Comparison of six-month outcome of coronary artery stenting in patients <65, 65-75, and >75 years of age.

We studied 1,238 patients receiving 1,880 coronary stents. In-hospital outcomes were divided by age into <65 years (n = 747, group 1), 65 to 75 years (n = 326, group 2), and >75 years (n = 165, group 3). Procedural success was 97.2%, 95.1%, and 98.8% in groups 1, 2, and 3, respectively (p = NS). There was 1 death (group 1). Myocardial infarction occurred in 1.2%, 2.8%, and 1.8%, bypass surgery occurred in 0.9%, 1.8%, and 1.2%, and repeat balloon angioplasty in 0.3%, 0.6%, and 0% of patients in groups 1, 2, and 3, respectively (p = NS for all comparisons). Vascular complications occurred in 2.8%, 4.9%, and 6.1% in groups 1, 2, and 3, respectively (p <0.05). Six-month follow-up of patients was divided by age: <65 years (n = 564, group 1); 65 to 75 years (n = 221, group 2); and >75 years (n = 122, group 3). Event-free survival was 94.5%, 90.5%, and 89.3% for groups 1, 2, and 3, respectively (p = NS). Death occurred in 0.4%, 0.5%, and 1.6%; myocardial infarction occurred in 1.2%, 2.3%, and 1.6%, and target vessel revascularization in 4.3%, 8.6%, and 7.4% for groups 1, 2, and 3, respectively (p = NS for all comparisons). Thus, coronary stenting produced favorable in-hospital and 6-month outcomes in all 3 age groups. Age itself should not preclude patients from undergoing coronary stenting.

Microparticle deposition in periarterial microvasculature and intramural dissections after porous balloon delivery into atherosclerotic vessels: quantitation and localization by confocal scanning laser microscopy.

Local delivery of pharmacologic or genetic agents with a porous balloon catheter offers a potential therapeutic approach to reducing restenosis and atherosclerosis and minimizing undesirable systemic toxicity. However, the delivery efficiency and intramural retention of liquid agents is low. The local intramural delivery and prolonged retention of 5 microns microparticles (MP) has been described previously. The current study was designed to evaluate the distribution of locally delivered MPs and to determine the effects of MP size and infusion pressure on intramural delivery efficiency. A 1% suspension of fluorescent, latex MPs (1 or 4.5 microns in diameter) was infused at either 3 or 6 atm into atherosclerotic rabbit femoral arteries (n = 32) immediately after angioplasty. Four groups of arteries were evaluated: 1) 1 micron MPs infused at 3 atm; 2) 1 micron MPs at 6 atm; 3) 4.5 microns MPs at 3 atm; and 4) 4.5 microns MP at 6 atm. The location of MPs was evaluated by fluorescent and light microscopy and confocal laser scanning microscopy. The tissue was dissolved and the delivered MPs quantified. All groups manifested numerous MPs within the vasa vasorum and periadventitial microvasculature, with a substantially lesser number within the neointimal and medial layers. The intramural deposition of the MPs was associated with dissection within the intima or media caused by the antecedent angioplasty or local delivery, indicating that an intact vessel wall is an anatomic barrier to MP delivery. The median values of fractional intramural delivery, defined as the percentage of infused MPs retained within the arterial wall, were 0.059%, 0.071%, 0.047%, and 0.062% for the groups 1 through 4, respectively (p not significant [NS]). The values of intramural particle concentration, expressed as the total number of MPs per weight of arterial tissue, were 55, 65, 1.5, and 1.2 x 10(4) MPs/mg for groups 1 through 4, respectively (p < 0.001 for 1 micron vs 4.5 microns MPs). Although more 1 microM MPs were delivered than 4.5 microns MPs, the fractional intramural delivery was unaffected by particle size or infusion pressure. The local delivery of MPs at atherosclerotic sites after angioplasty is characterized by fractional intramural delivery values similar to values of nonparticulate agents, with few MPs deposited into intima or media in the absence of a dissection caused by the antecedent angioplasty or the delivery procedure itself.

Peripheral vascular complications following coronary interventional procedures.

We report the incidence, diagnosis, prevention, and treatment of peripheral vascular complications following coronary interventional procedures as reviewed in the English-language literature. Peripheral vascular complications include hematomas, pseudoaneurysms, arteriovenous fistulae, acute arterial occlusions, cholesterol emboli, and infections that occur with an overall incidence of 1.5-9%. Major predictors of such complications following coronary interventional procedures include advanced age, repeat percutaneous transluminal coronary angioplasty, female gender, and peripheral vascular disease. Minor predictors include level of anticoagulation, use of thrombolytic agents, elevated creatinine levels, low platelet counts, longer periods of anticoagulation, and use of increased sheath size. Ultrasound-guided compression repair of pseudoaneurysms and arteriovenous fistulae are discussed, as are newer methods of treatment such as hemostatic puncture closure devices. Anticipation and early recognition of possible peripheral vascular complications in conjunction with careful attention to the optimal activated clotting time for sheath removal following coronary interventional procedures may translate into fewer vascular complications as well as into shorter and less costly hospital stays.

Wide QRS tachycardia.

Wide QRS tachycardia is a diagnostic challenge when confronted on a 12-lead electrocardiogram. The differential diagnosis includes: ventricular tachycardia; supraventricular tachycardia with aberration; and Wolff-Parkinson-White syndrome. Confronted with a wide QRS tachycardia, one must determine whether the origin is ventricular or supraventricular because the therapy will differ. The electrocardiographic findings of capture beats, fusion beats and atrioventricular dissociation are highly specific for ventricular tachycardia but not very sensitive. After careful assessment of the 12-lead electrocardiogram following selected diagnostic features, the correct diagnosis of the cause of wide QRS tachycardia can be made in about 90 percent of patients. This article contains a brief discussion of the diagnostic features of wide QRS tachycardia.

Cardiac myxoma: the Indiana Heart Institute experience.

Surgical resection of a cardiac myxoma was performed in 14 patients at the Indiana Heart Institute at St. Vincent Hospital and Health Care Center in Indianapolis from 1974 to 1989. Thirteen were located in the left atrium and one in the right atrium. The 10 women and four men ranged in ages from 28 to 75 years. Surgical complications included one perioperative death, one late death and one late recurrence requiring reoperation. Physicians must be highly suspicious to correctly diagnose this unusual but surgically correctable entity. Two-dimensional echocardiography is the diagnostic technique of choice for both early diagnosis of a cardiac myxoma and late follow-up after resection.

Cardiac rupture following acute myocardial infarction: a case with successful surgical treatment.

This report involves a patient who sustained an acute lateral wall myocardial infarction complicated by cardiogenic shock. Cardiac catheterization revealed diastolic equilibration of all intracardiac pressures. Cardiac angiography revealed only acute occlusion of a small branch of the left circumflex coronary artery with good left ventricular systolic function. Since these findings could not explain the degree of cardiogenic shock, an immediate echocardiogram revealed a moderate pericardial effusion with an echo-dense mass suggestive of subacute cardiac rupture. Emergency cardiac surgery confirmed the diagnosis and successful surgical correction resulted in survival of the patient.