Correlation between transient ischemic dilatation (TID) and coronary artery disease in Saudi male patients.

OBJECTIVE: A high transient ischemic dilatation ratio (TID) for the left ventricle (LV) from a gated myocardial perfusion imaging (G-MPI) study is widely believed to be associated with significant coronary artery disease (CAD). We have investigated the relationship between TID and CAD for our male Saudi Arabian patient population. METHODS: In this retrospective study, all male Saudi Arabian patients who underwent a two-day G-MPI study using Tc99m MIBI during the year 2011 having a TID â©¾ 1.20 were included. Quantitative perfusion and gated parameters were obtained using Cedar Sinai's AutoQuant software version 3.0, 2003, Means of summed stress scores, summed rest scores and summed difference scores (SSS, SRS, SDS, respectively), stress and rest ejection fraction (EF) were calculated. Visual interpretation was performed to classify the perfusion as normal, fixed, mixed (fixed and reversible defects), single reversible or multiple reversible defects. Coronary angiograms were assessed as normal with no CAD, single vessel, two-vessel or three-vessel disease. Correlations between the TID and other parameters were studied using analysis of variance (ANOVA) with IBM-SPSS version 20. RESULTS: A total of 52 male patients had a high TID of ⩾1.20 (mean 1.30 ± 0.13). Ten patients had a SSS of 0-3 and 16 were classified as normal by visual assessment. Stress EF (mean 50.4 ± 12%) was lower than the rest EF (mean 56.6 ± 12.8%) with the difference being statistically significant (Students paired t-test, p = 0.001). Angiography results were available in 44 patients, 3 having a normal angiogram, 24 having three vessel disease, 7 having two vessel disease and 10 having one vessel disease. Five patients with normal perfusion and SSS = 0-3 had CAD as seen on a coronary angiography. CAD on coronary angiography showed a significant correlation with perfusion abnormalities as assessed by visual interpretation (p = 0.002). TID showed a significantly correlation with both perfusion abnormalities (p = 0.009), as assessed by visual interpretation, and with Summed difference scores, SDS (p = 0.000). CONCLUSION: A high TID on G-MPI was a very sensitive indicator of significant CAD. In patients with normal perfusion and high TID further workup is warranted.

Mixed aneurysmal and obstructive coronary artery disease causing acute myocardial infarction in a young woman with Takayasu's arteritis.

Takayasu's disease is a chronic inflammatory pathology of the aorta and its main branches. The present report describes a rare presentation of the disease in a young woman who presented with anterior myocardial infarction, and was subsequently found to have mixed aneurysmal and obstructive coronary artery disease involving the left anterior descending artery and its diagonal branches. Issues surrounding the management of coronary artery disease in this patient are discussed.

Long-term clinical results after stent implantation in old obstructed saphenous vein grafts.

STUDY OBJECTIVE: To assess the long-term clinical outcome of treating patients with coronary artery disease and obstructed saphenous vein grafts (SVGs) with stents deployed by oversized balloon catheters. DESIGN: The study included 89 of 92 consecutive patients who had 121 SVG stent implants (average, 1.4 stents per patient). We aimed at achieving a negative stenosis using oversized balloons to achieve a catheter to artery ratio of 1.1:1, and a 100% follow-up at 24+/-14 months (range, 0 to 54 months) was achieved. PATIENTS: As 3 of 92 patients died during hospital admission, the study follow-up population consisted of 89 of 92 patients (mean age, 67+/-10 years). The age of the SVGs was 10+/-4 years. RESULTS: We implanted 118 Palmaz-Schatz and 3 Gianturco-Roubin stents. Procedural success was achieved in 87 of 92 patients (94.5%; < 50% stenosis, and no death, Q-wave acute myocardial infarction, or coronary artery bypass graft [CABG]). Mean SVG stenosis diameter was reduced from 80+/-13% to -11+/-12% (p<0.001) and mean luminal diameter increased from 0.6+/-0.5 mm to 3.3+/-0.8 mm (p<0.001). At follow-up, angina pectoris had developed in 42 of 89 patients (47%), acute myocardial infarction in 12 of 89 patients (14%), reperformed CABG in 12 of 89 patients (14%), cardiac death in 10 of 89 patients (11%), and unrelated death in 6 of 89 patients (7%). Coronary angiography was performed in 37 of 89 patients (42%), with restenosis in 16 of 37 patients (43%) and disease progression at other sites in 11 of 37 patients (30%). Only 25 of 89 patients (28%) experienced event-free survival at follow-up. CONCLUSIONS: Despite high procedural success and excellent angiographic results with oversized balloon catheters, the long-term clinical outcome of SVG stent implantation is suboptimal.

Immediate and long-term results comparing coronary versus biliary tubular-slotted stents to treat old obstructed saphenous vein grafts.

Stenting of old obstructed saphenous vein grafts improves immediate angiographic results and long-term clinical outcome compared to standard balloon angioplasty. Comparison of results and long-term clinical outcome between different types of stents in the treatment of vein graft disease is scarce. The authors studied two matched groups of 33 patients each, receiving either coronary or biliary tubular-slotted stents in old vein graft lesions to compare immediate results and long-term clinical outcome. Patients in the two groups were matched for age and left ventricular function. Baseline angiographic characteristics, the minimal luminal diameter (MLD) (0.68 +/- 0.56 mm vs 0.61 +/- 0.51 mm, p = 0.9), and diameter stenosis (DS) (81 +/- 14% vs 82 +/- 15%) were similar between the groups. After stenting, the MLD (3.15 +/- 0.65 mm vs 3.37 +/- 0.63 mm, p = 0.9) and residual stenosis (-7 +/- 19% vs -11 +/- 21%) were also similar. The in-hospital major complications (myocardial infarction and death) (one vs eight, p = 0.01) and the combination of major and minor (bleeding and vascular) complications (eight vs 17, p = 0.02) were higher in the biliary stent group. At long-term follow-up, both groups of patients had high but comparable rates of major cardiovascular events (39% vs 45%, p = 0.62). Kaplan-Meier event-free survival analysis did not show any statistically significant difference in event-free survival (log-rank statistic 0.98). The authors conclude that patients receiving biliary stents had higher rates of immediate minor and major complications, but at long-term follow up, major cardiovascular event rates were comparable between the two groups of patients.

Results of saphenous vein graft stent implantation: single center results from use of oversized balloon catheters.

The results and complications of a single-center experience of stent implantation in old saphenous vein grafts (SVGs) need to be defined. The authors studied their initial consecutive 92 patients (125 stents, 1.4 stents/per patient) with a mean age of 67+/-9 years. The patients' mean saphenous vein graft (SVG) age was 10+/-4 years, and the mean left ventricular ejection fraction was 46%+/-15. Patient population included unstable angina (65%), stable angina (10%), myocardial infarction (21%), and silent ischemia (4%). The authors implanted 122 Palmaz-Schatz/biliary and three Gianturco-Roubin stents. They aimed at a balloon-artery ratio of 1.1/1.0. Procedural success, defined as stent deployment with <50% stenosis without death/Q-wave myocardial infarction/coronary artery bypass grafting (MI/CABG) was 95%. The mean luminal diameter (MLD) increased from 0.6+/-0.5 to 3.3+/-0.8 mm (p<0.001) and mean SVG stenosis diameter was decreased from 80%+/-14 to -10%+/-11 (p<0.001). Angiographic SVG lesions exhibited thrombus (17%), ulceration (38%), and plaque rupture (28%). Sixty-two patients were treated with warfarin and aspirin and 30 with ticlid and aspirin. Complications included death in three patients (3.3%) who sustained subacute stent thrombosis, and two of three had Q-wave MI. Distal embolization occurred in seven patients (8%); six of seven sustained a non Q-wave acute myocardial infarction (AMI); and one of seven a Q-wave MI. Eight (9%) patients had major groin hematoma, two had pseudoaneurysm (2.2%), one had arteriovenous (A-V) fistula (1.1%), two had vascular surgery (2.2%), nine had blood transfusion (9.8%), and three had stent migration (3.3%). Single-center experience with stents in SVGs indicates a highly successful procedural and angiographic immediate result. However, it was complicated by significant risk of non Q-wave MI due to distal coronary embolization which may affect prognosis.

Pulmonary artery pressure and pulmonary vascular resistance before and after mitral balloon valvotomy in 100 patients with severe mitral valve stenosis.

We studied the pulmonary vascular hemodynamics before and after mitral balloon valvotomy in 100 patients with severe mitral valve stenosis. Before balloon valvotomy 23 patients had a pulmonary artery systolic pressure of < 31 mm Hg (group 1), 54 patients had a pulmonary artery systolic pressure between 31 and 50 mm Hg (group 2), and 23 patients had a pulmonary artery systolic pressure of > 50 mm Hg (group 3). After balloon valvotomy the mean systolic pulmonary artery pressure in group 1 decreased from 28 +/- 3 to 26 +/- 5 mm Hg (p = NS). In group 2 the systolic pulmonary artery pressure after balloon valvotomy decreased from 41 +/- 5 to 33 +/- 7 mm Hg (p < 0.0001) and normalized to < 31mm Hg in 27 patients (50%). The mean left atrial pressure was abnormal (> or = 13 mm Hg) in 6 of 27 patients (22%) who had a systolic pulmonary artery systolic pressure of < 31 mm Hg and in 6 of 27 patients (22%) with a pulmonary artery systolic pressure of > or = 31 mm Hg. The pulmonary vascular resistance was abnormal in 36 of 54 patients (67%) after mitral balloon valvotomy; only 5 of 36 patients (14%) had a raised left atrial pressure (> or = 13 mm Hg). In group 3 the pulmonary vascular resistance was abnormal (> 125 dynes/sec/cm-5) in all 23 patients before and in 19 of 31 patients (91%) after balloon valvotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between single (Inoue) and double balloon mitral valvuloplasty: immediate and short-term results.

This study compared the results in 60 consecutive patients with severe rheumatic mitral stenosis, who underwent percutaneous double-balloon mitral valvuloplasty by means of a combination of 20 mm + 20 mm diameter balloon catheters (group A), with a similar group of 60 consecutive patients who underwent single (Inoue) balloon mitral valvuloplasty (group B). After balloon mitral valvuloplasty the hemodynamic measurements showed significant improvement in both groups: in groups A and B, respectively, mitral valve area calculated with the Gorlin formula increased from 0.9 +/- 0.2 to 2.1 +/- 0.5 cm2 (p less than 0.001) and from 0.8 +/- 0.2 to 1.9 +/- 0.4 cm2 (p less than 0.001). There was a significant improvement in cardiac functional status in both groups. There was no significant difference between the groups with regard to clinical or hemodynamic improvement, technical failure rate, inadequacy of dilatation, or complications. However, the double-balloon technique was more complex and involved a longer screening time--group A, 40 +/- 12 minutes; group B, 21 +/- 10 minutes (p less than 0.001). In our institution the disposable supplies used for the Inoue balloon technique were 40% more expensive than those used for the double-balloon technique.

Percutaneous double balloon tricuspid valvotomy for severe tricuspid stenosis: 3-year follow-up study.

We performed percutaneous double balloon tricuspid valvotomy in four patients (36 +/- 12 years of age), with severe symptomatic rheumatic tricuspid stenosis and mild mitral valve disease. Two 9F Meditech balloon catheters, 15-20 mm diameter, were positioned simultaneously across the tricuspid valve and inflated up to five atmospheres pressure achieving valvotomy. After balloon valvotomy there was symptomatic improvement, and the Doppler tricuspid valve area was increased from a mean of 1 +/- 0.2 to 2.2 +/- 0.2 cm2 (P less than 0.001). At 3-year follow-up the symptomatic improvement persisted and the mean tricuspid valve area was maintained at 2.2 +/- 0.1 cm2. During the follow-up period there was no increase in degree of tricuspid regurgitation assessed by colour Doppler. We conclude that 3 years after balloon valvotomy of the tricuspid valve, the 120% increase in valve area persists, with no objective evidence of restenosis.

Beta-adrenergic receptor blockade in the management of pregnant women with mitral stenosis.

Twenty-five pregnant women with symptomatic mitral valve stenosis (mean valve area, 1.1 +/- 0.25 cm2) were managed by initiation or modification of beta-adrenergic receptor blockade with the use of either propranolol or atenolol. Significant improvement of symptoms occurred in 23 patients (92%) (p less than 0.01); the mean maternal heart rate was reduced significantly from 86 +/- 4 to 78 +/- 5 beats/min (p less than 0.0001). The overall fetal heart rate ranged between 130 to 150 beats/min during treatment. Only two patients required urgent closed mitral valvotomy, after pulmonary edema developed as a result of poor compliance to beta-blockade. All patients were safely delivered of infants at term. Fetal heart rates ranged between 120 to 140 beats/min at delivery. There was no maternal or fetal death. Pregnant woman with symptomatic mitral valve stenosis can be safely managed with beta-blockade, giving significant reduction in the incidence of pulmonary edema with no unwanted neonatal side effect.

Left atrial systolic antegrade flow in patients with mitral regurgitation: a pulsed Doppler sign displayed by color flow imaging.

Twenty-two patients with severe mitral regurgitation were observed to have turbulent systolic antegrade flow on pulsed Doppler mapping of the left atrium. All were studied by color flow imaging to delineate the mechanism of this peculiar flow. Pulsed Doppler findings of an eccentric regurgitant flow in one side, an antegrade systolic flow with slightly delayed onset in the other side, and a low velocity flow near the posterior wall, were consistant with the theory of a large eccentric regurgitant jet swirling in the left atrium. Color flow imaging confirmed this mechanism in all patients. Nineteen patients had flail mitral valve with a positive predictive value of 86%. The other three patients had deformed rheumatic mitral valve. The severity of mitral regurgitation was confirmed in all 16 patients studied by left ventricular cineangiography. We have shown that the antegrade systolic left atrial flow is the result of the swirling of a large regurgitant eccentric jet, is commonly observed with flail mitral valve, can occur in patients with deformed rheumatic mitral valve without flail leaflet, and most significantly indicates the presence of severe mitral regurgitation.

The value and extent of valve area increase by balloon dilatation of the stenosed bioprosthesis: in vitro studies.

The value and extent in which balloon dilatation increases the valve area in severe bioprosthesis stenosis has not been defined. In-vitro double balloon dilatation, using 15 to 20 mm diameter Meditech balloon catheters, simultaneously inflated to 5 atmospheres, was attempted in 10 intact, stenosed, surgically excised bioprosthetic valves, 7 mitral and 3 aortic, size 21 to 35 mm. Radiological studies and calculation of the valve area, using a conical sizer, were performed both before and after balloon dilatation. After balloon dilatation the valve area was increased from 1.1 +/- 0.4 to 2.0 +/- 0.5 cm2 (p less than 0.001). The valve area increase was due to improved leaflet mobility in all cases. Leaflet calcium fractures were noted in 9 valves, 5 exhibited leaflet tears and the valve annulus was distorted in 3. A control group of balloon dilatation in 10 unused bioprostheses of the same sizes showed no leaflet tears. The mechanism of valve area increase, (80%), of stenotic bioprostheses by balloon dilatation, is improvement in leaflet mobility, partially secondary to leaflet calcium fractures and tears. Despite the marked increase in the bioprosthesis valve area the induction of leaflet tears will limit the clinical use of this technique for the dilatation of stenosed bioprosthetic valve.

Double balloon aortic valvotomy for rheumatic aortic stenosis; in vivo studies.

The manner in which aortic valve area increases after in vitro double balloon aortic valvotomy for severe rheumatic aortic stenosis has not been defined. We selected ten intact aortic valves excised at cardiac surgery from patients (mean age 45 +/- 10 years) with severe rheumatic aortic stenosis, with a valve area less than or equal to 1 cm2. In vitro double balloon aortic valvotomy was attempted on each valve using two Meditech 15 mm diameter balloon catheters. The balloon catheters were simultaneously inflated to 4 atm pressure for 10 s. Before and after balloon valvotomy the valve area was calculated with a conical sizer, and radiological studies were also performed to study the effect of balloon valvotomy on calcified aortic commissures. The mean valve area increased from 0.7 +/- 0.2 (mean +/- SD) to 1.1 +/- 0.2 cm2 (P less than or equal to 0.001) after balloon valvotomy, with a mean total commissural splitting for each aortic valve of 9.3 +/- 6 mm. Overall, 63% of the aortic commissures were split, splitting occurring in 81% of non-calcified commissures and 43% of calcified commissures. There was no leaflet tear or calcium fracture either macroscopically or radiologically. Commissural splitting of rheumatic aortic stenosis is the manner in which valve area is increased after double balloon aortic valvotomy. The inflated balloon catheters split not only non-calcified, but also calcified arotic commissures. The adequate commissural splitting achieved and consequent 57% increase in valve area indicate that the double balloon aortic valvotomy technique may become a palliative therapeutic procedure for patients with severe rheumatic aortic stenosis.

A prospective study comparing the haemodynamic with the cross-sectional echocardiographic diagnosis of rheumatic tricuspid stenosis.

The value of cross-sectional echocardiography in the diagnosis of tricuspid valve stenosis is not clearly established. We prospectively studied by cardiac catheterization 42 consecutive patients, with a mean age of 29 +/- 11 years, who exhibited the cross-sectional echocardiographic features of tricuspid valve stenosis, defined as: diastolic doming of all three tricuspid leaflets and leaflet thickening with restrictive motion. To expose occult and amplify borderline tricuspid diastolic gradients, simultaneous right atrial and right ventricular pressures were recorded in the basal state, after incremental infusions of normal saline to 200, 400, 500, 700 or 1000 ml until a mean right atrial pressure of 12 mmHg was achieved, and finally after intravenous administration of 0.6 mg of atropine. Eighteen patients, Group 1, (43%) exhibited mean tricuspid diastolic gradients greater than 2 mmHg after saline infusion, increasing from a mean of 4 +/- 2 to 9 +/- 3 mmHg, (P less than 0.001), 14 (33%) having gradients greater than 2 mmHg in the basal state, together with four (10%) increasing from 1.7 +/- 0.2 to 4.5 +/- 1.2 mmHg (P less than 0.01) after provocation with fluid challenge. In the remaining 24 patients, Group 2, (57%) the mean tricuspid diastolic gradient was less than 2 mmHg, both at rest and after provocative manoeuvres. We conclude that the cross-sectional echocardiographic features of tricuspid valve stenosis are not a precise indicator of tricuspid valve stenosis. Provocative manoeuvres during haemodynamic studies are required to expose occult or amplify borderline tricuspid diastolic gradients in a minority of patients with the cross-sectional echocardiographic features of tricuspid stenosis.