Alternatives to conventional chest compression.

Alternative techniques to precordial compression are sought to improve the return of spontaneous circulation after cardiopulmonary arrest. The pathophysiology of cardiac arrest and the methods to determine the efficacy of a new technique need critical re-examination. Vest cardiopulmonary resuscitation (CPR), active compression/decompression with abdominal counterpulsation (LifeStick [Datascope, Fairfield, NJ]) CPR, and ascending aortic balloon inflation with saline infusion are promising methods that have been shown to augment coronary perfusion pressure and improve the return of spontaneous circulation in animals. Preliminary studies in human cardiopulmonary arrest have been performed with vest CPR and ascending aortic balloon inflation with saline infusion, with favorable hemodynamic results. In parallel with the development of new methods, the availability and adequacy of bystander CPR should be re-emphasized.

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.

Predictors of successful PTCA using coronary perfusion balloon catheters.

The purpose of this retrospective study was to define clinical, angiographic and procedural predictors of successful PTCA using perfusion balloon catheters (PBC). Age, gender, diabetes, clinical state (stable or unstable angina), coronary vessel, AHA/ACC lesion type, lesion contour, pre-procedural thrombus, percent stenosis, lesion length, balloon size, maximum PBC pressure, and maximum inflation time were analyzed for 207 lesions in 193 successive patients. Unsuccessful results occurred more frequently in patients with unstable angina, pre-PTCA thrombus, and those treated with smaller balloon catheter diameter. Logistical regression analysis identified larger balloon size (odds ratio [OR] = 0.447 [95% confidence interval 0.203, 0.986], p < .05); and absence of thrombus (OR = 2.217 [95% confidence interval 1.066, 4.610], p < .05) as predictors of success. This study suggests that small vessel size, approximated by balloon size selection, and the presence of pre-PTCA thrombus reduces the likelihood of success, especially in the setting of unstable angina. In these cases other percutaneous interventions may be warranted.

Examination of common PTCA guide wires used for side branch protection during directional coronary atherectomy of bifurcation lesions performed in vivo and in vitro.

Side branch protection of bifurcation lesions with guide wires treated with directional coronary atherectomy has been performed safely in a small number of patients using a nickel/titanium (Nitinol) alloy guide wire. There is no information about the safety of using other guide wires in this scenario. The purpose of this study was to microscopically examine a variety of guide wires exposed to the directional coronary atherectomy (DCA) device in vitro. Eight common guide wires used in percutaneous coronary angioplasty were positioned in a side branch of a simulated coronary bifurcation and exposed to the operating DCA device. The guide wires were examined grossly and under scanning electron microscopy. The Nitinol guidewire suffered no discernible damage in comparison to varying degrees of damage seen on the other guide wires, and this guidewire appears to be best suited for side branch protection. Examination of the protecting guide wire and cutting cylinder used in the initial patients also showed no damage. Further clinical trials are necessary to assess the efficacy of DCA under such conditions.

Modified "kissing" atherectomy procedure with dependable protection of side branches by two-wire technique.

We report a new two-wire atherectomy technique for side branch protection. Newer, more resilient wire designs are capable of withstanding cutting forces of the Simpson atherocath device. This technique expands atherectomy application to lesions previously excluded from atherectomy as high risk lesions.

Coronary angioplasty in cardiac transplant patients. Results of a multicenter study.

BACKGROUND: Accelerated allograft atherosclerosis is the main cause of death of cardiac transplant recipients after the first year after transplantation. Because no medical therapy is known to prevent or retard graft atherosclerosis and transplantation is associated with a shortened allograft survival, alternative, palliative therapy with percutaneous transluminal coronary angioplasty (PTCA) has been attempted. Because no single medical center has performed angioplasty in a large number of cardiac transplant recipients, representatives of 11 medical centers retrospectively analyzed their complete experience of coronary angioplasty in cardiac transplant patients to determine the safety, efficacy, limitations, and long-term outcome of angioplasty in allograft coronary vascular disease. METHODS AND RESULTS: Thirty-five patients underwent 51 angioplasty procedures for 95 lesions 46 +/- 5 months (mean +/- SEM) after transplantation. The primary indications for angioplasty included angiographic coronary disease in 22 cases (43%) and noninvasive evidence of ischemia in 18 procedures (35%). Angiographic success, defined as less than or equal to 50% post-PTCA stenosis, occurred in 88 of 95 lesions (93%). Mean pre-PTCA stenosis was 83 +/- 1.1%; mean post-PTCA stenosis was 29 +/- 2.1% (p less than 0.0001). Periprocedural complications included myocardial infarction and late in-hospital death in one patient and three groin hematomas. Twenty-three of the 35 patients (66%) had no major adverse outcome such as death, retransplantation, or myocardial infarction at 13 +/- 3 months after angioplasty. Four patients died less than 6 months after angioplasty, and four died more than 6 months after angioplasty (range, 6-23 months). Two patients had retransplantation 2 months after PTCA, and one patients had retransplantation 18 months after angioplasty. CONCLUSIONS: Coronary angioplasty may be applied in selected cardiac transplant recipients with comparable success and complication rates to routine angioplasty. Whether angioplasty prolongs allografts survival remains to be determined by a prospective, controlled trial.

Complete left main coronary artery occlusion: angiographic evaluation of collateral vessel patterns and assessment of hemodynamic correlates.

An angiographic study of eight patients with total occlusion of the left main coronary artery identified six patients with chronic occlusion and two with acute complete occlusion. In each of six patients, there were two to six different intercoronary collateral pathways. Altogether, a total of 13 specific collateral channels were recognized. One patient had evidence of unique homocollaterals represented by enlarged vasa vasorum, which created a vascular cuff that surrounded a totally obstructed left main artery. The ventricular function and hemodynamic parameters in these patients not only depend on the collateral vessels but may also be affected by the severity of coronary artery disease in the artery that supplies collaterals.

Dose effects of adenine on myocardial ATP content in the post-anoxic nonworking rat heart.

1. Tissue ATP levels were measured in Langendorff perfused nonworking rat hearts subjected to 50 min anoxia prior to reperfusion with Krebs-Ringer bicarbonate (KRB) buffer alone or supplemented with 50 microM or 1 mM adenine for 60 min. 2. ATP content was restored to the normoxic range in hearts reperfused with 50 microM adenine in KRB (20.82 +/- SEM 1.90 mumol/g dry weight vs 24.95 +/- 0.83 in normoxic hearts, P = NS). 3. Reperfusion with oxygenated KRB alone or buffer with 1 mM adenine failed to improve ATP levels (17.23 +/- 0.91 mumol/g dry weight for buffer alone, 15.60 +/- 0.46 with 1 mM adenine and 13.45 +/- 0.93 for anoxic hearts not reperfused). 4. These findings indicate that adenine at 50 microM dosage can restore ATP concentrations to the normoxic range after 60 in of anoxia in the nonworking rat heart while raising the adenine dose to 1 mM inhibited the tissue ATP content.

Efficacy of pentoxifylline in patients with stable angina pectoris.

Pentoxifylline, a methyl xanthine derivative, improves symptoms of peripheral vascular disease probably by reducing whole blood viscosity. The authors assessed the value of this agent in treating myocardial ischemia in 11 patients with angiographically documented coronary artery disease and stable angina pectoris. Maximal, symptom limited treadmill exercise stress tests were performed before and after six weeks of therapy with 1200 mg of pentoxifylline per day. Clinical symptoms proved in 9 [82%] of patients; none developed drug side effects. After therapy, mean total exercise time [7.7 +/- 1.3 vs 10.1 +/- 1.2 minutes], time to onset of angina [5.5 +/- 0.9 vs 7.9 +/- 1.0 minutes], heart rate at onset of angina [93.4 +/- 6.7 vs 112.0 +/- 10.5 beats/min] and rate at onset of ST depression [94.0 +/- 5.8 vs 115.9 +/- 7.4 beats/min] all increased significantly [p less than 0.05]. Mean maximum ST segment depression also decreased [1.6 +/- 0.3 vs 1.2 +/- 0.4mm], but the difference was not significant. Thus, pentoxifylline increases exercise performance in patients with angina pectoris and increases exercise capacity before development of of myocardial ischemia. It may, therefore, be a useful agent for treating ischemic heart disease.

General fibrosis syndrome.

Fibrosis of the extraocular muscles can involve multiple muscles, including the levator, and become part of the general fibrosis syndrome, which is characterized by the replacement of normal muscle tissue by fibrous tissue of varying degrees. The characteristics of this syndrome are well described although they are often confused with other similar entities. Fourteen patients are presented who display the typical characteristics of the syndrome with three members of one family being highlighted in our study. It is not currently known or described that visual acuities are problems in these children, but refractive error may not only be significant but it may vary with time and failure to pay particular attention to this fact may lead to amblyopia. The surgical correction of the strabismus is difficult but should be attempted because of the benefit it can offer, particularly from the cosmetic standpoint.

Ocular manifestations of pituitary adenomas.

Fifty patients with pituitary adenomas were evaluated preoperatively by an ophthalmologist; of these, 68% had visual field defects, the most common (25%) a superior bitemporal depression and 16%, bitemporal hemianopsia. Almost 60% of patients with field defects had visual complaints; 38% had visual acuity in one eye of 20/60 or less. Patients with larger, nonsecreting tumors had more visual defects than patients with secreting pituitary adenomas.