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Ozonoff A, Schaenman J, Jayavelu ND, Milliren CE, Calfee CS, Cairns CB, Kraft M, Baden LR, Shaw AC, Krammer F, van Bakel H, Esserman DA, Liu S, Sesma AF, Simon V, Hafler DA, Montgomery RR, Kleinstein SH, Levy O, Bime C, Haddad EK, Erle DJ, Pulendran B, Nadeau KC, Davis MM, Hough CL, Messer WB, Higuita NIA, Metcalf JP, Atkinson MA, Brakenridge SC, Corry D, Kheradmand F, Ehrlich LI, Melamed E, McComsey GA, Sekaly R, Diray-Arce J, Peters B, Augustine AD, Reed EF, Altman MC, Becker PM, Rouphael N, Ozonoff A, Schaenman J, Jayavelu ND, Milliren CE, Calfee CS, Cairns CB, Kraft M, Baden LR, Shaw AC, Krammer F, van Bakel H, Esserman DA, Liu S, Sesma AF, Simon V, Hafler DA, Montgomery RR, Kleinstein SH, Levy O, Bime C, Haddad EK, Erle DJ, Pulendran B, Nadeau KC, Davis MM, Hough CL, Messer WB, Higuita NIA, Metcalf JP, Atkinson MA, Brakenridge SC, Corry D, Kheradmand F, Ehrlich LI, Melamed E, McComsey GA, Sekaly R, Diray-Arce J, Peters B, Augustine AD, Reed EF, McEnaney K, Barton B, Lentucci C, Saluvan M, Chang AC, Hoch A, Albert M, Shaheen T, Kho AT, Thomas S, Chen J, Murphy MD, Cooney M, Presnell S, Fragiadakis GK, Patel R, Guan L, Gygi J, Pawar S, Brito A, Khalil Z, Maguire C, Fourati S, Overton JA, Vita R, Westendorf K, Salehi-Rad R, Leligdowicz A, Matthay MA, Singer JP, Kangelaris KN, Hendrickson CM, Krummel MF, Langelier CR, Woodruff PG, Powell DL, Kim JN, Simmons B, Goonewardene IM, Smith CM, Martens M, Mosier J, Kimura H, Sherman AC, Walsh SR, Issa NC, Dela Cruz C, Farhadian S, Iwasaki A, Ko AI, Chinthrajah S, Ahuja N, Rogers AJ, Artandi M, Siegel SA, Lu Z, Drevets DA, Brown BR, Anderson ML, Guirgis FW, Thyagarajan RV, Rousseau JF, Wylie D, Busch J, Gandhi S, Triplett TA, Yendewa G, Giddings O, Anderson EJ, Mehta AK, Sevransky JE, Khor B, Rahman A, Stadlbauer D, Dutta J, Xie H, Kim-Schulze S, Gonzalez-Reiche AS, van de Guchte A, Farrugia K, Khan Z, Maecker HT, Elashoff D, Brook J, Ramires-Sanchez E, Llamas M, Rivera A, Perdomo C, Ward DC, Magyar CE, Fulcher JA, Abe-Jones Y, Asthana S, Beagle A, Bhide S, Carrillo SA, Chak S, Fragiadakis GK, Ghale R, Gonzalez A, Jauregui A, Jones N, Lea T, Lee D, Lota R, Milush J, Nguyen V, Pierce L, Prasad PA, Rao A, Samad B, Shaw C, Sigman A, Sinha P, Ward A, Willmore A, Zhan J, Rashid S, Rodriguez N, Tang K, Altamirano LT, Betancourt L, Curiel C, Sutter N, Paz MT, Tietje-Ulrich G, Leroux C, Connors J, Bernui M, Kutzler MA, Edwards C, Lee E, Lin E, Croen B, Semenza NC, Rogowski B, Melnyk N, Woloszczuk K, Cusimano G, Bell MR, Furukawa S, McLin R, Marrero P, Sheidy J, Tegos GP, Nagle C, Mege N, Ulring K, Seyfert-Margolis V, Conway M, Francisco D, Molzahn A, Erickson H, Wilson CC, Schunk R, Sierra B, Hughes T, Smolen K, Desjardins M, van Haren S, Mitre X, Cauley J, Li X, Tong A, Evans B, Montesano C, Licona JH, Krauss J, Chang JBP, Izaguirre N, Chaudhary O, Coppi A, Fournier J, Mohanty S, Muenker MC, Nelson A, Raddassi K, Rainone M, Ruff WE, Salahuddin S, Schulz WL, Vijayakumar P, Wang H, Wunder Jr. E, Young HP, Zhao Y, Saksena M, Altman D, Kojic E, Srivastava K, Eaker LQ, Bermúdez-González MC, Beach KF, Sominsky LA, Azad AR, Carreño JM, Singh G, Raskin A, Tcheou J, Bielak D, Kawabata H, Mulder LCF, Kleiner G, Lee AS, Do ED, Fernandes A, Manohar M, Hagan T, Blish CA, Din HN, Roque J, Yang S, Brunton A, Sullivan PE, Strnad M, Lyski ZL, Coulter FJ, Booth JL, Sinko LA, Moldawer LL, Borresen B, Roth-Manning B, Song LZ, Nelson E, Lewis-Smith M, Smith J, Tipan PG, Siles N, Bazzi S, Geltman J, Hurley K, Gabriele G, Sieg S, Vaysman T, Bristow L, Hussaini L, Hellmeister K, Samaha H, Cheng A, Spainhour C, Scherer EM, Johnson B, Bechnak A, Ciric CR, Hewitt L, Carter E, Mcnair N, Panganiban B, Huerta C, Usher J, Ribeiro SP, Altman MC, Becker PM, Rouphael N. Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study. EBioMedicine 2022; 83:104208. [PMID: 35952496 PMCID: PMC9359694 DOI: 10.1016/j.ebiom.2022.104208] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/11/2022] [Accepted: 07/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management. METHODS Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed. FINDINGS The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC. INTERPRETATION Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19. FUNDING NIH.
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Affiliation(s)
- Al Ozonoff
- Clinical & Data Coordinating Center (CDCC); Precision Vaccines Program, Boston Children's Hospital, Boston, MA, United States
| | - Joanna Schaenman
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
| | | | - Carly E. Milliren
- Clinical & Data Coordinating Center (CDCC); Precision Vaccines Program, Boston Children's Hospital, Boston, MA, United States
| | - Carolyn S. Calfee
- University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Charles B. Cairns
- Drexel University/Tower Health Hospital, Philadelphia, PA, United States
| | - Monica Kraft
- University of Arizona, Tucson, AZ, United States
| | - Lindsey R. Baden
- Boston Clinical Site: Precision Vaccines Program, Boston Children's Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Albert C. Shaw
- Yale School of Medicine, and Yale School of Public Health, New Haven, CT, United States
| | - Florian Krammer
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Harm van Bakel
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Denise A. Esserman
- Yale School of Medicine, and Yale School of Public Health, New Haven, CT, United States
| | - Shanshan Liu
- Clinical & Data Coordinating Center (CDCC); Precision Vaccines Program, Boston Children's Hospital, Boston, MA, United States
| | | | - Viviana Simon
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - David A. Hafler
- Yale School of Medicine, and Yale School of Public Health, New Haven, CT, United States
| | - Ruth R. Montgomery
- Yale School of Medicine, and Yale School of Public Health, New Haven, CT, United States
| | - Steven H. Kleinstein
- Yale School of Medicine, and Yale School of Public Health, New Haven, CT, United States
| | - Ofer Levy
- Boston Clinical Site: Precision Vaccines Program, Boston Children's Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, United States
| | | | - Elias K. Haddad
- Drexel University/Tower Health Hospital, Philadelphia, PA, United States
| | - David J. Erle
- University of California San Francisco School of Medicine, San Francisco, CA, United States
| | | | | | | | | | | | | | - Jordan P. Metcalf
- Oklahoma University Health Sciences Center, Oklahoma, OK, United States
| | - Mark A. Atkinson
- University of Florida, Gainesville and University of South Florida, Tampa, FL, United States
| | - Scott C. Brakenridge
- University of Florida, Gainesville and University of South Florida, Tampa, FL, United States
| | - David Corry
- Baylor College of Medicine, and the Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey, Houston, TX, United States
| | - Farrah Kheradmand
- Baylor College of Medicine, and the Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey, Houston, TX, United States
| | | | - Esther Melamed
- The University of Texas at Austin, Austin, TX, United States
| | | | - Rafick Sekaly
- Case Western Reserve University, Cleveland, OH, United States
| | - Joann Diray-Arce
- Clinical & Data Coordinating Center (CDCC); Precision Vaccines Program, Boston Children's Hospital, Boston, MA, United States
| | - Bjoern Peters
- La Jolla Institute for Immunology, La Jolla, CA, United States
| | - Alison D. Augustine
- National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, United States
| | - Elaine F. Reed
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
| | | | - Patrice M. Becker
- National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, United States
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Montgomery JM, Hossain MJ, Gurley E, Carroll GDS, Croisier A, Bertherat E, Asgari N, Formenty P, Keeler N, Comer J, Bell MR, Akram K, Molla AR, Zaman K, Islam MR, Wagoner K, Mills JN, Rollin PE, Ksiazek TG, Breiman RF. Risk factors for Nipah virus encephalitis in Bangladesh. Emerg Infect Dis 2008; 14:1526-32. [PMID: 18826814 PMCID: PMC2609878 DOI: 10.3201/eid1410.060507] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Patients in Goalando were likely infected by direct contact with fruit bats or their secretions, rather than through contact with an intermediate host. Nipah virus (NiV) is a paramyxovirus that causes severe encephalitis in humans. During January 2004, twelve patients with NiV encephalitis (NiVE) were identified in west-central Bangladesh. A case–control study was conducted to identify factors associated with NiV infection. NiVE patients from the outbreak were enrolled in a matched case-control study. Exact odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using a matched analysis. Climbing trees (83% of cases vs. 51% of controls, OR 8.2, 95% CI 1.25–∞) and contact with another NiVE patient (67% of cases vs. 9% of controls, OR 21.4, 95% CI 2.78–966.1) were associated with infection. We did not identify an increased risk for NiV infection among persons who had contact with a potential intermediate host. Although we cannot rule out person-to-person transmission, case-patients were likely infected from contact with fruit bats or their secretions.
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Cote AV, Berger PB, Holmes DR, Scott CG, Bell MR. Hemorrhagic and vascular complications after percutaneous coronary intervention with adjunctive abciximab. Mayo Clin Proc 2001; 76:890-6. [PMID: 11560299 DOI: 10.4065/76.9.890] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To examine the frequency and nature of hemorrhagic and peripheral vascular complications associated with use of abciximab during percutaneous coronary intervention and to characterize high-risk patients. PATIENTS AND METHODS We report the frequency and severity of bleeding and vascular complications recorded prospectively in 2,559 consecutive nonselected patients who underwent percutaneous coronary intervention at Mayo Clinic, Rochester, Minn, between July 1, 1996, and April 30, 1998, 831 of whom received abciximab and 1,728 did not. Abciximab and heparin were administered according to guidelines of the Evaluation of PTCA [percutaneous transluminal coronary angioplasty] to Improve Long-Term Outcome With Abciximab GP IIb/IIIa Blockade (EPILOG). RESULTS Patients who received abciximab were more likely to be men, were more often treated within 12 hours of an acute myocardial infarction, and were more likely to have received heparin after the procedure (8.7 % vs 4.5%, P<.001). Major bleeding occurred in 18 patients (2.4%) who received abciximab and in 10 patients (0.6%) who did not receive abciximab (P<.001). Minor bleeding occurred in 108 patients (14.3%) and in 92 patients (5.9%), respectively (P<.001). Both major bleeding and minor bleeding were more frequent among patients within 12 hours of an acute myocardial infarction and were more frequent if abciximab had been used. Multivariate analysis revealed that use of abciximab was independently associated with major and minor bleeding. CONCLUSION In this clinical setting, use of adjunctive abciximab during percutaneous coronary intervention was associated with a significantly increased risk of both major and minor bleeding.
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Affiliation(s)
- A V Cote
- Department of Anesthesiology, Mayo Clinic, Rochester, Minn 55905, USA
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Singh M, Nuttall GA, Ballman KV, Mullany CJ, Berger PB, Holmes DR, Bell MR. Effect of abciximab on the outcome of emergency coronary artery bypass grafting after failed percutaneous coronary intervention. Mayo Clin Proc 2001; 76:784-8. [PMID: 11499816 DOI: 10.1016/s0025-6196(11)63221-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To evaluate the outcome of coronary artery bypass grafting (CABG) for failed percutaneous coronary intervention (PCI) in patients who had received abciximab. PATIENTS AND METHODS In this retrospective study, we analyzed the records of patients who had PCI at our institution between January 1994 and December 1998 and identified those who had urgent or emergency CABG within 48 hours after PCI. CABG was performed for failed PCI in patients who had ongoing ischemia, hemodynamic compromise, or both. These patients were categorized into 2 groups depending on whether they had been given abciximab during PCI. We compared blood product transfusion requirements, bleeding complications, and frequency of in-hospital adverse events of the 2 groups. RESULTS Of 5636 patients who had PCI, 77 (1.4%) had urgent or emergency CABG within 48 hours, including 11 who were given abciximab (abciximab group) during PCI and 66 who were not given abciximab (no abciximab group). The 2 groups had similar baseline characteristics. The mean +/- SD time to surgery was 8.4 +/-8.0 hours (median, 6 hours) for the abciximab group vs 12.1 +/- 12.5 hours (median, 4 hours) for the no abciximab group. Major bleeding (Thrombolysis in Myocardial Infarction criteria) occurred in 9 (90%) of 10 patients in the abciximab group vs 48 (77%) of 62 patients in the no abciximab group. The total volumes of intraoperative autotransfusion and transfusion of red blood cells and fresh frozen plasma tended to be higher for the abciximab group. Also, this group received a mean of 13.9 U of platelets vs 3.2 U for the no abciximab group (P<.001). However, no in-hospital deaths occurred among patients in the abciximab group, and adverse events were infrequent and comparable between the 2 groups. No difference was noted between the 2 groups in the frequency of surgical reexploration for bleeding. CONCLUSION Transfusion requirements are higher for patients who undergo emergency or urgent CABG after having received abciximab during PCI. However, in-hospital adverse events are infrequent and comparable to those for patients who do not receive abciximab.
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Affiliation(s)
- M Singh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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Abstract
STUDY OBJECTIVE The use of abciximab, a chimeric monoclonal antibody Fab fragment specific for platelet glycoprotein IIb/IIIa receptors, is associated with improved outcome after angioplasty and stent placement. Major complications include bleeding, but pulmonary hemorrhage has been reported rarely. This study was done to identify patients with pulmonary hemorrhage following abciximab infusion and to define, if possible, any specific risk factors. DESIGN Retrospective review of institutional coronary angiography and bronchoscopy databases to identify patients who received abciximab and developed pulmonary hemorrhage. SETTING Tertiary-care teaching hospital. PATIENTS All patients who underwent coronary angiography and received abciximab between June 1995 and March 2000. INTERVENTION None. MEASUREMENTS AND RESULTS Seven of 2,553 patients (0.27%) had documented severe pulmonary hemorrhage associated with chest radiographic abnormalities, impaired oxygenation, and the need for blood product transfusions. The initial symptom was hemoptysis in four of the seven patients. There were two early deaths and one late death. No cases of pulmonary hemorrhage were identified in 5,412 patients who underwent coronary procedures without abciximab infusion. No other risk factors predicting hemorrhage were identified. CONCLUSIONS Severe pulmonary hemorrhage is a complication of abciximab use. Although hemoptysis is an important alerting symptom, it may not be present initially and the diagnosis may be missed or considered late, with the potential for inappropriate treatment until the diagnosis is established. Lesser degrees of bleeding are potentially easily missed, and this report should alert physicians to this complication so that it can be considered early in the evaluation of patients presenting with pulmonary events after abciximab use.
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Affiliation(s)
- S Kalra
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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Berger PB, Bellot V, Bell MR, Horlocker TT, Rihal CS, Hallett JW, Dalzell C, Melby SJ, Charnoff NE, Holmes DR. An immediate invasive strategy for the treatment of acute myocardial infarction early after noncardiac surgery. Am J Cardiol 2001; 87:1100-2, A6, A9. [PMID: 11348610 DOI: 10.1016/s0002-9149(01)01469-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- P B Berger
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
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Wilson SH, Bell MR, Rihal CS, Bailey KR, Holmes DR, Berger PB. Infarct artery reocclusion after primary angioplasty, stent placement, and thrombolytic therapy for acute myocardial infarction. Am Heart J 2001; 141:704-10. [PMID: 11320356 DOI: 10.1067/mhj.2001.114971] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The benefits of thrombolytic therapy for acute myocardial infarction (AMI) are limited by reocclusion of the infarct-related artery, which occurs in 25% to 30% of patients after successful reperfusion. The frequency of reocclusion after balloon angioplasty and stenting in this setting is less well documented. The aim of this study was to analyze the frequency and timing of reocclusion after percutaneous transluminal coronary angioplasty (PTCA) and stent placement during AMI from all available studies compared with previously published reocclusion rates after thrombolysis. METHODS AND RESULTS The previously published thrombolysis data included 4231 patients in 19 studies with > or = 75 patients. Only PTCA studies with > or = 50 patients and stent studies with > or = 30 patients, in which routine angiographic follow-up was obtained in > or = 60% of patients, were included. Ten PTCA studies with a total of 1943 patients were analyzed, with follow-up angiography in 1391 (72%). Reocclusion rates ranged from 5% to 16.7%. The stent studies included 698 patients from 7 studies, with follow-up angiography in 92%. Reocclusion rates ranged from 0% to 6%. With the use of logistic regression analysis with allowance for overdispersion, there was a significantly lower rate of reocclusion after PTCA (odds ratio, 0.38; confidence interval, 0.24 to 0.57; P <.0001) and stent placement (odds ratio, 0.11; confidence interval, 0.05 to 0.22; P <.0001) compared with thrombolysis. Reocclusion after stent placement was lower than after PTCA (odds ratio, 0.28; confidence interval, 0.13 to 0.6; P <.0001). CONCLUSIONS Reocclusion after PTCA and stent placement during AMI is less frequent than after thrombolysis. This may contribute to the superior outcome of patients treated with PTCA and stent placement in this setting.
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Affiliation(s)
- S H Wilson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Gerber TC, Sheedy PF, Bell MR, Hayes DL, Rumberger JA, Behrenbeck T, Holmes DR, Schwartz RS. Evaluation of the coronary venous system using electron beam computed tomography. Int J Cardiovasc Imaging 2001; 17:65-75. [PMID: 11495511 DOI: 10.1023/a:1010692103831] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
New therapeutic strategies in interventional cardiology and electrophysiology involve the coronary veins. This study examines the potential usefulness of electron beam computed tomography to obtain detailed noninvasive definition of the coronary venous anatomy and of arteriovenous relationships. Electron beam computed tomography allows acquisition and three-dimensional reconstruction of tomographic images of the beating heart with high spatial and temporal resolution. Contrast-enhanced, thin-section electron beam computed tomographic coronary arteriographic images of 34 patients (21 men and 13 women, age 60+/-10 years) were analyzed. The visibility of the coronary veins and their spatial relationship to the coronary arteries were assessed qualitatively on two- and three-dimensional displays. The coronary sinus was visible in 91%, the great cardiac vein in 100%, the middle cardiac vein in 88%, at least one vein overlying the lateral surface of the left ventricle in 97%, the anterior interventricular vein in 97%, and the small cardiac vein in 68%. A left marginal and a left posterior vein were seen in 44%, one of the two in 38%, and neither in 3%. The course of the anterior interventricular vein was parallel to the left anterior coronary artery in 79% and a crossover between the two vessels at an obtuse angle occurred in 12%. Contrast-enhanced electron beam computed tomography imaging of the heart noninvasively provides information on the coronary venous system and arteriovenous relationships that may help guide new interventional procedures.
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Affiliation(s)
- T C Gerber
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.
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Suwaidi JA, Garratt KN, Berger PB, Rihal CS, Bell MR, Grill DE, Holmes DR. Immediate and one-year outcome of intracoronary stent implantation in small coronary arteries with 2.5-mm stents. Am Heart J 2000; 140:898-905. [PMID: 11099994 DOI: 10.1067/mhj.2000.110936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The role of coronary stenting in the treatment of stenoses in small coronary arteries with use of 2.5-mm stents is not well defined. METHODS AND RESULTS Between January 1995 and August 1999, 651 patients with stenoses in small coronary arteries were treated with 2.5-mm stents (n = 108) or 2.5-mm conventional balloon angioplasty (BA) (n = 543). Patients who received treatment with both 2.5-mm and > or =3.0-mm stent placement or balloons were excluded. Procedural success and complication rates as well as 1-year follow-up outcomes were examined. Baseline clinical characteristics were similar between the two groups, except patients in the stent group were more likely to have hypertension and a family history of coronary artery disease and less likely to have prior myocardial infarction. Angiographic success rates were higher in the stent group (97.2% vs 90.2%, P =.02). In-hospital complication rates were comparable between the two groups. Among successfully treated patients, 1-year follow-up revealed no significant differences in the survival (96.2% vs 95.2%, P =.89) or the frequency of Q-wave myocardial infarction (0% vs 0.4%, P =.60) or coronary artery bypass grafting (8.4% vs 6.8%, P =.89) between the stent and BA groups, respectively. However, patients in the stent group were more likely to have adverse cardiac events (35.4% vs 22.1%, P =.05). Stent use after excluding GR II stent use, however, was not independently associated with reduced cardiac events at follow-up (relative risk 1. 3 [95% confidence interval 0.8-2.3], P =.30). CONCLUSIONS Intracoronary stent implantation of stenoses in small coronary arteries with 2.5-mm stents can be carried out with high success and acceptable complication rates. However, compared with BA alone, stent use was not associated with improved outcome through 1 year of follow-up.
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Affiliation(s)
- J A Suwaidi
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Holmes DR, Lansky A, Kuntz R, Bell MR, Buchbinder M, Fortuna R, O'Shaughnessy CD, Popma J. The PARAGON stent study: a randomized trial of a new martensitic nitinol stent versus the Palmaz-Schatz stent for treatment of complex native coronary arterial lesions. Am J Cardiol 2000; 86:1073-9. [PMID: 11074202 DOI: 10.1016/s0002-9149(00)01162-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A new martensitic nitinol stent with improved flexibility and radiopacity was tested to evaluate whether these differences improve initial or long-term outcome. Patients who underwent percutaneous revascularization of a discrete native coronary lesion were randomly assigned to the new stent (PARAGON, n = 349) or to the first-generation Palmaz-Schatz (PS) stent (n = 339). The primary end point was target vessel failure at 6 months (a composite of cardiac or noncardiac death, any infarction in the distribution of the treated vessel, or clinically indicated target vessel revascularization). Secondary end points were, among others, device and procedural success and angiographic restenosis. Mean age was 62 years; diabetes was present in 21% of patients, prior bypass surgery in 6%, and recent infarction in 22% (p = NS for comparison between the 2 randomized arms). The PARAGON stent group had smaller reference vessels (2.97 vs 3.05 mm, p = 0.05), more prior restenosis (8.0% vs 4.5%, p = 0.07), and a longer average stent length (21.3 vs 19.4 mm, p < 0.05). Device success was significantly higher in the PARAGON arm (99.1% vs 94.3%, p < 0.05). Death and infarction at 6-month follow-up were infrequent in both groups. There was no significant difference in death (2.0% vs 1.2%, p = 0.546), but a higher rate of infarction for the PARAGON cohort (9.2% vs 4.7%, p = 0.025). Although target vessel failure (20.3% vs 12.4%, p = 0.005) and target lesion revascularization (12.0% vs 5.9%, p = 0.005) were higher in the PARAGON group, there was no significant difference in 6-month follow-up in in-stent minimal lumen diameter or in the rate of binary angiographic restenosis. Both PARAGON and PS stents are safe and associated with infrequent adverse events. The PARAGON stent can be delivered more frequently than the first-generation PS stent. Although there was no significant difference in in-stent minimal lumen diameter or the frequency of angiographic restenosis, clinical restenosis was more frequent in the PARAGON group.
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Affiliation(s)
- D R Holmes
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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12
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Velianou JL, Wilson SH, Reeder GS, Caplice NM, Grill DE, Holmes DR, Bell MR. Decreasing mortality with primary percutaneous coronary intervention in patients with acute myocardial infarction: the Mayo Clinic experience from 1991 through 1997. Mayo Clin Proc 2000; 75:994-1001. [PMID: 11040846 DOI: 10.4065/75.10.994] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI). PATIENTS AND METHODS We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year. RESULTS The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997. Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P < .001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P < .001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P < .001). An increase in beta-blocker (58.3% to 75.3%; P < .001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%; P < .001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%; P < .001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%; P < .001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%; P = .05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P = .09). After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89; 95% confidence interval, 0.79-1.00; P = .05) and during long-term follow-up (odds ratio, 0.93; 95% confidence interval, 0.87-1.00; P = .04). CONCLUSIONS Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.
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Affiliation(s)
- J L Velianou
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn. 55905, USA
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Singh M, Rihal CS, Berger PB, Bell MR, Grill DE, Garratt KN, Barseness GW, Holmes DR. Improving outcome over time of percutaneous coronary interventions in unstable angina. J Am Coll Cardiol 2000; 36:674-8. [PMID: 10987583 DOI: 10.1016/s0735-1097(00)00768-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This study was performed to evaluate the recent changes in the outcome of coronary interventions in patients with unstable angina (UA). BACKGROUND An early invasive strategy has not been shown to be superior to conservative treatment in patients with UA. Earlier studies had utilized older technology. Interventional approaches have changed in the recent past, but to our knowledge, no large studies have addressed the impact of these changes on the outcome of coronary interventions. METHODS We analyzed the in-hospital and intermediate-term outcome in 7,632 patients with UA who underwent coronary interventions in the last two decades. The study population was divided into three groups: group 1, n = 2,209 who had coronary intervention from 1979 to 1989; group 2, n = 2,212 with interventions from 1990 to 1993; and group 3, n = 3,211 treated from 1994 to 1998. RESULTS Group 2 and 3 patients were older and sicker compared with group 1 patients. The clinical success improved significantly in group 3 (94.1%) compared with group 2 (87%) and group 1 (76.5%) (p < 0.001). There was a significant reduction in in-hospital mortality, Q-wave myocardial infarction and need for emergency bypass surgery in group 3 compared with the earlier groups. One-year event-free survival was also significantly higher in the recent group compared with the earlier groups: 77% in group 3, 70% in group 2 and 74% in group 1 (p < 0.001). With the use of multivariate models to adjust for clinical and angiographic variables, treatment during the most recent era was found to be independently associated with improved in-hospital and intermediate-term outcomes. CONCLUSIONS There has been significant improvement in the in-hospital and intermediate-term outcome of coronary interventions in patients with UA in recent years; newer trials comparing conservative and invasive strategies are therefore needed.
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Affiliation(s)
- M Singh
- Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Holmes DR, Berger PB, Garratt KN, Mathew V, Bell MR, Barsness GW, Higano ST, Grill DE, Hammes LN, Rihal CS. Application of the New York State PTCA mortality model in patients undergoing stent implantation. Circulation 2000; 102:517-22. [PMID: 10920063 DOI: 10.1161/01.cir.102.5.517] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study applied the New York State conventional coronary angioplasty (PTCA) model of clinical outcomes to evaluate whether it has relevance in the current era of stent implantation. The model was developed in 62 670 patients treated with conventional PTCA from 1991 to 1994 to risk adjust mortality and bypass surgery after PTCA. Since then, stents have become the dominant form of intervention. Whether that model remains relevant is uncertain. METHODS AND RESULTS All patients undergoing stenting at the Mayo Clinic from 1995 to 1998 were analyzed for in-hospital mortality, bypass surgery performed after attempted stenting, and longer-term mortality. No patients were excluded. The New York model was used to risk adjust and predict in-hospital and follow-up mortality. There were 3761 patients with 4063 procedural admissions for stenting; 6,472 target vessel segments were attempted, and 96.1% of procedures were successful. With the New York multivariable risk factor equation, 79 in-hospital deaths were expected (1.95%); 66 deaths (1.62%) were observed. The New York model risk score in a logistic regression model was the most significant factor associated with in-hospital mortality (OR, 1.86; P<0.001). During a mean follow-up of 1.2+/-1.0 years, there were 154 deaths. Multivariable analysis documented 6 factors associated with subsequent mortality; New York risk score was the most significant (chi(2)=16.64, P=0.0001). CONCLUSIONS Although the New York mortality model was developed in an era of conventional angioplasty, it remains relevant in patients undergoing stenting. The risk score derived from that model is the variable most significantly associated with not only in-hospital but also longer-term outcome.
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Affiliation(s)
- D R Holmes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Abstract
BACKGROUND The prediction and comparison of procedural death after percutaneous coronary interventional procedures is inherently difficult because of variations in case mix and practice patterns. The impact of modern, expanded patient selection criteria, and newer technologic approaches is unknown. Our objective was to determine whether a risk equation based on patient-related variables and derived from an independent data set can accurately predict procedural death after percutaneous coronary intervention in the current era. METHODS AND RESULTS An analysis was made of the Mayo Clinic Coronary Interventional Database January 1, 1995, to October 31, 1997. Expected mortality rate was calculated with the use of the New York State multivariate risk score. In 3387 patients, 3830 procedures (55.1% stents) were performed, with an expected mortality rate of 2.32% and observed mortality rate of 2.38% (P = not significant). The risk score derived from the New York multivariate model was highly predictive of death (chi-square = 213.8; P <.0001). The presence of a high-risk lesion characteristic such as calcium, thrombus, or type C lesion was modestly associated with death. CONCLUSIONS The New York State multivariate model accurately predicted procedural death in our database.
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Affiliation(s)
- C S Rihal
- Division of Cardiovascular Diseases and Internal Medicine and the Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Bell MR, Tseng SM. Capacity of the low-photon-rate direct-detection optical pulse-position-modulation channel in the presence of noise photons. Appl Opt 2000; 39:1776-1782. [PMID: 18345074 DOI: 10.1364/ao.39.001776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
We derive expressions for the capacity of the pulse-position-modulated (PPM) direct-detection photon-counting channel in the presence of noise photons in addition to the signal-dependent shot noise that is normally considered in studying photon counting at low photon rates. We note that even a small mean number of noise photons per PPM count bin significantly decreases the capacity of the channel. These results are useful for comparisons of performance that are obtained by use of real coding and synchronization algorithms with photon-counting PPM schemes that are currently being considered for deep-space optical communications.
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Affiliation(s)
- M R Bell
- School of Electrical and Computer Engineering, West Lafayette, Indiana 47907-1285, USA.
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Al Suwaidi J, Berger PB, Rihal CS, Garratt KN, Bell MR, Ting HH, Bresnahan JF, Grill DE, Holmes DR. Immediate and long-term outcome of intracoronary stent implantation for true bifurcation lesions. J Am Coll Cardiol 2000; 35:929-36. [PMID: 10732890 DOI: 10.1016/s0735-1097(99)00648-8] [Citation(s) in RCA: 202] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the immediate and long-term outcome of intracoronary stent implantation for the treatment of coronary artery bifurcation lesions. BACKGROUND Balloon angioplasty of true coronary bifurcation lesions is associated with a lower success and higher complication rate than most other lesion types. METHODS We treated 131 patients with bifurcation lesions with > or =1 stent. Patients were divided into two groups; Group (Gp) 1 included 77 patients treated with a stent in one branch and percutaneous transluminal coronary angioplasty (PTCA) (with or without atherectomy) in the side branch, and Gp 2 included 54 patients who underwent stent deployment in both branches. The Gp 2 patients were subsequently divided into two subgroups depending on the technique of stent deployment. The Gp 2a included 19 patients who underwent Y-stenting, and Gp 2b included 33 patients who underwent T-stenting. RESULTS There were no significant differences between the groups in terms of age, gender, frequency of prior myocardial infarction (MI) or coronary artery bypass grafting (CABG), or vessels treated. Procedural success rates were excellent (89.5 to 97.4%). After one-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp 1 and Gp 2. Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs. 30.4%, p = 0.004). CONCLUSIONS Stenting of bifurcation lesions can be achieved with a high success rate. However, stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch.
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Affiliation(s)
- J Al Suwaidi
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Wilson SH, Berger PB, Mathew V, Bell MR, Garratt KN, Rihal CS, Bresnahan JF, Grill DE, Melby S, Holmes DR. Immediate and late outcomes after direct stent implantation without balloon predilation. J Am Coll Cardiol 2000; 35:937-43. [PMID: 10732891 DOI: 10.1016/s0735-1097(99)00639-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of our study was to compare the in-hospital and long-term clinical outcomes of direct coronary stenting with balloon predilation followed by stent placement. BACKGROUND With improvement in stent designs, the practice of direct stenting without balloon predilation has become more widespread. METHODS We analyzed the Mayo Clinic Coronary Intervention data base between January 1, 1995 and March 5, 1999 and identified 777 patients who were treated with direct stenting (DS) and 3,176 patients treated with balloon angioplasty plus stenting (BA+S). RESULTS The procedural success rates between the DS and BA+S groups were not significantly different (96.3% vs. 96.4%). The ability to deliver the stent in a subgroup of patients who had DS was 95%, with 5% requiring crossover to predilation. Multivariate analysis showed no significant differences with respect to in-hospital death (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.5 to 1.8), in-hospital myocardial infarction (OR 0.9, 95% CI 0.6 to 1.2) or revascularization (OR 0.7, 95% CI 0.4 to 1.5) in the DS compared with the BA+S group. Long-term outcomes were not significantly different between the DS and BA+S groups. The procedural duration was significantly shorter in the DS group, and there was a decreased utilization of contrast agent, balloons and wires. CONCLUSIONS The in-hospital and long-term clinical outcomes in patients undergoing a coronary intervention are equivalent when comparing stenting without balloon predilation with balloon angioplasty followed by stenting. Direct stenting is associated with decreased utilization of contrast agent and equipment and shorter procedure times. A randomized study should be performed to better determine the impact of this technique on short- and long-term procedural outcomes.
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Affiliation(s)
- S H Wilson
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Singh M, Mathew V, Garratt KN, Berger PB, Grill DE, Bell MR, Rihal CS, Holmes DR. Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic. Am J Med 2000; 108:187-92. [PMID: 10723971 DOI: 10.1016/s0002-9343(99)00429-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE Elderly patients, especially those 80 years of age and older, have been excluded from most studies of thrombolysis or primary coronary angioplasty in patients with acute myocardial infarction. We compared the outcomes of elderly patients who underwent coronary angioplasty with the outcomes of younger patients and determined whether there were any temporal trends in survival. PATIENTS AND METHODS We reviewed the outcomes of 1,597 consecutive patients who underwent primary coronary angioplasty between 1979 and 1997, including 127 patients who were 80 years of age or older (mean [+/-SD] age, 83 +/- 3 years, 47% male). Their in-hospital and long-term outcomes were compared with those of 524 patients who were 70 to 79 years old, 527 patients who were 60 to 69 years old, and 419 patients who were 50 to 59 years old. The oldest group of patients was divided into two groups, based on whether they had intervention through the end of 1993 (n = 56) or between 1994 and 1997 (n = 71). The survival rate of the patients who had no complications and left the hospital was compared with expected survival based on age- and sex-adjusted data. RESULTS Patients 80 years of age or older had more adverse baseline characteristics, including risk factors and comorbid conditions, than the younger patients. The clinical success rate of primary angioplasty in this group was lower than those in the other three groups (61% versus 74% in those aged 70 to 79 years, 73% in those aged 60 to 69 years, and 81% in those aged 50 to 59 years, P < 0.001). The in-hospital mortality rate among patients 80 years of age or older was significantly greater than among patients in the other three groups (21% in those aged 80 years or older, 13% in those aged 70 to 79 years, 9% in those aged 60 to 69 years, and 4% in those aged 50 to 59 years, P < 0.001 ). The clinical success rate of the angioplasty improved significantly in the more recent period (75% versus 45%, P = 0.0006) and in-hospital mortality declined (16% versus 29%, P = 0.07). During follow-up, mortality in the oldest age group in whom angioplasty was successful was significantly greater than in the three younger groups, but was similar to the expected survival in the general US population. CONCLUSIONS The mortality associated with primary angioplasty for acute myocardial infarction in octogenarians remains high, although there has been significant improvement in the clinical success rate. The long-term prognosis following a successful angioplasty is not different from that in an age- and sex-adjusted U.S. white population.
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Affiliation(s)
- M Singh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Zacharski LR, Chow B, Lavori PW, Howes PS, Bell MR, DiTommaso MA, Carnegie NM, Bech F, Amidi M, Muluk S. The iron (Fe) and atherosclerosis study (FeAST): a pilot study of reduction of body iron stores in atherosclerotic peripheral vascular disease. Am Heart J 2000; 139:337-45. [PMID: 10650308 DOI: 10.1067/mhj.2000.102909] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Levels of body iron stores, represented by the serum ferritin concentration, rise with age after adolescence in men and menopause in women. This rise has been implicated mechanistically and epidemiologically in the pathogenesis of atherosclerosis through iron-induced oxygen free radical-mediated lipid oxidation. However, the precise contribution of iron stores to atherosclerosis and its complications are unknown because prospective randomized trials designed to test effects of reduction of iron stores on clinical outcomes in this disease have not been performed. METHODS AND RESULTS In preparation for a prospective randomized trial, a randomized pilot study was conducted to evaluate the feasibility, safety, and methodologic accuracy of calibrated reduction in iron stores by phlebotomy in a cohort of patients with advanced peripheral vascular disease. Phlebotomy resulted in a significant reduction in serum ferritin concentration to near targeted levels. Thus the formula for calculating the volume of blood to be removed to achieve a predetermined decrement in serum ferritin concentration was accurate and phlebotomy was not associated with any adverse laboratory or clinical effects. CONCLUSIONS Reduction of body iron stores to a predetermined level is feasible and can be achieved in a timely manner with excellent patient compliance. Prospective randomized trials of calibrated reduction of body iron stores may be undertaken to define their pathophysiologic significance in atherosclerosis and other diseases in which excessive iron-induced oxidative stress has been implicated.
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Affiliation(s)
- L R Zacharski
- Department of Veterans Association Medical Centers, White River Junction, VT 05009-0001, USA.
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Berger PB, Bell MR, Rihal CS, Ting H, Barsness G, Garratt K, Bellot V, Mathew V, Melby S, Hammes L, Grill D, Holmes DR. Clopidogrel versus ticlopidine after intracoronary stent placement. J Am Coll Cardiol 1999; 34:1891-4. [PMID: 10588199 DOI: 10.1016/s0735-1097(99)00442-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The study compared the safety and efficacy of ticlopidine with clopidogrel in patients receiving coronary stents. BACKGROUND Stent thrombosis is reduced when ticlopidine is administered with aspirin. Clopidogrel is similar to ticlopidine in chemical structure and function but has fewer side effects; few data are available about its use in stent patients. METHODS We compared 30-day event rates in 500 consecutive coronary stent patients treated with aspirin and clopidogrel (300 mg loading dose immediately prior to stent placement, and 75 mg/day for 14 days) to 827 consecutive stent patients treated with aspirin and ticlopidine (500 mg loading dose and 250 mg twice daily for 14 days). RESULTS Patients treated with clopidogrel had more adverse clinical characteristics including older age, more severe angina, and more frequent infarction within the prior 24 h. Nonetheless, mortality was 0.4% in clopidogrel patients versus 1.1% in ticlopidine patients; nonfatal myocardial infarction occurred in 0% versus 0.5%, stent thrombosis in 0.2% versus 0.7%, bypass surgery or repeat angioplasty in 0.4% versus 0.5%, and any event occurred in 0.8% versus 1.6% of patients, respectively (p = NS). Based on the observed 30-day event rate of 1.6% with ticlopidine, the statistical power of the study was 43% to detect an even rate of 0.5% with clopidogrel, and 75% to detect an event rate with of 4% with clopidogrel, with a p value of 0.05. CONCLUSIONS These data indicate that clopidogrel can be safely substituted for ticlopidine in patients receiving coronary stents.
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Affiliation(s)
- P B Berger
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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Suh WW, Grill DE, Holmes DR, Bell MR, Berger P, Garratt KN. Clinical, angiographic, and procedural correlates of abrupt vascular closure during coronary intervention: a 10-year experience at Mayo Clinic. Catheter Cardiovasc Interv 1999; 47:391-5. [PMID: 10470464 DOI: 10.1002/(sici)1522-726x(199908)47:4<391::aid-ccd1>3.0.co;2-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A large matched-cohort study was carried out to determine correlates of in-hospital abrupt vascular closure (AC). Univariate analysis identified current cigarette smoking (P = 0.021), myocardial infarction within 24 hr prior to procedure (P = 0.0035), emergency procedure (P = 0.02), lesion thrombus (P = 0.0001), and lesion angulation (P = 0.021) as significant clinical and angiographic variables. Relative to balloon angioplasty (PTCA), use of atherectomy (P = 0.015) and laser devices (P = 0.018) but not elective stent placement (P = 0.97) were associated with increased risk of AC. In the multivariate model, current cigarette smoking (P = 0.0474), lesion thrombus (P = 0.0001), lesion angulation (P = 0.0124), use of atherectomy devices (P = 0.001), and laser devices (P = 0.0037) remained as significant correlates of increased AC events. In conclusion, the risk of AC appears associated primarily with lesion characteristics and use of nonballoon devices other than stents. Elective stent placement did not appear to reduce AC risk over conventional PTCA; the small number of patients studied may have prevented any benefit from being observed.
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Affiliation(s)
- W W Suh
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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Bell MR, Lerman LO, Rumberger JA. Validation of minimally invasive measurement of myocardial perfusion using electron beam computed tomography and application in human volunteers. Heart 1999; 81:628-35. [PMID: 10336923 PMCID: PMC1729070 DOI: 10.1136/hrt.81.6.628] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To measure myocardial perfusion using an estimate of intramyocardial vascular volume obtained by electron beam computed tomography (EBCT) in an animal model; to assess the feasibility and validity of measuring regional myocardial perfusion in human volunteers using the techniques developed and validated in the animal studies. METHODS Measurements of myocardial perfusion with EBCT employing intravenous contrast injections were compared with radioactive microsphere measurements (flow 57 to 346 ml/100 g/min) in seven closed chest dogs. Fourteen human volunteers then underwent EBCT scans using intravenous contrast injections. RESULTS Mean (SEM) global intramyocardial vascular volume by EBCT was 7.6 (1.1)%. The correlation between global EBCT (y) and microsphere (x) perfusion was y = 0.59x + 15.56 (r = 0.86) before, and y = 0.72x + 6. 06 (r = 0.88) after correcting for intramyocardial vascular volume. Regional perfusion correlation was y = 0.75x + 23.84 (r = 0.82). Corresponding improvements in agreement between the two techniques were also seen using Bland-Altman plots. In the human subjects, mean resting global myocardial flow was 98 (6) ml/100 g/min, with homogeneous flow across all regions. In 10 of these subjects, perfusion was studied during coronary vasodilatation using intravenous adenosine. Global flow increased from 93 (5) ml/100 g/min at rest to 250 (19) ml/100 g/min during adenosine (p < 0.001), with an average perfusion reserve ratio of 2.8 (0.2). Similar changes in regional perfusion were observed and were uniform throughout all regions, with a mean regional perfusion reserve ratio of 2.8 (0.3). CONCLUSIONS Accounting for intramyocardial vascular volume improves the accuracy of EBCT measurements of myocardial perfusion when using intravenous contrast injections. The feasibility of providing accurate measurements of global and regional myocardial perfusion and perfusion reserve in people using this minimally invasive technique has also been demonstrated.
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Affiliation(s)
- M R Bell
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA.
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25
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Abstract
In patients receiving coronary stents treated with aspirin and coumadin, the peak incidence of stent thrombosis occurs on the fifth and sixth days following the implantation procedure. Little is known about the timing of stent thrombosis in patients treated with aspirin and ticlopidine. We compared the timing of coronary stent thrombosis in patients treated with ticlopidine and aspirin with the timing in those receiving coumadin and aspirin. A retrospective databank analysis was performed and 39 patients were identified who experienced stent thrombosis after successful coronary stent implantation. Of these, 21 had been treated with ticlopidine and aspirin and 18 with coumadin and aspirin therapy. The median time from stent implantation to stent thrombosis in the ticlopidine and aspirin group was 12 hours (interquartile range 6 to 72 hours) compared with 4 days in the coumadin and aspirin group (interquartile range 21 to 68 hours) (p <0.0001). There was no significant difference between the timing of stent thrombosis in patients treated with abciximab in addition to ticlopidine and aspirin (median 17 hours, interquartile range 6 to 29) versus ticlopidine and aspirin patients who did not receive abciximab (median 11 hours, interquartile range 9 to 12, p = 0.57). Thus, in patients who receive coronary stents, stent thrombosis occurs much earlier after the procedure in patients treated with ticlopidine and aspirin than in patients treated with anticoagulation therapy.
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Affiliation(s)
- S H Wilson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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26
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Singh M, Bell MR, Berger PB, Holmes DR. Utility of bilateral coronary injections during complex coronary angioplasty. J Invasive Cardiol 1999; 11:70-4. [PMID: 10745484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
We describe a technique useful in complex coronary interventions wherein timed bilateral contrast injections are given in both coronary arteries. This technique is useful in chronic total occlusions in which the distal coronary vessel is not visualized except by collateral filling via the contralateral artery. This technique was applied in 12 patients; 11 with native coronary occlusion and one in whom the target site was visualized by contrast injections into a vein graft supplying competitive flow to an otherwise patent native vessel. With this technique, the distal coronary artery segment can be better visualized, which helps to aim and track the guide wire across the occluded segment.
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Affiliation(s)
- M Singh
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Graduate School of Medicine, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA
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27
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Cusma JT, Bell MR, Wondrow MA, Taubel JP, Holmes DR. Real-time measurement of radiation exposure to patients during diagnostic coronary angiography and percutaneous interventional procedures. J Am Coll Cardiol 1999; 33:427-35. [PMID: 9973023 DOI: 10.1016/s0735-1097(98)00591-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to accurately assess the radiation exposure received by patients during cardiac catheterization in a large sample representative of the current state of practice in cardiac angiography. BACKGROUND Radiation exposure to patients and laboratory staff has been recognized as a necessary hazard in coronary angiography. The effects on x-ray exposure of the increased complexity of coronary angiographic procedures and, in particular, the increasing use of coronary artery stenting, have not been adequately addressed in previous studies. METHODS X-ray exposure measurements were performed on a consecutive series of 972 patients undergoing 992 diagnostic and interventional studies in the Mayo Clinic catheterization laboratory within an eight week period in late 1997. Data were acquired from 706 diagnostic procedures and 286 interventional procedures using a real-time exposure measurement system to continuously calculate and record the exposure rate and total exposure, reflecting all parameters relevant to the specific patient and procedure situation. RESULTS The median exposure for all 992 procedures was 41.8 mC/kg (162.1 R); the corresponding values for diagnostic and interventional procedures were 34.9 and 95.6 mC/kg, respectively (135.3 vs. 370.5 R). There were significant differences in the fluoroscopy exposure time between diagnostic and interventional procedures: 4.7 min vs. 21.0 min. Heavier patients (>83 kg) received x-ray exposures at a significantly higher rate than did lighter patients (<83 kg) during both fluoroscopy and cine; 44.9 mC/kg/min (173.9 R/min) vs. 27.9 mC/kg/min (108.3 R/min) for cine exposure rate and 2.3 mC/kg/min (8.8 R/min) vs. 1.5 mC/kg/min (5.8 R/min) for fluoroscopy exposure rate. CONCLUSIONS Changes in practice have led to higher values for patient x-ray radiation exposures during cardiac catheterization procedures. The real-time display and recording of x-ray exposure facilitates the reduction of exposure in the catheterization laboratory.
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Affiliation(s)
- J T Cusma
- Mayo Foundation and Clinic, Rochester, Minnesota 55905, USA.
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28
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Abstract
BACKGROUND In patients receiving intracoronary stents, stent thrombosis is reduced when ticlopidine therapy is combined with aspirin after the procedure. However, ticlopidine causes neutropenia in 1% of patients when administered for >2 weeks, and little is known about the duration that ticlopidine needs be administered to prevent stent thrombosis. METHODS AND RESULTS We analyzed 827 patients undergoing successful stent placement in 1061 coronary segments at Mayo Clinic who were treated between May 1, 1996, and October 31, 1997. Chronic warfarin therapy, cardiogenic shock, and enrollment in research protocols requiring 4 weeks of ticlopidine were exclusion criteria; ticlopidine was discontinued after 14 days in all remaining patients. The mean age of the study population was 64+/-11 years; 49% had suffered a prior infarction, 20% had undergone coronary artery bypass surgery, and 65% had multivessel disease. The indication for stent placement was dissection or abrupt closure in 31% of patients and suboptimal results from balloon angioplasty in 18%. Placement was elective in 51% of patients, and 10.3% of patients were treated within 12 hours of an acute myocardial infarction. Mean nominal stent size was 3.3+/-0.5 mm. High-pressure inflations (>/=12 atm) were performed in all patients (mean, 17+/-4 atm). Intravascular ultrasound was used to facilitate stent placement in 8.8% of patients. Abciximab was administered to 38% of patients; 11% of patients who were at increased risk of stent thrombosis were treated with enoxaparin for 10 to 14 days. Adverse cardiovascular events in the 14 days after stent placement occurred in 11 patients (1.3%). Two patients died of nonischemic causes (sepsis and renal failure) in the 15th through 30th days after ticlopidine was stopped. However, there were no cardiovascular deaths, myocardial infarctions, coronary artery bypass operations, or repeat angioplasty procedures between the 15th and 30th days; stent thrombosis did not occur in any patient after ticlopidine had been stopped. No patient developed neutropenia, although 1.8% of the first 489 patients who were closely monitored for side effects from ticlopidine developed side effects requiring its discontinuation, and milder side effects occurred in 4.7%. CONCLUSIONS In patients receiving intracoronary stents, the discontinuation of ticlopidine therapy 14 days after stent placement is associated with a very low frequency of stent thrombosis and other adverse events.
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Affiliation(s)
- P B Berger
- Division of Cardiovascular Diseases, Department of Internal Medicine and the Section of Biostatistics, Mayo Clinic, Rochester, MN, USA.
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29
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Abstract
We present a generalization of the regularity model, which is a stationary point process model describing how often and how regularly a random "event" occurs. The generalization allows the amplitude of each event to be a sample from a random process. First, we developed closed-form approximations of the power spectra of data segments; then we examined the accuracy of a procedure that estimates the regularity and mark process parameters by minimizing the error between measured spectra and the approximations. We found the following. In the absence of measurement noise, joint estimation of both mark and regularity parameters is accurate only if the ratio of the square of the mean of the marks to the variance of the marks (the SMNPR) is small. Marginal estimation of the regularity process parameters can be accurate if the mark process is taken into account by minimizing overall parameters; the accuracy then depends on both measurement noise and SMNPR. Error in the marginal estimation of the regularity process parameters will be inversely proportional to the SMNPR if the marks are ignored by minimizing only with respect to the regularity parameters, so ignoring the marks can cause a substantial degradation in accuracy when the SMNPR is small. We illustrate these findings with an acoustic scattering example in which simulated ultrasound measurements of tissue samples are characterized by their description in the parameter space.
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30
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Abstract
The clinical and angiographic outcomes of 10 patients who received abciximab as part of their therapy for early stent thrombosis was compared with 25 patients (using historical controls) who received conventional therapy. Although the angiographic outcome and the incidence of myocardial infarction in both groups was similar, there were no deaths or referral for emergency coronary bypass surgery in the abciximab-treated group versus 3 deaths and 10 referrals for emergency bypass surgery in the conventionally treated group.
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Affiliation(s)
- I P Casserly
- Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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31
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Abstract
Although adjunctive abciximab therapy improves outcome after angioplasty or atherectomy, there are few data demonstrating its benefit for intracoronary stent implantation. We characterized patients receiving abciximab for stent placement in our practice and determined the impact of abciximab on outcome. Abciximab was introduced to our practice in April 1995 for percutaneous revascularization. Demographic, clinical, and angiographic variables that were independently associated with the use of abciximab for stent placement through 1996 (abciximab era) were examined. We then examined among all patients receiving stents from 1992 through 1996 (preabciximab and abciximab eras) whether the use of abciximab was independently associated with improved outcome (death, nonfatal Q-wave myocardial infarction, coronary bypass surgery, or target vessel percutaneous revascularization) in the hospital and at 30 days. The 30-day event rate was 7% for those who did or did not receive abciximab. The following characteristics were independently associated with the use of abciximab for stent placement in the abciximab era: thrombus before stent placement (chi-square 50.5), > or =2 stents implanted (chi-square 10.8), stent in venous graft (chi-square 7.4), calcific lesion (chi-square 5.8), and hypertension (chi-square 5.5). Among all patients receiving stents in the preabciximab and abciximab eras (n=1,859), the presence of these characteristics was independently associated with worse outcome. Abciximab, however, did not improve outcome in the hospital (odds ratio [95% confidence interval]=0.96 [0.58 to 1.58]) or at 30 days (0.87 [0.53 to 1.41]), even after adjusting for these characteristics. Abciximab for stent placement was used in high-risk patients in our practice but was not associated with improved outcome.
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Affiliation(s)
- D Hasdai
- Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Hurrell DG, Nobrega TP, Christian TF, Bell MR, Gibbons RJ. Reversible perfusion defects on exercise tomographic thallium imaging in patients with and without collateral flow. Am J Cardiol 1998; 82:234-6. [PMID: 9678296 DOI: 10.1016/s0002-9149(98)00321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A consecutive series of patients underwent exercise thallium imaging and coronary angiography that identified single-vessel right coronary artery disease. Redistribution in the left anterior descending territory was significantly associated with the presence of left-to-right collaterals, whereas collaterals were significantly less frequent in individuals who did not exhibit redistribution.
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Affiliation(s)
- D G Hurrell
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota 55905, USA
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33
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Abstract
The acceptance of the Digital Imaging and Communication in Medicine (DICOM) standard and the Compact Disk-Recordable (CD-R) as the interchange medium have been critical developments for laboratories that need to move forward on the cine replacement front, while at the same time retain a means to communicate with other centers. One remaining essential component which has not been satisfactorily addressed is the issue of how digital image data should be archived within an institution. Every laboratory must consider the diverse issues which affect the choice of a digital archiving system. These factors include technical and economic issues, along with the clinical routines prevailing in their laboratory. A complete understanding of the issues will lead to the formulation of multiple options which may prove acceptable and will help to overcome the last obstacle which remains for the complete replacement of cine film in the cardiac catheterization laboratory.
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Affiliation(s)
- D R Holmes
- Mayo Foundation and Clinic, Rochester, Minnesota 55905, USA
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Schmermund A, Rensing BJ, Sheedy PF, Bell MR, Rumberger JA. Intravenous electron-beam computed tomographic coronary angiography for segmental analysis of coronary artery stenoses. J Am Coll Cardiol 1998; 31:1547-54. [PMID: 9626833 DOI: 10.1016/s0735-1097(98)00132-6] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We sought to identify and localize significant coronary stenoses on a segmental basis by electron-beam computed tomography (EBCT) and intravenous administration of a contrast agent. BACKGROUND The clinical applicability and limitations of intravenous EBCT coronary angiography have not been defined. METHODS EBCT was performed within 24 h of selective coronary angiography (SCA) in 28 patients (19 men and 9 women, mean [+/-SD] age 60 +/- 10 years). After examination for coronary calcium, EBCT coronary angiography was performed using overlapping slices (in-plane resolution 0.34 to 0.41 mm) with a nominal slice thickness of 1 mm. Based on quantitative analysis of SCA, lumen diameter narrowing > or = 50% (i.e., significant stenoses) was evaluated in 8 (major) or 12 (including side branches) coronary artery segments, using both two-dimensional (tomographic) and three-dimensional (volume) data sets. RESULTS Of the 330 segments assessable by SCA, 237 (72%) were visualized by EBCT. The sensitivity (+/-SE) for detection of significant stenoses was 82 +/- 6%; specificity was 88 +/- 2%; positive and negative predictive values were 57 +/- 7% and 96 +/- 2%, respectively; and overall accuracy was 87 +/- 2%. If only eight (major) coronary artery segments were considered, 194 (88%) of 221 segments were visualized, and the overall accuracy was 90 +/- 2%. Seven (18%) of 38 significantly stenotic segments were classified as having < 50% stenoses by EBCT. Six of these segments (86%), but only 9 (29%) of the 31 correctly classified stenotic segments, were severely calcified (area > 20 mm2, p = 0.02). In 23 (12%) of 199 nonstenotic segments falsely classified as having > or = 50% stenosis by EBCT, the lumen diameter was significantly smaller than that of the segments correctly classified as negative (mean [+/-SD] 1.5 +/- 0.8 vs. 2.9 +/- 1.1 mm, p < 0.001). CONCLUSIONS Intravenous EBCT coronary angiography allows for accurate segmental evaluation of significant disease in the major coronary arteries and may be of value for ruling out significant disease. The main determinant of false negative results is substantial segmental calcification, whereas the main determinant of false positive results is small vessel size.
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Affiliation(s)
- A Schmermund
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
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35
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Rabbani RR, Bell MR, Grill DE, Simari RD, Holmes DR. Clinical outcomes after successful percutaneous coronary angioplasty of saphenous vein graft disease and the importance of long-term assessment. Int J Cardiol 1998; 65:11-7. [PMID: 9699925 DOI: 10.1016/s0167-5273(98)00090-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We examined the short- and long-term outcome of 327 patients at Mayo Clinic who had undergone coronary angioplasty of saphenous vein graft stenoses to determine whether the traditional 6-month assessment of clinical end points after coronary angioplasty is as useful as it is for patients who have had angioplasty of native vessel disease. Follow-up over 3.3+/-2.7 years was performed. At 6 months, 96+/-1% of the patients were alive, whereas at the 1- and 5-year end points, survival had deteriorated to 92+/-2 and 67+/-3%, respectively. Only 80+/-2% were free of severe angina at 6 months and 62+/-3 and 36+/-3% after 1 and 5 years. Combined event-free rate for death, Q-wave myocardial infarction or repeat coronary artery bypass surgery was 86+/-2% at 6 months, 78+/-2% at 1 year, and 45+/-4% at 5 years. Independent predictors of mortality included advancing age, diabetes mellitus, target vein grafts >5 years old and left ventricular ejection fraction <40%. In conclusion, despite reasonable 6- to 12-month outcomes following vein graft angioplasty, significant attrition in survival and event-free survival was observed. These observations have important implications for the interpretation of results of trials comparing conventional angioplasty and coronary bypass surgery with newer interventional devices if only the traditional 6-month follow-up interval is used.
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Affiliation(s)
- R R Rabbani
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Berger PB, Bell MR, Grill DE, Melby S, Holmes DR. Frequency of adverse clinical events in the 12 months following successful intracoronary stent placement in patients treated with aspirin and ticlopidine (without warfarin). Am J Cardiol 1998; 81:713-8. [PMID: 9527080 DOI: 10.1016/s0002-9149(97)01005-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Little is known about the frequency of adverse events in the year following stent placement in patients treated with aspirin and ticlopidine, without warfarin. We analyzed the first such 234 consecutive patients treated at our hospital between October 1994 and December 1995. Their mean age was 62+/-12 years; 40% had had a prior myocardial infarction, 22% had undergone coronary artery bypass surgery, and 65% had multivessel disease. The indication for stent placement was dissection or abrupt closure in 24% of patients and suboptimal balloon angioplasty results in 14%; placement was elective in 62% of patients. Three hundred forty-five coronary segments were treated in the 234 patients; 305 stents (1.3 stents/patient) were placed. Palmaz-Schatz coronary stents (75%), Gianturco-Roubin stents (21%), and Johnson & Johnson biliary stents (4%) were used. Mean nominal stent size was 3.4+/-0.4 mm. High-pressure inflations (> or = 14 atm, mean 17+/-2) were performed in all patients. The mean residual stenosis was 3+/-5% by visual estimate. Intravascular ultrasound was utilized to facilitate stent placement in 53% of patients. Mean follow-up was 1.6+/-0.5 years. There were no deaths, Q-wave myocardial infarctions, coronary artery bypass operations, or repeat angioplasty procedures required during the remainder of the hospitalization or in 30 days after stent placement; stent thrombosis did not occur. Kaplan-Meier analysis of adverse events in the 6 months following the procedure revealed a mortality rate of 0.9%; the rate of myocardial infarction (Q-wave or non-Q-wave) was 1.3%. Bypass surgery was performed in 0.9% and angioplasty for in-stent restenosis was performed in 9.5% of patients. Any 1 of these events occurred in 11.7% of patients in the 6 months after the procedure. The corresponding event rates at 1 year were 1.3%, 2.2%, 3.5%, and 12.2%, respectively; any 1 of these events occurred in 16.5% of patients. In patients receiving intracoronary stents of varying designs followed by high-pressure postdeployment inflations in whom an excellent visual angiographic result is achieved, antithrombotic therapy with aspirin and ticlopidine is associated with a very low frequency of adverse cardiovascular events in the 12 months following the procedure regardless of the indication for stent placement.
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Affiliation(s)
- P B Berger
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
OBJECTIVES To evaluate the outcome of patients undergoing multivessel coronary stent implantation. BACKGROUND Percutaneous transluminal coronary angioplasty has been shown to be an effective treatment for multivessel coronary artery disease, although the need for repeat revascularization continues to be a limitation. Intracoronary stent placement has been shown to reduce the need for subsequent revascularization. METHODS Seventy-seven patients without prior coronary artery bypass grafting (CABG) undergoing multivessel coronary revascularization in which stents were placed in all treated segments over a 5 year period at our institution were identified. Clinical and angiographic characteristics and outcomes were analyzed. RESULTS One hundred and eighty-eight coronary lesions were successfully treated (2.1+/-0.3 treated vessels/patient, 2.4+/-0.6 treated lesions/patient) using 2.8+/-1.2 stents/patient (range 2-9) and 1.4+/-0.8 stents/vessel (range 1-6). Procedural success rate [angiographic success without in-hospital death, Q-wave myocardial infarction (Q-wave MI) or CABG] was achieved in 76 of 77 patients (98.7%). Anatomically complete revascularization was achieved in 46 (59.7%) patients. Modified ACC/AHA Type B2 and C lesions comprised 75.5% of the 188 lesions. The left anterior descending artery was treated in 57 (74.0%) patients. The indication for stent placement was dissection or threatened/abrupt closure in 54 segments (28.8%). In-hospital events included death in one patient (1.3%); no patient suffered a Q-wave MI or required CABG. Stent occlusion occurred in two (2.6%) patients, and repeat percutaneous intervention of the target vessel was also required in these two patients. Any of these adverse events occurred in three (3.9%) patients. No further events occurred after hospital discharge in the 30 days after the procedure. Of hospital survivors (n=76), adverse events at 6 months included death in two patients (2.6%), MI in two (2.6%), CABG in six (7.9%); nine (11.8%) patients underwent repeat percutaneous intervention and 15 (19.7%) underwent any revascularization. CONCLUSIONS Multivessel coronary stent placement is associated with an excellent procedural success rate despite a high rate of adverse lesion characteristics, and a low rate of death or MI during follow-up. The need for further revascularization compares favorably with published rates with multivessel PTCA and single stent implantation for discrete de novo lesions.
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Affiliation(s)
- V Mathew
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Mathew V, Hasdai D, Holmes DR, Garratt KN, Bell MR, Lerman A, Melby S, Grill DE, Berger PB. Clinical outcome of patients undergoing endoluminal coronary artery reconstruction with three or more stents. J Am Coll Cardiol 1997; 30:676-81. [PMID: 9283525 DOI: 10.1016/s0735-1097(97)00207-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We sought to evaluate the outcome of patients undergoing multiple (three or more), contiguous stent implantation within a single native coronary artery. BACKGROUND The implantation of multiple stents within a single coronary artery is increasing in frequency, although the outcome of such patients is not well described. METHODS Forty-five patients without previous coronary artery bypass graft surgery (CABG) undergoing multiple, contiguous stent implantation in a single coronary artery were identified. Clinical and angiographic characteristics and outcomes were analyzed. RESULTS The angiographic success rate was 97.8%. The procedural success rate was 91.1%; stent occlusion during the initial hospital period occurred in four patients (8.9%). Death, myocardial infarction (MI), CABG, repeat target vessel intervention or severe angina occurred in 10 (23.3%) of 43 hospital survivors at 6-months follow-up. The indication for stent placement was threatened or abrupt closure in 30 patients (66.7%). Of the 25 patients with abrupt or threatened closure whose clinical and angiographic data would have indicated emergent CABG had stents not been available, the frequency of in-hospital death and Q wave MI was similar to that of a matched consecutive series of patients at our institution who underwent emergent CABG after failed angioplasty. At 1 year, the frequency of death, Q wave MI, CABG and severe angina at 1 year was similar in the two groups; the need for repeat percutaneous intervention was more common in the stent group (25% vs. 0%, p = 0.01). CONCLUSIONS Implantation of multiple, contiguous intracoronary stents was associated with a high initial success rate, although the incidence of early stent closure was relatively high. Adverse events at 6 months of follow-up were more frequent than previously reported for elective single-stent implantation; however, adverse angiographic characteristics such as dissection and thrombus were frequent in this group. In addition, the strategy of multiple stent implantation in the setting of failed angioplasty is a reasonable alternative to emergent CABG, although the need for further percutaneous intervention must be anticipated.
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Affiliation(s)
- V Mathew
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Rumberger JA, Behrenbeck T, Bell MR, Breen JF, Johnston DL, Holmes DR, Enriquez-Sarano M. Determination of ventricular ejection fraction: a comparison of available imaging methods. The Cardiovascular Imaging Working Group. Mayo Clin Proc 1997; 72:860-70. [PMID: 9294535 DOI: 10.4065/72.9.860] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Knowledge of left ventricular ejection fraction has been shown to provide diagnostic and prognostic information in patients with known or suspected heart disease. In clinical practice, the ejection fraction can be determined by using one of the five currently available imaging techniques: contrast angiography, echocardiography, radionuclide techniques of blood pool and first pass imaging, electron beam computed tomography, and magnetic resonance imaging. In this review, we discuss the clinical application as well as the advantages and disadvantages of each of these methods as it relates to determination of ventricular ejection fraction.
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Affiliation(s)
- J A Rumberger
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905, USA
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Hasdai D, Bell MR, Grill DE, Berger PB, Garratt KN, Rihal CS, Hammes LN, Holmes DR. Outcome > or = 10 years after successful percutaneous transluminal coronary angioplasty. Am J Cardiol 1997; 79:1005-11. [PMID: 9114755 DOI: 10.1016/s0002-9149(97)00038-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients (n = 611) after successful percutaneous transluminal coronary angioplasty were prospectively followed over 10 to 16 years for major adverse events. The effect of gender, extent of coronary artery disease, left ventricular dysfunction, and age on occurrence of adverse events were analyzed in detail. The incidence of death, Q-wave myocardial infarction, and coronary bypass surgery was 23.1%, 3.9%, and 32.7%, respectively. Men and women had similar mortality (p = 0.13) and Q-wave myocardial infarction (p = 0.57), but men had more coronary bypass surgery (p = 0.06). Patients with multivessel disease had higher mortality (p < 0.0001), and patients with 3-vessel disease had a higher incidence of Q-wave myocardial infarction (p = 0.04) and coronary bypass surgery (p < 0.001). Left ventricular dysfunction was associated with higher mortality (p < 0.0001) and coronary bypass surgery (p = 0.045), but not Q-wave myocardial infarction (p = 0.99). Mortality was higher in elderly patients (p < 0.0001), but the incidence of Q-wave myocardial infarction was similar (p = 0.64). Older patients underwent coronary bypass surgery less often (p = 0.004). By multivariate analysis, only the extent of coronary disease (relative risk [RR] 1.71, confidence interval [CI] 1.34 to 2.19; p = 0.0001), diabetes mellitus (RR 1.82, CI 1.28 to 2.59; p = 0.001), hypertension (RR 1.30, CI 1.08 to 1.96, p = 0.009), male gender (RR 1.30, CI 0.99 to 1.71, p = 0.058), and prior myocardial infarction (RR 1.44, CI 1.14 to 1.81, p = 0.002) independently influenced the incidence of major adverse events. We conclude that it is possible to identify patients with worse long-term prognosis after percutaneous transluminal coronary angioplasty based on clinical and angiographic parameters.
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Affiliation(s)
- D Hasdai
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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41
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Hasdai D, Berger PB, Bell MR, Rihal CS, Garratt KN, Holmes DR. The changing face of coronary interventional practice. The Mayo Clinic experience. Arch Intern Med 1997; 157:677-82. [PMID: 9080922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Devices designed to facilitate or replace conventional percutaneous transluminal coronary angioplasty have been introduced in recent years. OBJECTIVES To characterize the changes in percutaneous coronary interventional practice over 16 years and to assess the relative use of these new devices. METHODS We performed a retrospective analysis of all patients who underwent percutaneous coronary revascularization at Mayo Clinic, Rochester, Minn, during a 16-year period (1980-1995) and characterized the changes in procedural and clinical factors. RESULTS The number of coronary interventional procedures performed increased from 38 in 1980 to 1284 in 1995. Atherectomy and laser angioplasty were incorporated in 1988; their use peaked in 1994 (17% of procedures) but decreased to 9.9% by 1995. In contrast, the use of intracoronary stents has increased steadily since 1990. By 1995, intracoronary stents were placed in 48.2% of procedures. The success rate improved from 55.3% in 1980 to 91.4% in 1995, although patients were older (51 +/- 10 [mean +/- SD] years in 1980 vs 63 +/- 12 years in 1995), had more extensive coronary artery disease (0% with multivessel disease in 1980 vs 47.4% in 1995), had more complex lesions, and often underwent intervention in the peri-infarction setting (2.6% of procedures in 1980 vs 17% in 1995). The rate of referral to emergency coronary bypass surgery after percutaneous procedures declined from 5.2% in 1980 to 0.4% in 1995. CONCLUSIONS Current coronary interventional practice is expanding and improving. In contrast to intracoronary stents that have greatly affected current practice, other new devices are used infrequently. Conventional angioplasty, with or without intracoronary stents, remains the dominant treatment strategy.
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Affiliation(s)
- D Hasdai
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn., USA
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Holmes DR, Bell MR, Holmes DR, Berger PB, Bresnahan JF, Hammes LN, Grill DE, Garratt KN. Interventional cardiology and intracoronary stents--a changing practice: approved vs. nonapproved indications. Cathet Cardiovasc Diagn 1997; 40:133-8. [PMID: 9047049 DOI: 10.1002/(sici)1097-0304(199702)40:2<133::aid-ccd1>3.0.co;2-c] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Our objective was to document change in stent usage in a single practice over time and to study "off-label" compared to Food and Drug Administration (FDA)-approved indications. Although only two intracoronary stents have been approved by the FDA, the relatively limited approved indications do not account for the dramatic increase in stent implantation. This increase has important implications for patient health care delivery. This study of stent usage in a single center over a 36-mo period included all patients treated with coronary stents at the Mayo Clinic from January 1993-December 1995, and evaluated the relative difference in frequency between "off-label" and FDA-approved indications for implantation. During the 36-mo period of study, 3,614 interventional procedures were done and one or more stents were placed in 25.4% of patients. The proportion of patients receiving stents increased throughout this time: during the first 6-mo period, stents were placed in 6.2% of procedures; during the last 6-mo period, stents were placed in 46.3% of procedures, an eightfold increase. During the final 6 mo, an unapproved device or an unapproved indication for an approved device constituted 59.4% of all stent procedures. In addition, use of the non-FDA-approved adjunctive treatment regimen without warfarin increased from 2.9% in the first 6-mo period of observation to 82.7% in the last 6 mo. The use of stents increased strikingly over a 36-mo period, from 6% to 46% of all procedures. The majority of implantations were performed either for an "off-label" unapproved indication or with an unapproved device.
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Affiliation(s)
- D R Holmes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Schmermund A, Bell MR, Lerman LO, Ritman EL, Rumberger JA. Quantitative evaluation of regional myocardial perfusion using fast X-ray computed tomography. Herz 1997; 22:29-39. [PMID: 9088938 DOI: 10.1007/bf03044568] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Clinical quantitation of regional myocardial perfusion using a minimally invasive and easily applied technique could allow for ready quantitation of the functional significance of coronary disease, allow for further understanding of flow reserve in various cardiomyopathic and hemodynamic overload (pressure versus volume) conditions, and possibly provide basic information needed regarding the development and clinical significance of coronary collateral vessels and diseases of the myocardial microcirculation. Electron beam CT (EBCT) is a unique cardiac imaging modality that allows for rapid acquisition tomographic slices of the heart with excellent spatial resolution. It has been demonstrated to provide accurate measurements of cardiac anatomy, biventricular function, myocardial mass, and estimates of mural atherosclerotic plaque burden via quantification of coronary calcium. The application of classical indicator techniques for use by fast x-ray computed tomography techniques such as electron beam CT has been shown to allow quantitative analysis of regional myocardial perfusion throughout the myocardium. Initial studies using central intravenous contrast injection in experimental animals showed a close correlation of regional myocardial perfusion as quantitated by electron beam CT with measurements using radiolabeled microspheres at resting and moderately increased flow states. At high flow states, however, electron beam CT significantly underestimated absolute myocardial perfusion and thus myocardial flow reserve. Using another fast CT device, the Dynamic Spatial Reconstructor (DSR), concepts of intramyocardial vascular blood volume and its relation to myocardial flow have been established. By adapting these concepts to electron beam CT scanning and accounting for the increase in intramyocardial vascular blood volume at vasodilatation, the ability to correctly quantitate perfusion states up to approximately 400 mL.min-1. 100 g-1 using central intravenous contrast administration was demonstrated. This implies that studies can be done with intravenous injection methods for characterization of regional myocardial perfusion up to the normal flow reserve of approximately 4:1. Important physiologic and clinical abnormalities in flow reserve generally result in a ratio < 3:1. Electron beam CT offers the capability to quantitate regional myocardial perfusion in both the clinical and research setting. Of particular interest is the ability to provide quantitative regional myocardial perfusion which can be coupled to the evaluation of cardiac anatomy and function as well as mural coronary atherosclerotic calcium burden during the same scanning session. Thus, electron beam CT has the potential to become a valuable, minimally invasive clinical tool for comprehensive analysis of cardiac function and coronary status.
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Affiliation(s)
- A Schmermund
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
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Abstract
BACKGROUND The use of exercise echocardiography for the diagnosis of coronary artery disease (CAD) has been validated in pilot studies but is not documented in clinical practice and in women comparatively with men. The objectives of this study were to determine the effects of sex and of test verification bias on the diagnostic performance of exercise echocardiography. METHODS AND RESULTS Three thousand six hundred seventy-nine consecutive patients (1714 women, 1965 men) who underwent an exercise echocardiographic study were studied; the observed sensitivity, specificity, and correct classification rate were calculated among 340 patients (244 men, 96 women) who underwent angiography; to study the effect of test verification bias, sensitivity and specificity were estimated for all patients who underwent exercise echocardiography including those not referred to angiography. In the angiographic group, the prevalence of CAD was 60% in women and 80% in men. The observed sensitivity and specificity of exercise echocardiography was 78% and 44% in men and 79% and 37% in women. After adjustment for test verification bias, the estimated sensitivity was lower in women (32% versus 42% in men), whereas specificity was similar in both sexes. The positive predictive value was lower in women (66%) compared with men (84%). CONCLUSIONS In clinical practice, test verification bias results in a lower observed specificity and a higher sensitivity of exercise echocardiography. In women, positive predictive value and adjusted sensitivity are lower compared with that in men.
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Affiliation(s)
- V L Roger
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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Bell MR, Britson PJ, Chu A, Holmes DR, Bresnahan JF, Schwartz RS. Validation of a new UNIX-based quantitative coronary angiographic system for the measurement of coronary artery lesions. Cathet Cardiovasc Diagn 1997; 40:66-74. [PMID: 8993818 DOI: 10.1002/(sici)1097-0304(199701)40:1<66::aid-ccd12>3.0.co;2-s] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We describe a method of validation of computerized quantitative coronary arteriography and report the results of a new UNIX-based quantitative coronary arteriography software program developed for rapid on-line (digital) and off-line (digital or cinefilm) analysis. The UNIX operating system is widely available in computer systems using very fast processors and has excellent graphics capabilities. The system is potentially compatible with any cardiac digital x-ray system for on-line analysis and has been designed to incorporate an integrated database, have on-line and immediate recall capabilities, and provide digital access to all data. The accuracy (mean signed differences of the observed minus the true dimensions) and precision (pooled standard deviations of the measurements) of the program were determined x-ray vessel phantoms. Intra- and interobserver variabilities were assessed from in vivo studies during routine clinical coronary arteriography. Precision from the x-ray phantom studies (6-In. field of view) for digital images was 0.066 mm and for digitized cine images was 0.060 mm. Accuracy was 0.076 mm (overestimation) for digital images compared to 0.008 mm for digitized cine images. Diagnostic coronary catheters were also used for calibration; accuracy.varied according to size of catheter and whether or not they were filled with iodinated contrast. Intra- and interobserver variabilities were excellent and indicated that coronary lesion measurements were relatively user-independent. Thus, this easy to use and very fast UNIX based program appears to be robust with optimal accuracy and precision for clinical and research applications.
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Affiliation(s)
- M R Bell
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Keelan ET, Nunez BD, Grill DE, Berger PB, Holmes DR, Bell MR. Comparison of immediate and long-term outcome of coronary angioplasty performed for unstable angina and rest pain in men and women. Mayo Clin Proc 1997; 72:5-12. [PMID: 9005287 DOI: 10.4065/72.1.5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether a sex-related difference in outcome is present among patients who undergo percutaneous transluminal coronary angioplasty (PTCA) for unstable angina. DESIGN We retrospectively analyzed the results after PTCA was performed between January 1981 and June 1993 in a series of 2,073 men and 941 women with unstable angina and rest pain. RESULTS The success rates of PTCA were similar for women and men (87.9% and 87.2%, respectively), as were the in-hospital mortality rates (4.1% and 3.2%, respectively) and the need for emergency coronary artery bypass operation (3.1% and 3.5%, respectively). Fewer women than men had Q-wave myocardial infarction (0.5% versus 1.6%; P = 0.02). During the follow-up period (mean, 4 years), no significant differences were noted between women and men in overall survival (81% and 85% at 6 years, respectively) or survival free of Q-wave myocardial infarction (81% and 83% at 6 years, respectively) with use of the Kaplan-Meier method. Women were less likely than men to have had coronary artery bypass grafting (19% versus 22% at 6 years; P = 0.02), and the occurrence of severe angina was higher in women than in men (52% versus 44% at 6 years; P = 0.001). A subgroup analysis of patients who had myocardial infarction within 7 days preceding PTCA showed a similar pattern of results. CONCLUSION After PTCA performed for unstable angina and rest pain, survival rates were excellent in both women and men, and no difference was observed in subsequent myocardial infarction rates. During follow-up, however, women were more likely to have severe angina and were less likely to have had coronary artery bypass grafting. Concerns about possible sex-related complications should not dissuade physicians from performing PTCA when clinically indicated for unstable angina and rest pain.
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Affiliation(s)
- E T Keelan
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905, USA
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Berger PB, Bell MR, Grill DE, Simari R, Reeder G, Holmes DR. Influence of procedural success on immediate and long-term clinical outcome of patients undergoing percutaneous revascularization of occluded coronary artery bypass vein grafts. J Am Coll Cardiol 1996; 28:1732-7. [PMID: 8962559 DOI: 10.1016/s0735-1097(96)00414-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study sought to determine whether successful recanalization of an occluded vein graft is associated with improvement in long-term clinical outcome. BACKGROUND Coronary angioplasty of occluded vein grafts is associated with a lower initial success rate and a higher complication rate than angioplasty of vein grafts with subtotal stenoses and native coronary arteries. Whether successful angioplasty improves clinical outcome is unknown. METHODS We analyzed 77 consecutive patients who underwent angioplasty of an occluded saphenous vein coronary artery bypass graft between August 1983 and June 1994. Patients with a myocardial infarction in the previous 24 h were excluded from the study. RESULTS The mean age of the study cohort was 65 years; the mean (+/- SD) age of the treated grafts was 7.5 +/- 3.9 years. As an adjunct to balloon angioplasty, stents were used in 9% of procedures, laser in 30%, and atherectomy in 16%, and thrombolytic therapy was administered in 23% of patients. The angioplasty success rate was 71%. Major complications within 30 days of the procedure included death in 5.2% of patients, Q wave myocardial infarction in 1.3% and repeat bypass surgery in 7.8%; these events occurred with similar frequency in patients in whom angiographic success was and was not achieved. Kaplan-meier analysis comparing patients in whom angioplasty was successful (n = 55) and not successful (n = 22) revealed no differences in survival or occurrence of myocardial infarction or recurrent severe angina between the two groups in the 3 years after the procedure. Univariate analysis identified the age of the graft and use of newer interventional devices as predictors of death or myocardial infarction during this time period; procedural success was not associated with freedom from these adverse events after adjusting for these variables. CONCLUSIONS Angioplasty of occluded vein grafts is associated with a low initial success rate and a high complication rate. Successful angioplasty does not appear to reduce the occurrence of adverse events in the 3 years after the procedure.
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Affiliation(s)
- P B Berger
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
We describe a case of idiopathic long-QT syndrome in a 4-year-old Hispanic girl. She had been seen previously at an outside hospital for possible new-onset seizure disorder but was brought to our emergency department after sustaining an unwitnessed fall. Her ECG was significant for changes consistent with long-QT syndrome. Emergency physicians should understand the necessity of electrocardiography in all pediatric patients who present with multiple spontaneous falls, episodes of dizziness, new-onset seizure activity and syncopal episodes.
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Affiliation(s)
- M R Bell
- Department of Emergency Medicine, University of California at Irvine, Orange, USA
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Hasdai D, Garratt KN, Holmes DR, Berger PB, Schwartz RS, Bell MR. Coronary angioplasty and intracoronary thrombolysis are of limited efficacy in resolving early intracoronary stent thrombosis. J Am Coll Cardiol 1996; 28:361-7. [PMID: 8800110 DOI: 10.1016/0735-1097(96)00136-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study sought to evaluate treatment of early intracoronary stent thrombosis. BACKGROUND Although refinements in intracoronary stent implantation technique and pharmacologic treatment have reduced the frequency of early stent thrombosis, stent thrombosis remains a feared complication of this procedure. Optimal treatment for stent thrombosis is still undefined. METHODS Twenty-nine patients (44 stents) with early (< or = 30 days) coronary stent thrombosis over a 5-year period at our institution were identified. Treatment and outcome of stent thrombosis were analyzed. RESULTS Mean (+/- SD) time from implantation to stent thrombosis was 6.1 +/- 5 days. Twenty-three patients were treated with catheter-based therapies (angioplasty alone in 14, angioplasty and intracoronary urokinase in 7, intracoronary urokinase alone in 2). Flow was restored without residual thrombus in 11 (48%) of the catheter-treated patients (6 of 14 with angioplasty alone, 4 of 7 with angioplasty and urokinase, 1 with urokinase alone). Of the 23 patients, 2 died despite restoration of anterograde flow, and 9 were referred for emergent or urgent bypass surgery because of residual thrombus and refractory angina despite restoration of blood flow. Of the remaining six patients, five were treated medically and one with coronary bypass surgery; three died. Acute myocardial infarction evolved in 26 patients (90%), including 20 (87%) of the 23 catheter-treated patients. CONCLUSIONS Stent thrombosis is associated with severe adverse outcomes. Although catheter-based therapies are effective in restoring patency in a majority of patients, patients are referred frequently for coronary bypass surgery because of residual thrombus and refractory angina. These findings suggest that alternative or adjunctive therapies for stent thrombosis are needed.
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Affiliation(s)
- D Hasdai
- Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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Keelan ET, Bailey KR, Garratt KN, Berger PB, Bell MR, Schwartz RS, Holmes DR. Impact of stent size and indication for stent placement on immediate outcome. Cathet Cardiovasc Diagn 1996; 38:145-51. [PMID: 8776516 DOI: 10.1002/(sici)1097-0304(199606)38:2<145::aid-ccd6>3.0.co;2-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The immediate outcome of 271 procedures involving the intracoronary implantation of 305 stents was determined. Data were analyzed with regard to indication for stenting and stent size. Elective indication was associated with a higher success rate than emergency indication (95.6% vs. 86.6%, P = 0.013) and a lower Q-wave infarction rate (0 vs. 6.4%, P = 0.006). Univariate analysis showed that the odds ratio for procedural success was significantly favored by elective indication (3.37, P = 0.018) but was unrelated to stent size (1.10, P = 0.087). These findings were confirmed on multivariate analysis. The likelihood of Q-wave infarction was lower for elective placement (P = 0.0008) but was not related to size. Requirement for emergency bypass surgery, incidence of subacute closure, and death were not related to indication or to stent size on either univariate or multivariate analysis. Therefore, the immediate outcome of stent placement is related to the indication for stenting, but not to the size of stent implanted. Procedural success is significantly favored by elective indication.
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Affiliation(s)
- E T Keelan
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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