Spontaneous coronary artery embolus associated with calcific aortic stenosis.

Calcific embolization from aortic stenosis may be more frequent than commonly appreciated. Most calcific emboli are clinically silent, although transient ischemic attacks, cerebral infarcts, blindness (from central retinal artery occlusions), and myocardial infarctions have been reported. We describe a patient with calcific bicuspid aortic stenosis who presented with transient ischemic attacks and angina secondary to a calcific embolus to the second circumflex marginal coronary artery. The calcific embolus was retrieved during aortic valve replacement surgery. A review of the literature suggests that calcific embolization from calcific aortic stenosis may occur more commonly in patients with bicuspid valves.

Safety and clinical use of exercise testing one to three days after percutaneous transluminal coronary angioplasty.

To evaluate both the safety and clinical use of predischarge symptom-limited exercise testing after successful uncomplicated percutaneous transluminal coronary angioplasty (PTCA), 100 patients were randomized to undergo exercise testing (n = 50) or no exercise testing (n = 50). There were no differences in clinical or angiographic characteristics between the groups. Exercise testing was performed 38 +/- 14 hours after PTCA. Patients who exercised achieved 71 +/- 12% of predicted maximal heart rate, with 38% reaching greater than or equal to stage III of the Bruce protocol. No patient in either group developed cardiac complications during 48-hour follow-up. Of the 11 patients with a positive test result, 92% had angiographically incomplete revascularization. Attending physicians (n = 16) were questioned both before and after exercise testing about when, after discharge, they would allow their patient to perform each of 11 specific activities of daily living. Questionnaires were administered to physicians at similar time frames for patients in the no-exercise group. Comparison of the responses between initial and repeat questionnaires showed that patients in the exercise group (with a test result negative for ischemia) were allowed to perform 7 of 11 activities, including return to work, earlier (p less than 0.05) than the no-exercise patients. These data indicate that in this well-defined group of patients, symptom-limited exercise testing early after PTCA appears to be safe, and alters physician management in allowing patients with a negative test result to return to various activities at an earlier date. Such testing may be useful in counseling patients after PTCA.

Outcome after major dissection during coronary angioplasty using the perfusion balloon catheter.

Coronary artery dissection is an infrequent but serious complication of coronary angioplasty that can lead to periprocedural vessel occlusion, emergency bypass surgery, myocardial infarction or death. Recently, a perfusion balloon catheter was developed that permits passive perfusion of blood through the central lumen of the catheter. It enables prolonged balloon inflations to be performed and has been used to provide distal blood flow after coronary occlusion. To evaluate the effectiveness of the perfusion balloon catheter in patients with major coronary dissections, 36 consecutive patients treated with the perfusion balloon catheter were compared with 46 consecutive patients treated before its availability. The 2 groups were similar in terms of clinical, angiographic and initial procedural characteristics. Use of the perfusion balloon catheter permitted a significantly longer inflation than standard balloon inflation (average 18 +/- 5 min). Angiographic success was significantly greater with the perfusion balloon catheter (84 vs 62% for conventional therapy), whereas complications were markedly reduced (48 vs 78%). With the perfusion balloon catheter there were fewer deaths (2 vs 6%), myocardial infarctions (14 vs 40%) and emergency bypass operations (11 vs 25%). The findings of this retrospective comparison demonstrate that the perfusion balloon catheter is effective for the management of major dissections after coronary angioplasty. The use of the perfusion balloon catheter should be considered when a major coronary dissection occurs and when emergency bypass surgery is contemplated.