Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients.

OBJECTIVES: This study sought to analyze the outcomes of revascularization procedures in the treatment of allograft coronary disease. BACKGROUND: Allograft vasculopathy is the main factor limiting survival of heart transplant recipients. Because no medical therapy prevents allograft atherosclerosis, and retransplantation is associated with suboptimal allograft survival, palliative coronary revascularization has been attempted. METHODS: Thirteen medical centers retrospectively analyzed their complete experience with percutaneous transluminal coronary angioplasty, directional coronary atherectomy and coronary bypass graft surgery in allograft coronary disease. RESULTS: Sixty-six patients underwent coronary angioplasty. Angiographic success (< or = 50% residual stenosis) occurred in 153 (94%) of 162 lesions. Forty patients (61%) are alive without retransplantation at 19 +/- 14 (mean +/- SD) months after angioplasty. The consequences of failed revascularization were severe. Two patients sustained periprocedural myocardial infarction and died. Angiographic restenosis occurred in 42 (55%) of 76 lesions at 8 +/- 5 months after angioplasty. Angiographic distal arteriopathy adversely affected allograft survival. Eleven patients underwent directional coronary atherectomy. Angiographic success occurred in 9 (82%) of 11 lesions. Two periprocedural deaths occurred. Nine patients are alive without transplantation at 7 +/- 4 months after atherectomy. Bypass graft surgery was performed in 12 patients. Four patients died perioperatively. Seven patients are alive without retransplantation at 9 +/- 7 months after operation. CONCLUSIONS: Coronary revascularization may be an effective palliative therapy in suitable cardiac transplant recipients. Angioplasty has an acceptable survival in patients without angiographic distal arteriopathy. Because few patients underwent atherectomy and coronary bypass surgery, assessment of these procedures is limited. Angiographic distal arteriopathy is associated with decreased allograft survival in patients requiring revascularization.

Prospective case-control comparison of percutaneous transluminal coronary revascularization in patients with multivessel disease treated in 1986-1987 versus 1991: improved in-hospital and 12-month results. Multivessel Angioplasty Prognosis Study (MAPS) Group.

OBJECTIVES: This study sought to ascertain whether early and 12-month clinical outcomes after percutaneous coronary revascularization have improved between 1986-1987 and 1991. BACKGROUND: Since the mid-1980s, when the results of percutaneous revascularization were considered to be somewhat static, justifying large-scale clinical trials of percutaneous transluminal coronary angioplasty versus other modes of therapy, balloon technology has improved, and several new percutaneous revascularization techniques have become available. The clinical results of the current integrated approach to revascularization compared with those for coronary angioplasty alone in the late 1980s are not known. METHODS: In this prospective case-control study, 200 consecutively treated patients with multivessel disease in 1991 were studied prospectively and compared with 400 consecutive patients from the same centers during 1986-1987. Patients from 1991 were matched with earlier patients on the basis of four previously described prognostic determinants (left ventricular ejection fraction, presence of unstable angina, diabetes and target lesion morphology score) and the treating institution and were assessed for treatment outcome (completeness of revascularization, procedural success and event-free survival [freedom from death, myocardial infarction and further revascularization]). RESULTS: The 1991 cohort of patients was older (mean [+/- SD] age 62 +/- 11 vs. 58 +/- 11 years, p < 0.001) and tended to have slightly worse left ventricular function (ejection fraction 56 +/- 10% vs. 58 +/- 11%, p = 0.009) than the 1986-1987 cohort. Overall lesion morphology risk scores were similar. New devices (other than coronary angioplasty) were used in 26% of patients. The 1991 patient cohort had more frequent total revascularization (35% vs. 21%, p = 0.003), fewer emergency bypass operations (1.0% vs. 5.5%, p = 0.006) and an improved overall procedural success rate (90% vs. 84%, p = 0.04). In addition, at 12 months the event-free survival rate was superior in the 1991 cohort (73.3% vs. 63.6%, p = 0.02), although there was no difference in infarct-free survival rate (94.6% vs. 93.2%, p = NS). CONCLUSIONS: Improved results with percutaneous revascularization in 1991 have important implications for patient care and interpretation of ongoing randomized trials enrolling patients in the late 1980s and intending to compare standard coronary angioplasty with other forms of therapy.

Bypass Angioplasty Revascularization Investigation (BARI): baseline clinical and angiographic data.

This report presents baseline clinical and angiographic data from the Bypass Angioplasty Revascularization Investigation (BARI), a multicenter international trial assessing the relative efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG) in selected patients with multivessel coronary artery disease. PTCA is commonly performed in patients with multivessel coronary artery disease, yet its long-term efficacy in comparison to CABG is unknown. From August 1988 through August 1991, 1,829 qualifying patients with multivessel disease suitable for either procedure were randomized to PTCA or CABG; sample size estimates were based on anticipated 5-year mortality. Two registry populations were also defined for follow-up: (1) 2,013 patients eligible for randomization but not randomized; and (2) 422 patients considered by angiography as unsuitable for randomization. Patients randomized in BARI were at relatively high risk for subsequent cardiac events: 39% were > or = 65 years old, 55% had prior myocardial infarction, 69% presented with unstable angina or non-Q wave myocardial infarction, and 43% had 3-vessel coronary artery disease. Patients randomized to PTCA and CABG were equally matched in all the important baseline variables. The randomized and the eligible but not randomized groups were similar in most respects. However, the nonrandomized group had a higher proportion with college education; fewer with a history of myocardial infarction, heart failure, diabetes, and smoking; and a somewhat better average ejection fraction. At the 3-month follow-up, PTCA had been performed more commonly in the nonrandomized eligible patients, especially those with 2-vessel disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Histopathologic correlates of unstable ischemic syndromes in patients undergoing directional coronary atherectomy: in vivo evidence of thrombosis, ulceration, and inflammation.

Complex coronary morphologic abnormalities with thrombus and ulceration have been recognized in acute ischemic syndromes by angiography, angioscopy, and autopsy. However, in vivo histopathologic correlates of unstable ischemic syndromes have not been described. The purpose of this study was to characterize intracoronary lesion morphologic abnormalities by analyzing specimens excised by directional atherectomy in patients with different ischemic syndromes. Tissue specimens removed by directional coronary atherectomy of primary lesions in native vessels were matched blindly to the clinical status of 130 patients representing 43% of a consecutive directional coronary atherectomy population of 300 patients; 824 specimens (range per patient 1 to 30, mean 6.3) were obtained. Clinical subgroups were prospectively classified as recent myocardial infarction (< or = 15 days, mean 6, range 1 to 15 days), 48 patients; prolonged rest angina, 34 patients; crescendo angina, 29 patients; and stable angina, 19 patients. Shavings were prospectively analyzed for presence of thrombus, ulceration, or chronic inflammatory cells. Thrombus was observed in 33 (69%) patients with recent myocardial infarction, 17 (50%) with rest angina, 12 (41%) with crescendo angina, 7 (37%) with stable angina (p = 0.048). Plaque ulceration was identified in 12 (25%) patients with recent myocardial infarction, 4 (12%) with rest angina, 2 (7%) with crescendo angina, and 1 (5%) with stable angina (p = 0.09). Inflammatory cells were noted in the specimens of 32 (67%) patients with recent myocardial infarction, 16 (45%) with rest angina, 12 (41%) with crescendo angina, and 9 (45%) with stable angina.(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate results of interventional devices for coronary ostial narrowing with angina pectoris.

Angioplasty of aorto-ostial lesions has had suboptimal results. This study reports on the immediate results of new debulking devices (atherectomy, excimer laser) in the treatment of aorto-ostial disease. Thirty-one vessels (29 patients) with an ostial lesion treated with a new device (group I) were compared with 15 vessels (13 patients) with an ostial lesion treated with angioplasty alone during the preceding 24 months (group II). Both groups were similar in their clinical characteristics. A larger proportion of vessels in group I (64%) compared with group II (7%) had unfavorable features for angioplasty. Procedural success was similar: 28 vessels in group I (91%) and 14 in group II (93%). Among the new devices, success was also similar: atherectomy in 8 arteries (89%), rotablator in 4 (100%) and excimer laser in 17 (94%). The acute gain was more significant with new devices: absolute reduction in percent stenosis was 66% for directional atherectomy, 67% for rotational atherectomy (p = 0.016 compared with angioplasty), 52% for excimer laser (p = 0.09) and 46% for angioplasty. In group I, 2 patients (6%) required emergency bypass surgery during our early experience; no deaths or Q-wave myocardial infarctions occurred. Group II had no complications. Therefore in aorto-ostial lesions, despite a much higher prevalence of unfavorable angiographic characteristics, new devices had (1) a success rate of > or = 90%, (2) a significantly larger acute gain compared with angioplasty alone, and (3) an acceptable complication rate. Larger studies with complete angiographic follow-up are needed to assess restenosis.

Coronary collateral circulation in the transplanted heart.

BACKGROUND: The concept that coronary collateral (CC) circulation can develop in cardiac transplant recipients (CTR) is controversial. Indeed, a decreased occurrence of CC in CTR has been previously reported. METHODS AND RESULTS: We reviewed 102 coronary angiograms in 73 CTR to evaluate the presence and significance of CC in denervated human hearts. These angiograms were compared with angiograms of 70 nontransplanted patients. Twenty-six CTR who had undergone at least two coronary angiograms, thus allowing comparative evaluations, form the basis for this study. Angiograms were analyzed using a modification of CC classification (Rentrop et al) from grade 0 for complete absence to grade 4 representing mature collateral with clear filling of epicardial vessels. Coronary artery disease was classified according to the scheme reported by Gao et al. For the purpose of this study, all type A lesions were grouped as large vessel disease (LVD), and types B1, B2, and C were collectively grouped as small vessel (epicardial) disease (SVD). The presence of CC circulation in all 73 CTR was grade 0, 7 (10%); grade 1, 41 (56%); grade 2, 33 (45%); grade 3, 30 (41%); and grade 4, 5 (7%). However, in control nontransplanted subjects grades 0, 1, 2, 3, and 4 were found in 47 (67%), 22 (31%), 4 (6%), 11 (15%), and 16 (20%) patients, respectively. The presence of mature collaterals (grade 4) in both groups were associated with type A lesions and was frequent in nontransplanted hearts. In contrast, grade 2 and grade 3 vascular channels probably representing CC with "myocardial blush" was more frequent in CTR and was mostly associated with small vessel coronary arteriopathy. CONCLUSIONS: These results suggest the presence of atypical CC in patients with cardiac allograft arteriopathy. It is speculated that this atypical form of CC with "blush pattern" may represent an angiogenic response to microvascular ischemia due to allograft coronary arteriopathy.

Experience with directional coronary atherectomy since pre-market approval.

Directional coronary atherectomy (DCA) received Food and Drug Administration (FDA) Pre-Market Approval in September 1990 and was then released through formal training certification of physicians at each new site. Procedure volume has increased dramatically since approval, with > 17,000 DCA procedures performed in 1991 and a cumulative total of > 33,000 procedures by mid-1992, at > 670 centers in the United States. Clinical application and results since approval have generally been similar to preapproval multicenter investigational results. Comparison of pre- and postapproval usage at the Medical College of Virginia shows similar baseline characteristics and indications, although recent patients show a higher proportion of "salvage" DCA for failed or suboptimal angioplasty (6% vs 14%) or DCA in combination with multidevice multiple vessel intervention (30% vs 38%). Overall results in 300 patients and 345 procedures included procedural success in 95%, clinical success in 94%, with major complications in 4.6% (including urgent bypass surgery in 3.8%, Q wave myocardial infarction in 1.7%, and hospital mortality in 0.3%). Results before and after FDA approval were similar for procedural success (94% vs 96%), clinical success rate (94% vs 94%), and major complications (5.5% vs 4.4%). There was a trend toward lower urgent surgery rate (5.4% vs 3.3%) in the more recent experience. In addition to its established efficacy for highly eccentric lesions, newer applications for which DCA is being used following FDA approval include treatment of saphenous vein grafts, thrombus-associated lesions, aorto-ostial lesions, failed or suboptimal percutaneous transluminal coronary angioplasty result, bifurcation lesions, and use as part of multivessel intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of thallium scintigraphy and echocardiography during dobutamine infusion for the detection of coronary artery disease.

Dobutamine infusion was performed in 16 patients following cardiac catheterization, and non-invasive assessment was performed with thallium SPECT and echocardiography. Dobutamine thallium scintigraphy was abnormal in 93% of patients with significant coronary artery disease. In addition, individual epicardial vessel involvement was identified by a corresponding perfusion defect with 88% sensitivity and 93% specificity. Dobutamine echocardiography revealed segmental wall motion abnormalities in 62% of patients with significant coronary disease. However, in six patients baseline segmental wall motion abnormalities on echocardiography improved during dobutamine infusion. Dobutamine thallium SPECT is a safe and useful test for the detection and localization of coronary artery disease. Dobutamine echocardiography is less useful in screening for coronary disease, but may detect areas of abnormally functioning myocardium having retained viability.

Directional coronary atherectomy for saphenous vein graft disease.

Saphenous vein grafts (SVG) comprise a significant and increasing proportion of coronary interventional procedures at most centers. Directional coronary atherectomy (DCA) is well suited for treating focal SVG disease and is an effective therapy for lesions located in the ostium, shaft or body, and distal insertion site of saphenous vein grafts. Aorto-ostial SVG lesions may be technically difficult due to angulation and inability to fully engage the guide catheter, but success rates are relatively high and excellent angiographic results are usually achieved. Use of alternative guide catheters and stiffer guide wires can facilitate successful DCA of aorto-ostial lesions. DCA of SVG shaft segments or distal insertion sites are also associated with high success and low complication rates. Complex and thrombus-containing vein graft lesions are often well suited for DCA, and both patent and occluded grafts with extensive thrombus may also be effectively treated with DCA following selective intragraft thrombolysis. Technical aspects of vein graft DCA for these applications are reviewed.

Multivessel coronary angioplasty.

Multivessel coronary angioplasty is currently a revascularization alternative in selected patients with suitable anatomy. The literature on two- and three-vessel coronary angioplasty is reviewed with respect to both immediate success and long-term outcome. A therapeutic strategy for performing multivessel coronary angioplasty in the individual patient is outlined.

Long-term efficacy of triple-vessel angioplasty in patients with severe three-vessel coronary artery disease.

Between May 1982 and December 1988, a total of 103 patients underwent angioplasty of all three major coronary arteries at a single institution. Angiographic success was achieved in 334 of 352 vessels (95%) and in 441 of 460 lesions (96%). No patients required urgent bypass surgery, and none died during the procedure; six had non-Q wave infarctions. The mean length of follow-up time was 49 +/- 15 months (range 28 to 107 months). There have been 11 deaths, and one patient has undergone cardiac transplantation. Thirty-six patients had a clinical recurrence; 30 had repeat angioplasty and five had bypass surgery. Another nine patients eventually had bypass surgery after the clinical recurrence. At 48 months actuarial event-free rates are myocardial infarction, 98%; bypass surgery, 88%; and death, 89%. Of 86 current survivors, 58 are in functional class O to I, 21 are in class II, and seven are in class III.

Frequency and predictors of left ventricular segmental dysfunction in patients with recent rest angina.

The relation between coronary artery lesion morphology and associated segmental left ventricular (LV) dysfunction in patients with unstable angina is unclear. Fifty-two patients with angina occurring at rest who underwent cardiac catheterization within 3 days of the last episode of pain and had no enzymatic evidence for myocardial necrosis were evaluated. Coronary artery narrowings deemed responsible for the ischemic episodes were analyzed with regard to the artery involved, maximal diameter of the narrowing, presence of thrombus, and complex appearance. Time to catheterization, age, sex and electrocardiographic evidence of ischemia were also noted. Segmental LV dysfunction in the territory supplied by the "culprit lesion" was present in 58% of patients. It occurred significantly more often with lesion location in the left anterior descending coronary artery, and was less frequent with lesions in the left circumflex and ramus coronary arteries. Ischemic electrocardiographic changes were more sensitive in predicting LV dysfunction with culprit lesion location in the left anterior descending or right coronary artery. LV dysfunction could not be predicted by any other parameter analyzed. It is concluded that postischemic LV dysfunction occurs frequently in rest angina, especially when the severest narrowing is in the left anterior descending coronary artery.

Immediate and long-term results of delayed recanalization of occluded acute myocardial infarction-related arteries using coronary angioplasty.

Recent evidence suggests that late reperfusion of an occluded infarct-related artery after acute myocardial infarction (AMI) may convey a better prognosis. The clinical outcome of percutaneous transluminal coronary angioplasty (PTCA) as a means of mechanical reperfusion in this particular setting has not been clearly delineated. Ninety-seven patients with AMI underwent PTCA of the occluded infarct-related artery after the acute phase of the AMI (48 hours to 2 weeks, mean 8 +/- 4 days). The study consisted of 72 men (74%) (mean age 56.5 +/- 12 years) and 25 women. Seventy-seven patients (79%) had a Q-wave AMI and 20 patients (21%) a non-Q-wave AMI. Seventy-six patients (79%) had angina after AMI and 4 had previously undergone coronary bypass surgery. Clinical success was achieved in 85 patients (87%). Angiographic success was obtained in 90 of the 97 occluded arteries (93%) and was similar for all 3 major vessels: right coronary 97%, left anterior descending 93% and circumflex 85% (p = not significant). Major complications (AMI, emergency bypass and death) occurred in 3 patients (3.1%). Long-term follow up (3.7 +/- 0.8 years) revealed symptomatic recurrence in 20 (23%), whereas 51 (58%) remained asymptomatic. Most recurrences (16 of 20) were in the form of restenosis rather than reocclusion, with a high success rate for repeat dilation (93%). These results indicate that mechanical reperfusion of an occluded infarct artery, performing PTCA 48 hours to 2 weeks after AMI, has a high success rate, a low complication rate and low symptomatic restenosis.

Reduction of ischemia with a new flow-adjustable hemoperfusion pump during coronary angioplasty. The Coronary Hemoperfusion Ischemia Prevention Study (CHIPS) Investigators.

A new flow-adjustable pump for coronary hemoperfusion to prevent ischemia during routine coronary angioplasty was evaluated in a multicenter prospective study of 110 patients. The protocol included patients who had angina or ST segment elevation during a control balloon inflation of less than or equal to 3 min. Hemoperfusion was performed by means of a new large lumen angioplasty catheter utilizing the patient's renal vein or femoral artery blood. Vessels perfused were the left anterior descending coronary artery (n = 74), right coronary artery (n = 39), left circumflex artery (n = 9) and coronary vein grafts (n = 15). Mean (+/- SD) perfusion flow was 41 +/- 9 ml/min (range 17 to 70); mean perfusion time was 9.3 +/- 4 min (median 8.5, range 2 to 30). Chest pain score (0 to 4) decreased from 2.9 +/- 1 to 1.4 +/- 1 during hemoperfusion (p less than 0.001); ST segment elevation score (0 to 4) decreased from 2.6 +/- 1 to 0.7 +/- 1 (p less than 0.005) and inflation time increased from 1.3 +/- 0.9 to 7 +/- 4 min, (p less than 0.001). At least a 50% increase in tolerated inflation time was obtained in 104 patients (95%). Free plasma hemoglobin and creatine kinase levels did not increase significantly over baseline values. Angioplasty was successful in 107 patients (97%), with mean stenosis reduced from 87 +/- 11% to 20 +/- 17%; 3 patients had urgent bypass surgery, 2 (1.8%) had a myocardial infarction (1 Q wave, 1 non-Q wave) and 2 (1.8%) died later in the hospital of probable noncoronary causes.(ABSTRACT TRUNCATED AT 250 WORDS)