Smoking cessation and severity of disease: the Coronary Artery Smoking Intervention Study.

We tested the effectiveness of an individually delivered behavioral multicomponent smoking intervention (SI) against offering advice only (AO) to 267 patients after coronary arteriography. After 6 months, 51% of AO patients and 62% of SI patients reported abstinence. Validated rates were 34% and 45% for AO and SI patients, respectively. Logistic regression analyses, controlling for severity of illness, stage of change, and self-efficacy, among other variables, showed that, at 6 months, the SI had the most effect for patients with more severe coronary artery disease (CAD) who had been admitted with a myocardial infarction (95% confidence interval = 2.05, 124.85). At 12 months, only severity of disease mediated SI effects (95% confidence interval = 3.10, 58.00). Similar results were seen for cotinine-validated cessation. This study confirms the effectiveness of individually administered SI for more seriously ill patients with CAD and raises questions as to how to better intervene with those individuals with less severe disease.

Outpatient cardiac catheterizations: analysis of patients requiring admission.

The purpose of this study was to review the results of the first 1,000 outpatient cardiac catheterizations performed at our hospital with special emphasis on patients who were hospitalized. Nearly all patients had percutaneous femoral artery catheterization using #8F catheters. There were no deaths. The major complications included two myocardial infarctions and four cerebral emboli. Surgery on the femoral artery was required in 2 patients (1 occlusion and 1 pseudoaneurysm), 7 patients developed unstable angina without subsequent infarction, and 4 patients had ventricular tachycardia or fibrillation. Complications requiring admission were found in 39 patients. Another 59 were admitted, 51 for revascularization procedures. Of the latter 51 patients, 27 had main left coronary stenosis of 50% of greater. We have found outpatient catheterization to be a safe procedure. Complications requiring admission occurred in 3.9% of the patients. The most common reason for admission was to perform urgent bypass surgery in patients with main left coronary stenosis in excess of 50%.

Comparison of visual estimate with digital caliper measurement of coronary artery stenosis.

We compared visual estimate and digital caliper measurement of coronary stenoses, utilizing both a 50% and 70% diameter reduction as a definition of significance and both experienced angiographers and cardiology fellows as readers. Ten angiograms were interpreted twice, using the different methods, by four readers, two months apart. The angiograms were divided into 12 vessel segments. Stenoses were judged more severe by visual estimate in 11 segments. Seven of twelve segments had significant differences between readers using the visual estimate, but no significant differences were obtained using caliper measurements. Variability was highest for fellows using the visual method. Interobserver agreement was highest using the digital caliper and the 70% criteria. Intraobserver agreement was most dependent on the amount of time taken in film interpretation. The digital caliper appears to be preferable in interpreting angiograms, particularly for cardiology fellows.

Percutaneous transluminal coronary angioplasty--effect of the moveable guide wire on the complication rate.

Beginning with the first percutaneous transluminal coronary angioplasty (PTCA) performed at Baystate Medical Center, 152 consecutive procedures were analyzed. Sixty were done using USCI-G (nonsteerable) series catheters. In two patients both a G and S (steerable) catheter were used. In 90 procedures the S system was used exclusively. Among the attempted angioplasties with the G series catheter, the percutaneous transluminal coronary angioplasty was successful in 47 (78%). Eight coronary occlusions were induced and all these patients underwent coronary bypass surgery. There were no deaths, but three patients (5%) had acute myocardial infarctions (MI). The two patients in whom both G and S catheters were used had occlusions. One went to surgery and died postoperatively of uncontrollable ventricular arrhythmias. The other patient had a myocardial infarction and recovered. Of the 90 attempts with the exclusive use of the steerable system, 75 were successful (83%). Three coronary occlusions were induced in the 90 attempts and two of the patients had coronary artery bypass surgery. None of the three sustained a myocardial infarction. In summary, the proportion of patients requiring emergency surgery was significantly reduced from 13.3% (8 of 60) to 2.2% (2 of 90) (p=0.02), the incidence of myocardial infarction was reduced from 5 to 0%, and there was a slight increase in the siccess rate of the procedure after the introduction of the steerable system. It is concluded that the steerable system increases the safety of PTCA.

Fatal ventricular fibrillation following verapamil in Wolff-Parkinson-White syndrome with atrial fibrillation.

A 29-year-old man with Wolff-Parkinson-White syndrome and atrial fibrillation developed fatal ventricular fibrillation shortly after receiving intravenous verapamil. The patient presented with an irregular pulse of 190. A total of 23 mg of verapamil was administered in small intravenous doses over 35 minutes. The ventricular rate accelerated as verapamil was administered, and fatal ventricular fibrillation followed. Three theoretical mechanisms by which verapamil may enhance conduction of atrial fibrillation in Wolff-Parkinson-White syndrome, predisposing to ventricular fibrillation, are mentioned.

Distal coronary artery injury following successful percutaneous transluminal coronary angioplasty.

A 65-year-old woman underwent successful percutaneous transluminal coronary angioplasty of a right coronary artery stenosis. Shortly thereafter, she developed chest discomfort and repeat angiography demonstrated a new area of stenosis distal to the area of original angioplasty. An attempt at a second angioplasty resulted in vessel occlusion with subsequent successful bypass surgery. The etiology of the new distal lesion is discussed.

The effect of prolonged cardioplegic arrest on long-term ventricular function.

Twenty-five patients (15 coronary revascularizations and 10 valve replacements) having ischemic arrest times longer than 120 minutes (121 to 184 min) were studied by scintigraphy 7 to 27 months after operation. We sought to define if prolonged cardioplegic arrest could be correlated with late postoperative ventricular functional deterioration. Each patient had serial enzymes, EKG analyses, and a technetium pyrophosphate (PYP) scan immediately following operation to determine if an intraoperative infarct occurred which could predispose to functional deterioration. One coronary bypass patient (6.7%) suffered a perioperative myocardial infarct. After a follow-up period of 7 to 25 (mean 17.9) months, none of the 15 patients has developed recurrent angina, infarction or congestive heart failure. Comparing preoperative and late postoperative ventricular function, 3 patients (20%) had a greater than 10% fall in ejection fraction (EF) and 3 (20%) a greater than 10% rise. Mean EF (15 patients) prior to operation was 57.8 +/- 4.7% and at restudy 59.0 +/- 4.6%. One valve replacement patient (10%) suffered a perioperative infarction. After a follow-up period of 16 to 27 (mean 19.9) months, all patients continue to do well. Comparing preoperative to late postoperative ventricular function, 3 patients (30%), had a greater than 10% fall in EF and 2 (20%) a greater than 10% rise. Mean EF (10 patients) prior to operation was 60.5 +/- 5.0% and at restudy 60.1% +/- 5.8%. It is concluded that prolongation of cardioplegic arrest beyond 2 hours is well-tolerated in most patients. Routine early postoperative tests were not useful in prognosticating late functional deterioration in 4 of 6 patients not suffering a perioperative infarction, and in these patients depressed function may be secondary to myocardial fibrosis.

Spontaneous cure of infected left atrial myxoma following embolization.

A patient with prolonged duration, bacterial infection, and echocardiographic disappearance of an atrial myxoma following embolization is discussed. Following aortic saddle embolus, all echocardiographic manifestations of the patient's left atrial myxoma disappeared. Previous cases of infected atrial myxomas are reviewed. The necessity of early surgical intervention, despite active infection, is discussed.