivors]

Heart rupture was found in 25 (4.4%) of 560 patients with myocardial infarction admitted to the Coronary Care Unit of the Department of Cardiology, Padua Medical School. Ten (40%) of them had a breaking of the free wall, 10 the interventricular septum, 4 (16%) a papillary muscle and 1 (4%) the ventricular wall with formation of a pseudoaneurysm. Thirteen patients died suddenly, the other 12 (48%) had cardiac catheterisation and later surgery. Four patients with interventricular defect died immediately after surgery, the other patients were discharged. Mortality was 68%; 30% on the patients with VSD as well as those with papillary muscle rupture and pseudo aneurysm survived.