Safety and feasibility of coronary stenting during rescue PTCA: in-hospital outcome.

BACKGROUND: Rescue PTCA is still a debatable procedure and the results published in the literature may not justify routine application of this strategy. AIM: To evaluate the hospital outcome of patients undergoing rescue PTCA with the aim of achieving a complete recanalization of the infarct-related artery (IRA)--residual stenosis assessed with QCA < 30% and TIMI 3 forward flow--obtained with adjuvant coronary stenting when needed. METHOD: From April 1993 to December 1997, 59 consecutive patients underwent rescue PTCA after thrombolysis failure (SK or front-loaded r-tPA, UK) within 6 hours of chest pain onset. All patients had a pre-procedure TIMI 0-1 flow. IRA was the right coronary artery in 23 cases (39%), the left anterior descending in 26 (44%), the left circumflex in 9 (15.3%) and a saphenous vein graft in 1 case (1.7%). In 2 (3.3%) patients, PTCA was not performed (impossibility of crossing the stenosis with the guide-wire). Fifteen patients (26.3%) had a successful procedure (TIMI 3 flow, residual stenosis < 30%) with lone PTCA. Forty-two patients (73.6%) had an intracoronary stent placed (Palmaz-Schatz, Micro-Stent, Multilink, IRIS III): 24 patients (57.1%) for suboptimal angiographic result (TIMI 2 flow, residual stenosis > 30%), 11 patients (26.2%) for dissection, 7 patients (16.7%) for intracoronary thrombosis. All 57 patients had a TIMI 3 flow and a residual stenosis < 30% at the end of the procedure. Mean vessel diameter was 3.22 +/- 0.4 mm, mean balloon size 3.3 +/- 0.4 mm, mean inflation pressure 12 +/- 4 atm, mean residual stenosis 8 +/- 9%. RESULTS: The overall procedure success rate was 96.6%. During hospitalization, three patients (5.1%) suffered subacute reocclusion managed conservatively in one case, with CAGB in another and with re-PTCA in the last one. Three patients (5.1%) had minor vascular complications (groin hematoma) not requiring surgical correction or blood transfusion. No patients died, suffered reinfarction or stroke. All patients were discharged alive and free of angina or clinical heart failure. CONCLUSIONS: Coronary stenting performed in the setting of rescue PTCA leads to a good procedural success rate allowing TIMI 3 flow and low residual stenosis (< 30%). Therefore, when conventional balloon angioplasty is unable to achieve an optimal angiographic result, stenting can be accomplished safely, thereby improving the procedural success rate and allowing a bright event-free survival rate.

A surveillance-oriented medical record as a source of data for both drug and quality of care surveillance.

The medical record for hospitalized patients has been modified in order to orient it towards two types of surveillance: adverse drug reactions (ADRs) and the quality of medical care. The modification consists of an adaptation of the progress notes; the transfer of the information to a special database is facilitated by the use of a simple system of codes that identify and correlate the items necessary for surveillance purposes. During the 6 months of observation of the 1103 pediatric patients included in the study, 35 clinically important suspected ADRs were noted by physicians. For the quality of medical care surveillance, all drug prescriptions were evaluated and areas in which to intervene in order to improve the appropriateness of prescriptions were identified. Quality surveillance was also extended to the monitoring of 'unexplained' adverse events for which no particular cause was attributable. We consider it advantageous to carry out these two types of surveillance simultaneously because they require many common items of information. The use of an oriented medical record as a source of data makes it possible to integrate surveillance with everyday ward activities.

Absence of correlation between coronary thrombosis and postatherectomy restenosis.

This study endeavored to assess whether thrombus in directional coronary atherectomy was correlated with later subsequent restenosis. We concluded that the presence of thrombus in native plaque is not correlated with the occurrence of postatherectomy restenosis.

[Histopathologic features in atherectomy samples obtained from patient with unstable angina, stable angina and restenosis. Directional Atherectomy Lombardi Group]. / Reperti histopatologici [corrected] in campioni di aterectomia ottenuti da pazienti con angina instabile, con angina stabile e con ristenosi. Gruppo Lombardo Aterectomia Direzionale, GLAD.

BACKGROUND: The present study was aimed at investigating the pathologic features of directional coronary atherectomy (DCA) samples obtained from 194 patients (14 females) with stable (n = 68) and unstable (n = 95) angina, and with restenosis (n = 27). METHODS: DCA samples were obtained from culprit lesions, using the Simpson technique. Unstable angina was classified according to E. Braunwald criteria. Stable angina was grouped according to the presence or absence of a prior myocardial infarction (MI). DCA samples were fixed, processed, serially cut and stained with hematoxilin-eosin and with Movat pentachrome stain. RESULTS: The major pathologic findings were thrombosis, inflammation of the superficial plaque layers, and neointimal hyperplasia which often coexisted within a same sample. Their frequencies, in that order, were distributed in the differing groups of patients as follows: 21% (n = 9), 29.2% (n = 12) and 51% (n = 21) of the 41 cases with stable angina without prior MI. 40.7% (n = 11), 40.7% (n = 11), and 51.8% (n = 14) of the 27 cases with stable angina with prior MI. 25% (n = 4), 56.2% (n = 9) and 68.7% (n = 11), of the 16 cases with BI unstable angina. 35.3% (n = 14), 55.8% (n = 19) and 44% (n = 15), of the 34 cases with BII unstable angina. 44.4% (n = 4), 33.3% (n = 3) and 33.3% (n = 3), of the 9 cases with BIII unstable angina. 48.2% (n = 14), 48.2% (n = 14) and 51.8% (n = 15), of the 29 cases with CII unstable angina at 35.8 days after MI. 60% (n = 3), 60% (n = 3) and 40% (n = 2), of the 5 cases with CIII unstable angina at 8.3 days after MI. 26% (n = 7), 48% (n = 13) and 85.1% (n = 23), of the 27 cases with restenosis. According to above observation, the frequency of coronary thrombosis increases with the increase of the severity of myocardial ischemia. However, thrombosis is not found in most unstable angina without prior MI (63% of BI-II-III unstable angina cases do not have thrombus). In addition, thrombus is not a specific finding of unstable angina, given its occurrence, although in a much lower percentage of cases, in stable angina and in restenosis. CONCLUSIONS: Present data show that different ischemic and plaque lesions. This observation questions on the pathogenetic role of thrombus in unstable angina and calls for further investigations on inflammation and neointimal hyperplasia, as well as on the the reciprocal relation between these findings which are often combined within a same lesion.

Stenting of the Infarct-Related Artery During Complicated Angioplasty in Acute Myocardial Infarction.

The aim of this study was to assess safety and efficacy of coronary stenting as a strategy for improving PTCA suboptimal angiographic result. From March 1993 to December 1995, 104 patients underwent PTCA during acute myocardial infarction. Unplanned coronary stenting was required in 66 pts (63.5%). Procedural success was obtained in 64 pts (97%). Two patients had an unsuccessful stenting procedure: one patient for a suboptimal stent deployment and another for LAD reocclusion requiring emergency CABG (1.5%). Palmaz-Schatz stents were used in 60 pts (91%) and AVE micro-stent in 6 pts (9%). During the hospital course, subacute reocclusion of the vessel occurred in 3 pts (4.6%); one patient underwent a successful rePTCA while the other two underwent CABG. Two patients had vascular groin complications requiring surgical repair of the femoral artery. During hospitalization, one patient underwent elective CABG for early residual myocardial ischemia. At seventy-two hours from PTCA, one patient (1.5%) died as a result of intestinal infarct. Six months survival rate was 98.3% for 59 pts discharged alive from our department. Ten pts were symptomatic during the follow-up: One patient underwent PTCA on another vessel and the other underwent CABG for a multivessel disease. CABG was used in one patient who presented residual silent ischemia in multivessel coronary artery disease. At six months, the first group of patients (18 pts) underwent planned coronary angiography: Vessel patency was present in 17 patients. One patient had an asymptomatic reocclusion of the treated vessel. This study shows a good angiographic result obtained with intracoronary stenting during primary or rescue PTCA of the infarct-related artery. It does not appear to increase major in-hospital adverse events and may reduce the need for surgical revascularization, reducing in-hospital mortality rate and favorably affecting LVEF.

Comparison of coronary lesions obtained by directional coronary atherectomy in unstable angina, stable angina, and restenosis after either atherectomy or angioplasty.

The present study investigated the incidence of the histopathologic lesions and of growth factor expression in a consecutive series of directional coronary atherectomy (DCA) samples from 40 unstable angina pectoris patients without prior acute myocardial infarction and compared the findings with those obtained in DCA samples from 18 patients with stable angina without previous infarction and 18 patients with restenosis. We investigated coronary thrombosis, neointimal hyperplasia, and inflammation. For unstable angina, we correlated the angiographic Ambrose plaque subtypes with the histopathologic findings. The immunophenotype of plaque cells and the growth factor expression were assessed with specific antibodies for cell characterization and for the expression of basic fibroblast and platelet-derived AA and AB growth factors and receptors. The incidence of coronary thrombosis was 35% in patients with unstable angina, 17% in those with stable angina, and 11% in patients with restenosis. Neointimal hyperplasia was found in 38% of unstable angina cases, in 17% of stable angina cases, and in 83% of restenosis cases. Inflammation without thrombus or accelerated progression occurred in 20% of unstable angina and 6% of stable angina samples. In 52% of unstable angina cases, inflammation coexisted with thrombosis and/or neointimal hyperplasia. In the unstable angina group, 71% of the plaques with thrombus had a corresponding angiographic pattern of complicated lesions. The growth factor expression, reported as percentage of cells immunostaining with different growth factor antibodies, was highest in restenosis, followed by unstable angina and stable angina lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnostic and research potential of directional atherectomy]. / Potenzialità diagnostica e di ricerca dell'aterectomia direzionale.

Directional coronary atherectomy (DCA) is the sole technique for the in vivo study of coronary artery plaques which are responsible for myocardial ischemia. The technique confers the following advantages to the pathologic study of plaque samples: the brevity, in general, of the interval between acute myocardial ischemia and sampling of the guilty plaque; the absence in samples of autolytic phenomena (such as those that affect autopsy samples), an effect that enables the use of conventional histopathology, immunohistochemistry and molecular biology; the certainty with which the researcher can identify, and thus sample, the truly guilty lesions. The drawbacks of the technique are: the fragmentation of the plaque; the difficulty the pathologist has in correctly orientating the samples in the embedding phase, in distinguishing pre- from post-procedural lesions, and in providing a detailed description of the findings. Given the foregoing, the diagnostic information to which DCA sampling enables access is as follows: plaque derivation--the recognition of whether tissue removed with DCA originates from eccentric or concentric, atheromatous of fibrosclerotic, calcified or not calcified plaques; histopathology of coronary lesions that cause ischemia with regard to: evidence of acute events, such as thrombosis, ulceration and hemorrhage, thrombus composition, when it occurs, and definition of its age and presence of material deriving from the vascular wall that lies beyond the plaque; identification and immunophenotypical characterization of inflammatory infiltrates. As regards research, the main implications of DCA are for the study of the pathogenetic mechanisms that lead to plaque instability in acute ischemic syndromes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous mitral commissurotomy: immediate and short-term results]. / Commissurolisi mitralica percutanea: risultati immediati e a breve termine.

31 symptomatic patients with mitral stenosis were selected for percutaneous transvenous mitral commissurotomy using Inoue catheter. The patients were selected using the echocardiographic score for: leaflets mobility, leaflets thickening, subvalvular thickening, degree of calcifications. All patients had a score less than or equal to 8 and represented 17.5% of the patients studied in our echocardiographic laboratory for mitral stenosis. We were able to perform the commissurotomy in 30 of them. Mean left atrial pressure decreased from 26 +/- 5.2 mmHg to 14.6 +/- 6 mmHg (p less than 0.001). The mean mitral diastolic pressure gradient decreased from 8.9 +/- 3.1 mmHg to 3.9 +/- 1.3 mmHg (p less than 0.001). The mitral valve area, using the echocardiographic Pressure Half Time (PHT), increased from 0.94 +/- 0.17 cmq to 1.96 +/- 0.33 cmq (p less than 0.001). Mitral regurgitation, angiographically evaluated in 29 patients, increased in 11 (38%), being of degree + + + in 3 patients. There were 2 heart tamponades and 5 cases (16.6%) of left-to-right shunt with Qp / Qs less than 2. After 3 months, the follow-up showed improvement of one or more functional classes in 96.6% of all patients. The mitral valve area, determined after 6 months in 24 patients by PHT, was stable (1.98 +/- 0.31 vs 1.93 +/- 0.25) (p = 0.5); we did not find mitral stenosis recurrence in any instance. In the first 10 patients, after 1 year, the results are stable (1.85 +/- 0.28 cmq vs 1.93 +/- 0.21 cmq) (p = 0.5) without mitral stenosis recurrence. These data suggest that in selected tight mitral stenosis the percutaneous transvenous commissurotomy may be alternative to the open surgical solution. Using an Inoue catheter, the percutaneous transvenous mitral commissurotomy is easier and the complications are few. The major procedural hazards derive from the transseptal technique.

Management of complicated coronary angioplasty by intracoronary urokinase and immediate re-angioplasty.

Percutaneous transluminal coronary angioplasty was complicated by acute coronary occlusion, dissection of the arterial wall, or angiographic evidence of intraluminal thrombosis in 33 high-risk patients from 153 consecutive angioplasty procedures (21.5%). Ten patients (group I) were managed with nitroglycerin (0.2 to 0.4 mg i.c.) and repeated attempts at mechanical guide wire recanalization or dilation, but they did not receive thrombolytic therapy. In the remaining 23 patients (group II), intracoronary urokinase (100,000 to 360,000 U.I.) was administered over 15-20 min after onset of coronary occlusion or thrombosis and continued during attempts at repeated dilation of the stenosis. The incidence of sudden coronary artery occlusion was 70% in group I patients and 52% in group II. The angiographic evidence of thrombus formation was observed in a higher, but not significant, proportion of group II patients (65%) as compared with group I (30%). The incidence of intimal tearing or dissection was similar in the two groups of patients (40 vs. 34.7%). The overall final success rate of the complicated angioplasty series was 48% (6/33). However, the success rate was lower (10%) in group I than in group II patients (10 vs. 65%; P less than 0.005), and the frequency of emergency coronary artery bypass grafting was lower in group II patients (13 vs. 60%; P = 0.01), suggesting that thrombolytic therapy with urokinase may be effective in the management of acute coronary occlusion and thromboembolic complications of coronary angioplasty.

Emergency coronary angioplasty in patients with severe left ventricular dysfunction or cardiogenic shock after acute myocardial infarction.

Emergency percutaneous transluminal coronary angioplasty (PTCA) was performed during an acute myocardial infarction (AMI) after either systemic or intracoronary thrombolytic therapy in six patients with severe ischaemic left ventricular dysfunction or cardiogenic shock, among 37 patients (17%) who were treated with PTCA during AMI over a 13-month period. Thrombolytic therapy with streptokinase (1.5 x 10 Units) was initiated after a mean (+/- SD) time delay of 5.5 +/- 1.3 h from the onset of symptoms. The infarct-related artery was found to be occluded (TIMI grade 0-1) in three patients and partially reperfused (TIMI grade 2) in the remaining patients at baseline coronary angiography. Intracoronary administration of urokinase (100-200,000 Units) was ineffective in those patients failing systemic thrombolysis and resulted in only a slight increase of residual lumen in three patients. The coronary artery could be opened by a guidewire mechanical technique in patients with persistent coronary artery occlusion and coronary dilation could be done in all patients. The mean percentage diameter stenosis of the infarct-related vessel was reduced from 98.8 +/- 2% to 27 +/- 11% (P less than 0.005). After the procedure, left ventricular ejection fraction increased from 27 +/- 8% to 41 +/- 7% (P less than 0.02), systemic blood pressure and cardiac index increased respectively from 86 +/- 10 to 126 +/- 14 mmHg (P less than 0.005) and from 2.2 +/- 0.6 to 3.3 +/- 0.6 (P less than 0.01). Left ventricular end-diastolic pressure decreased from 26 +/- 8 to 18 +/- 3 mmHg (P less than 0.05). Severe mitral regurgitation was relieved in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Unusual origin and course of the first septal branch of the left coronary artery: angiographic recognition.

The anatomical variants of the origin and course of the first septal branch (S1) of the left coronary artery system have received little attention in the literature dealing with coronary angiography. We describe here the angiographic features of the ectopic origin of S1 from epicardial branches of the left coronary artery other than the left anterior descending artery as observed in 8 cases from a series of 700 consecutive patients (1.1%). The S1 originated from the left main coronary artery in 1 case, from a diagonal branch in 4, and from an intermediate branch in 3 cases. Previous reported cases are reviewed. Because the S1 may supply up to 15% of the blood to the myocardium, the recognition of this variable origin may have clinical implications and has to be considered as a part of the complete evaluation of coronary arteriograms of patients referred for coronary artery revascularization.

Transluminal extraction of a catheter fragment from the aortic arch.

Many different techniques have been previously reported for non-surgical transluminal removal of foreign bodies from venous system or right heart chambers, while only few cases of transluminal extraction from arterial vascular bed or left heart chambers have been published. We report a successful attempt of a Judkins' catheter fragment extraction from the aortic arch by a homemade loop-snare device. Tying the distal end of a long flexible guide-wire on the tip of a 8F Cournand catheter we obtained an easy to handle device which is practicable using instruments always available in any catheterization room.

Transcoronary platelet thromboxane A2 formation without platelet trapping in patients with coronary stenosis-effect of sulphinpyrazone treatment.

Platelet count, and plasma thromboxane B2 (TXB2) and circulating platelet aggregates (CPA) were determined in the coronary sinus (CS), aortic bulb (AO) and cubital vein (V) in 21 patients with stable angina and in 6 control subjects before and after atrial pacing (AP). TXB2 measurements were repeated before and after AP in 6 of the 21 angina patients after 15 days' sulphinpyrazone treatment. Platelet count and CPA ratio were similar in angina patients and controls at all three sampling sites and were unchanged at AP peak. In the controls, basal TXB2 values in CS, AO and V were not significantly different and were unchanged at AP peak. In the angina patients compared with the controls, basal TXB2 values in the AO, CS and V were not significantly different whereas the CS/AO TBX2 ratio was significantly higher; at AP-induced ischaemia, CS TXB2 was significantly increased and the CS/AO TXB2 ratio was increased. A weak but significant direct correlation was found between CS/AO TXB2 ratio and coronary score. Sulphinpyrazone treatment reduced CS TXB2 levels at rest and after AP, but not the ischaemic threshold at AP.

[Carcinoid heart disease. Report of a case with triple valvular lesion (author's transl)]. / Cardiopatia da carcinoide. Presentazione di un caso con triplice lesione valvolare.

A case of carcinoid syndrome, stemming from a tumor of the large intestine with hepatic metastases, is reported. Clinical features included cardiac disease with triple valvular lesion: tricuspid insufficiency with stenosis, pulmonary artery stenosis and mitral insufficiency. More recent views about the pathogenesis of the cardiac involvement in the carcinoid syndrome are reported, and the cardiac therapy is discussed.