Adjunctive thrombus aspiration and mechanical protection from distal embolization in primary percutaneous intervention for acute myocardial infarction.

Primary percutaneous intervention for acute occlusion of a native coronary artery may be complicated by distal embolization of plaque or thrombotic debris, with infarct extension. We tested the clinical application of a new therapeutic strategy combining maximal antiplatelet therapy, with glycoprotein IIb/IIIa inhibition, and adjunctive mechanical protection from distal embolization and direct aspiration of thrombus with a new balloon and catheter system (PercuSurgetrade mark). Successful aspiration of thrombus could be obtained in 7 out of 8 attempted procedures, with inability to negotiate the angulated take-off of the circumflex coronary artery in one patient. The current mechanical characteristics of the device, primarily developed for use in larger saphenous vein grafts, and certain caveats and limitations are discussed. New dedicated systems should be available in the near future for the native coronary circulation. Excellent immediate angiographic results were obtained in all treated patients, without evidence of loss of distal branches and no intraprocedural complications.

The elusive link between coronary lesion morphology and dobutamine stress echocardiography results. The EDIC (Echo Dobutamine International Cooperative) Study Group.

BACKGROUND: Coronary lesion angiographic morphology of the complex type is associated to enhanced susceptibility to ischemia during vasodilator adenosinergic stress testing and attributed to the reduced vasodilatory capacity of the damaged endothelium. Whether coronary lesion morphology can also influence the results of adrenergic pharmacologic stress test remains unknown. The aim of our study was to assess the relationship between coronary plaque morphology and dobutamine-atropine stress echocardiography (DASE) results. METHODS AND RESULTS: We analyzed DASE (up to 40 mcg/kg/min plus atropine) and coronary angiography data of 42 patients with single vessel disease and no totally occluded vessel at angiography. 7 patients had angina, 35 had previous infarction. A diagnostic DASE was performed in all patients within 1-10 (mean 4.7 +/- 3.4) days before coronary angiography. An angiographic lesion was considered complex when irregular borders and/or intraluminal lucencies, suggestive of ulcer and/or thrombus were present. According to the angiographic lesion morphology (Ambrose classification), 2 groups were identified: Group I, with simple lesion; Group II with complex lesion. The two groups were similar for number of patients (n = 21), age (I = 55 +/- 11 vs II = 53 +/- 7 years, p = ns), coronary stenosis severity expressed as % diameter reduction (I = 77 +/- 14 vs II = 78 +/- 15%, p = ns), presence of previous infarction (I = 17 vs II = 18 pts, p = ns). No difference was found in the prevalence of positivity between the two groups (I = 72 vs II = 62%, p = ns). The two groups achieved a similar peak dobutamine dose (I = 32 +/- 9 vs II = 33 +/- 9 mcg/kg/min, p = ns) and peak Wall Motion Score Index (I = 1.5 +/- 0.26 vs II = 1.45 +/- 0.28, p = ns). CONCLUSIONS: In patients with non occlusive single vessel disease, coronary morphology of complex type is not associated with greater vulnerability to dobutamine induced ischemia.

[Fatal aortic dissection in a young woman at the 32nd week of pregnancy]. / Dissecazione aortica fatale in giovane donna gravida alla 32 settimana di gestazione.

Aortic dissection in young women without Marfan disease is unusual. When it occurs it is often related to pregnancy. We report a fatal case of aortic dissection in a 29-year-old woman at the end of her first pregnancy. A prompt diagnosis and surgical treatment usually permits the physician to save both mother and fetus. In this case the delay in the diagnosis was fatal for both. We retain that knowledge of this rare complication of pregnancy is useful in order to refer patients early for surgical treatment.

[Comparison of 6 and 8 French catheters for arterial catheterization and coronarography: prospects of the development of coronarography in ambulatory care]. / Confronto fra cateteri 6 ed 8 French per cateterismo arterioso e coronarografia: prospettive di sviluppo della coronarografia in regime ambulatoriale.

The aim of this study was to evaluate day-hospital coronary angiography as a valid method to reduce hospital recovery costs and patient waiting lists. We evaluated its technical feasibility by randomizing sixty hospital patients. These were divided into two groups, and 6 or 8 French Judkins of Amplatz coronary angiography catheters were used for each group following the Judkins technique. Patients were invited to walk after four hours. Local complications, the number of catheters used, their stability and maneuverability, as well as the radiological resolution of the image were evaluated. No major cardiac complications occurred. One transient cerebral ischemic episode during 6F coronary angiography was quickly resolved by medical therapy. Two local haemorrhages and three cases of hypotension were observed in the 8 French group, while minor bleeding phenomena were similar in both groups (3 vs 5). Differences occurred in local haematoma incidence after 24 hours (13 in 8F vs 2 in 6F); there was no difference in the number of catheters used, the completion time of the examination, or the radiological resolution. Maneuverability and stability of the 6F group were reduced, but not so much as to compromise examination. The AA concluded that 6F catheters are useful in day-hospital coronary angiography, with a similar examination quality, and a reduction in local complication.

[A prospective study of the evolution of coronary lesions: clinico-morphologic correlations]. / Studio prospettico sulla evolutività delle lesioni coronariche: correlazioni clinico-morfologiche.

In order to evaluate the evolution (progression and regression) of coronary atherosclerosis, 61 patients (8 with stable angina, 9 with unstable angina, 15 with a recent myocardial infarction, 29 with multivessel coronary artery disease and treated with successful one-vessel angioplasty) were enrolled in a prospective study. In the angioplasty group, only untreated vessels were considered for the analysis. All patients underwent coronary angiography before hospital discharge and after one year, in accordance with the study protocol. In 13 patients (21%) a repeat angiography was performed at 6.3 +/- 2.7 months for clinical reasons (myocardial infarction, changing pattern angina, angina recurrence). All patients were asymptomatic or mildly symptomatic on medical therapy between the angiographic studies. Progression (decrease in internal luminal diameter at the site of stenosis greater than or equal to 20%; new onset of lesions, new episodes of total occlusions) was found in 16 out of 216 stenoses (7%) and in 14 out of 61 patients (23%). Regression (increase greater than or equal to 20% in internal luminal diameter; reopening of a previously occluded vessel) was found in 11 out of 227 lesions (5%) and in 7 out 61 patients (11%). At repeat angiography, the increase in severity was found more frequently in stenoses greater than 5 mm in length and with a reduction of greater than or equal to 75% in luminal diameter. Regression was more frequent in the occluded vessel supplying a recently infarcted area. No significant relationship was observed between lesion morphology (concentric, eccentric, with plaque ulceration, thrombi, border irregularities) and progression or regression. Lesions with plaque ulceration (with or without superimposed thrombi) were found only in patients submitted to coronary angiography close to an acute ischemic attack. Morphologic regression (disappearance of ulceration, border irregularities, thrombi) was also observed, without any significant changes occurring in the severity of the underlying stenosis. Progression may occur independently of worsening in the clinical status; on the contrary, regression was only found in patients without new cardiac events. Nevertheless, clinical status does not seem to be closely correlated to progression, regression, or changes in plaque morphology.

Effects of nifedipine, acebutolol, and their association on exercise tolerance in patients with effort angina.

The action of nifedipine (N), acebutolol (A), and their association (A+N) was studied in 16 patients suffering from effort angina with documented coronary artery disease. The therapeutic action was valued by bicycle effort stress test after oral administration of medications in comparison with placebo (P), following a double-blind random sequence of treatments. Working capacity significantly increased after A (507 +/- 450 mkp, p less than 0.05), after N (1,140 +/- 767 mkp, p less than 0.001), and after A+N (1,198 +/- 644 mkp, p less than 0.01). The increments of work after P administration were not significant. Moreover, fatigue instead of angina appeared as a stopping criterion in 8 patients after A+N, and in only 1 patient after P, A, and N.

[The significance of hemogasanalysis in acute myocardial infarction: hemodynamic and respiratory correlations (author's transl)]. / Significato dell'emogasanalisi nell'infarto miocardico acuto. Correlazioni emodinamiche e respiratorie

Hemodynamic and hemogasanalytic comparative study was performed in 46 patients admitted to our Coronary Care Unit because of myocardial infarction. The values of pH; PO2; PCO2; HbaO2; HbvO2; SBP; CVP; PAP; WP; Q; and CI were recorded simultaneously in every patient one or more times during the first 72 hours of the disease. The patients were divided into four classes according to the severity of hemodynamic impairment. Statistical analysis of the obtained results was then performed. In all patients more or less severe hypoxemia was found, but it was not statistically related to the severity of hemodynamic impairment. Instead, the values of PvO2 and HbvO2 showed a very significant correlation with Q and CI. Moreover, in 11 patients the venous admixture (QVA/Q) was measured several times in order to study the cause of the arterial hypoxemia thoroughly. It showed a very significant direct correlation with Q and CI. The interpretation of this phenomenon is then discussed and it is suggested that, in such patients, an increase of cardiac output causes an increased flow through poorly ventilated areas.

[His electrogram recordings in disturbances of atrio-ventricular conduction in acute ryocardial infarction (author's transl)]. / La registrazione dell'elettrogramma hisiano nei disturbi della conduzione atrioventricolare dell'infarto miocardioco acuto

48 His bundle recordings were performed on 30 patients with acute mycardial infarction and various degrees of atrioventricular block. Studies were undertaken at the time of transvenous pacemaker insertion and/or removal from the right ventricle, without pharmacological or electrical stimulation tests. The connections between site of the infarcted area and localization of the a-v block were investigated, to identify uncommon relations. Several atypical cases were observed: among 12 cases of patients with anterior infarction, 6 had prolonged P-H interval, with prolonged H-V interval in 4 cases, and normal H-V interval in the remaining 2 cases. Among the 18 cases of inferior infarction, 5 had prolonged H-V interval, 2 of which had a normal P-H interval and 3 with prolonged P-H interval. In the latter cases, the identification of a two-step a-v block by His bundle recordings was shown to be important from the clinical and prognostic viewpoint. Nevertheless, it is evident that the His bundle recording is insufficient by itself to provide any evidence of the inner pathogenetical mechanism of these phenomena, and only various hypotheses can be advanced.

Cytoplasmic and mitochondrial fractions of serum aspartate aminotransferase in the early phase of myocardial infarction.

The behavior of the mitochondrial and cytoplasmic fractions of aspartate aminotransferase (AAT) (E.C. 2.6.1.1) has been quantitatively evaluated in the serum of patients with acute myocardial infarction. For this purpose a new electrophoretic procedure on Cellogel strips with spectrophotometric evaluation has been used. An increase of the mitochondrial fraction of AAT has been observed in the very early phase of myocardial infarction (i.e., 6 hr after the onset of symptoms). The serum increase of the mitochondrial AAT precedes those of other enzymes, including creatine phosphokinase.