Comparative trial of stent-like balloon angioplasty versus coronary stenting for acute myocardial infarction.

Primary PTCA has been shown to be superior to any thrombolytic regimen and offers higher reperfusion rates and better coronary flow grades. Its limitations include recurrent ischemia (10%-15%), infarct-related artery reocclusion (5%-10%), angiographic restenosis (35%-50%), and need to perform repeat PTCA or CABG at 6-month follow-up (20%). Thus, the current role of coronary stenting for acute myocardial infarction (AMI) is very promising. From December 1995 through January 1997, 335 patients underwent primary angioplasty during the first 12 hr from symptom onset at our institution. We performed a retrospective study comparing the in-hospital and 6-month follow-up outcome of 61 patients who underwent coronary stenting (stent group) against 61 patients with optimal (residual lesion stenosis < 30%) balloon-only primary angioplasty (stent-like group). Patients were routinely treated with aspirin, and ticlopidine was given only to the stent group. In-hospital major adverse cardiac events (MACE) rate was 11.5% without statistical differences between the groups. Cardiac death rate was similar in both groups (4.9 vs. 6.6%; P = 1.0) and only two (3.3%) patients from the stent group and none from the PTCA group had nonfatal myocardial reinfarction. At 6-month follow-up, the rate of recurrent angina was higher in the stent-like group (30.9 vs. 7.1%; P < 0.001). Multivariate analysis showed that only stenting of the infarct-related artery was a borderline independent predictor for MACE (OR = 0; 95% CI = 0-1; P = 0.057). Primary stenting for AMI reduces the rate of recurrent angina or symptoms and MACE at 6-month follow-up.

[Stent coated with bovine pericardium: in vitro evaluation, in animals, and initial results in humans]. / Stent cubierto con pericardio bovino: evaluación in-vitro, en animales y resultados iniciales en el humano.

Covering a stent with a membrane (stent graft) allows treatment of diverse coronary abnormalities such as aneurysms, rupture and fistulas (which, until recently, required surgical therapy). A stent graft could also reduce embolic complications associated with angioplasty of saphenous vein grafts. The objective of this study is to evaluate bovine pericardium as a graft for conventional stents. In vitro testing of the bovine pericardium disclosed an elasticity of 15% and a resistance to rupture of 0.22 kg/mm2, well above the pressure commonly used during stent deployment. In 18 pigs, 29 of 32 (90.63%) attempts to implant stent grafts were successful. Histology of acute porcine studies revealed correct apposition of the stent graft to the vessel wall, subacute and chronic (10 days and 1 month) samples showed adequate endothelization and exclusion of proliferative media. Twenty stents were placed in 15 patients with a 100% success rate. Seven patients had coronary aneurysms and in all a complete exclusion of the aneurysm was obtained without complications. Fourteen patients have a follow-up of 6 or more months with evidence of clinical restenosis in 2 (14.28%), whereas angiographic follow-up in 9 patients, which included the 2 cases with recurrent angina, evidenced restenosis in 3 of 14 stents (21.4%), two of which were overlapped in the LAD of one patient and one corresponded to a series of 9 stents (in 5 patients) placed in saphenous vein grafts. It is concluded that bovine pericardium is a suitable material for stent-grafts and its efficacy to seal coronary aneurysms was demonstrated. These results warrant a larger comparative study to better define its restenosis rate and further delineate its usefulness in the treatment of diseased saphenous vein grafts.

[The benefit of a coronary stent in the reduction of major cardiac complications in acute coronary syndromes]. / Beneficio del stent coronario en la reducción de complicaciones cardiacas mayores en síndromes coronarios agudos.

To assess the incidence of in-hospital major adverse cardiac events (MACE), we analyzed 694 procedures in 613 consecutive patients during one year period. Patient population included 550 (79.2%) patients with unstable angina, 43 (6.2%) with stable angina and 101 (14.5%) with acute myocardial infarction. Elective percutaneous transluminal coronary angioplasty (PTCA) was performed in 593 (85.4%) patients, rescue PTCA in 7 (1%), and primary PTCA in 94 (13.5%). Angiographic lesion morphology was as follows: type A 30%; type B 58%; type C 12%. We compared patient population who received stent with PTCA-balloon only. Technical success was 95% and clinical success was achieved in 80% of the cases. Overall mortality was 1% in the stent group and 3% in the conventional PTCA. The incidence of MACE was 4% and 15.1% in the stent and angioplasty balloon groups respectively. We found a dramatic impact on reduction of the incidence of acute complications in the groups with stenting for unstable angina (p = 0.0001) and acute myocardial infarction (p = 0.0001). The major clinical advantage of stenting over balloon angioplasty was a lower need for repeated procedures.

Percutaneous mitral commissurotomy.

Rheumatic fever is the most common cause of acquired heart disease in children and young adults worldwide, mainly in developing countries, and is the reason that a large number of patients with mitral stenosis will require some modality of treatment during their life span. The early therapeutic approach for this condition was solely surgical, but since the early 1960s, several balloon catheter interventional techniques have emerged as alternatives to surgical treatment. In 1976 Inoue described a novel single-balloon device designed specifically for percutaneous transvenous mitral commissurotomy (PMC), and in 1982 the first clinical application of Inoue's technique was successfully accomplished. Ever since several clinical trials established PMC as an effective and safe procedure for severe mitral stenosis in more than 30,000 patients worldwide, percutaneous balloon techniques have been considered the method of choice in selected patients (functional class >II, mitral valve area <1.5 cm2, and Wilkins' score <8) for several reasons. PMC is a nonsurgical method with results similar to those of surgical intervention, but without the unnecessary risks and complications of general anesthesia and extracorporeal circulation pump. Both PMC and surgical commissurotomy yield comparable acute and long-term results and similar restenosis rates. Moreover, PMC is the strategy of choice in symptomatic pregnant women with mitral stenosis, as well as in some cases with restenosis after a previous PMC. Patient selection and procedural technique are reviewed in detail.

Myocardial contrast and transesophageal echocardiographic study of the left coronary artery from the main pulmonary artery.

A case of a 26-year-old woman with thoracic pain and anomalous origin of the left coronary artery from the main pulmonary artery is described. The diagnosis was by coronary angiography and complemented with Doppler and transesophageal myocardial contrast.

[Coronary stent in acute myocardial infarction]. / Stent coronario en el infarto agudo del miocardio.

UNLABELLED: From December 1995 to March 1997 fifty patients with acute myocardial infarction, had 57 stents implanted. Mean time since the beginning of symptoms to the procedure was 3.7 +/- 2.9 hours. Twenty-four stents were implanted "de novo", 17 for "sub-optimal" results, 5 for threatened closure and eleven for complex dissection. The arteries treated with stent were left anterior descending in 42%, right coronary in 42%, circumflex in 10%, vein grafts in 4%, intermedial branch in 1% and marginal obtuse branch in 1%. Stent used in most of the cases was AVE in 67% followed by Palmaz-Schatz, Wiktor, Crown, Gianturco-Roubin and Wallstent. Before procedure, coronary flow was TIMI 0 in 66% TIMI 1 in 10% and TIMI 2 in 24%. After procedure, TIMI 3 coronary flow was achieved in 92% of the arteries and other four had "no-reflow" phenomenon. Mean stenosis before procedure was 96% +/- 3.1 and after stenting was 1.76% +/- 2.6 with a stent/artery diameter rate of 1.01. Technical success was 100% and clinical success was achieved in 96% of the cases. Two cases were not successfully due to acute thrombotic closure in one patient and in another one because of cardiogenic shock after two days of a technical successful implantation of stent in LAD artery. There were not recurrent ischemic events (CABG, re-infarction or new coronary angioplasty procedure). Other two patients died for non-cardiac events (acute pancreatitis in one and by septic shock in other). At the time of discharge 96% of patients were treated with aspirin and ticlopidine. Major hematoma was evident in only one case. At a mean follow-up time of 5.6 months +/- 4.2 in 45 patients showed that 73% were in functional class I and none of them had re-infarction, death or needed a new revascularization. CONCLUSION: Stent implantation in acute myocardial infarction is feasible and safe procedure with a low rate of ischemic recurrent events.

[Acute fatty liver of pregnancy complicated by pancreatitis]. / Hígado graso agudo del embarazo complicado con pancreatitis.

A woman with acute fatty liver of pregnancy developed fulminant hepatic failure after delivery, a time when spontaneous recovery was expected. Pancreatitis and multiple organ failure was documented and intensive treatment in a critical care unit was needed to support organ function. She underwent plasmapheresis due to extreme hyperbilirubinemia and coma. She recovered completely.

Pentoxifylline and oxygen consumption in severe sepsis--a preliminary report.

OBJECTIVE: To demonstrate that pentoxifylline (PTX) and not placebo improves oxygen consumption (VO2) in critically ill patients with severe sepsis. SETTING: Multidisciplinary intensive care unit in a university affiliated hospital. DESIGN: A randomized, double blinded clinical trial comparing 300 mg of PTX administered in a 120 min iv infusion with an identically looking placebo. PATIENTS: 13 patients (9 men and 4 women) average age 39 (24-62) years old received PTX, and 12 patients (5 men and 7 women) average age 38 (21-83) years old received placebo. All satisfied ACCP/SCCM criteria for severe sepsis. MEASUREMENTS AND INTERVENTIONS: Patients fulfilling criteria for severe sepsis was identified on admission, cardiac output, DO2 and VO2 were measured by thermodilution and standard oximetric technics after adequate volume replacement at baseline, 60 and 120 during infusion. F-test of analysis of variance was used to test hypothesis about differences of DO2 and VO2 by group, by time and for the interaction terms, a "p" value < 0.05 was considered significant. RESULTS: Evaluation of baseline measurements of both groups revealed no significant difference in any haemodynamic function or oxygen transport variables. The average VO2 difference (0-120 min) between groups was 21 mL/min.m2 and it was higher in the experimental group, however, this difference was non significant. CONCLUSION: We think that the trend in VO2 followed by the experimental group is clinically important. If this difference is sustained we will probably be able to demonstrate our hypothesis.