Increased coronary perforation in the new device era. Incidence, classification, management, and outcome.

BACKGROUND: The incidence of coronary perforation using new percutaneous revascularization techniques may be increased compared with PTCA. Still, perforation is uncommonly reported, and the optimal management and expected outcome remain unknown. The objectives of the study were to determine the incidence of coronary perforation using balloon angioplasty (percutaneous transluminal coronary angioplasty, PTCA) and new revascularization techniques and to develop optimal strategies for its management based on classification and outcome. METHODS AND RESULTS: Eleven sites with frequent use of new revascularization devices and prospective coding of consecutive procedures for coronary perforation during 1990 to 1991 contributed to a perforation registry. Patients with perforation were matched by device with an equal-sized cohort without perforation. Data were collected centrally, and all procedural cineangiograms were reviewed at a core angiographic laboratory. A classification scheme based on angiographic appearance of the perforation (I, extraluminal crater without extravasation; II, pericardial or myocardial blushing; III, perforation > or = 1-mm diameter with contrast streaming; and cavity spilling) was evaluated as a predictor of outcome and as a basis for management. Perforation was observed in 62 of 12,900 procedures reported (0.5%; 95% confidence interval, 0.4% to 0.6%), more commonly with devices intended to remove or ablate tissue (atherectomy, laser) than with PTCA (1.3%, 0.9% to 1.6% versus 0.1%, 0.1% to 0.1%; P < .001). The perforation population was notable for its advanced age (67 +/- 10 years) and high incidence of female sex (46%) (both P < .001 compared with patients without perforation). Perforation could be treated expectantly or with PTCA but without cardiac surgery in 85%, 90%, and 44% of class I, II, and III perforations, respectively. Class I perforations (n = 13, 21%) were associated with death in none, myocardial infarction in none, and tamponade in 8%. The incidences of these adverse events were 0%, 14%, and 13% in class II perforations (n = 31, 50%) and 19%, 50%, and 63% in non-cavity spilling class III perforations, respectively (n = 16, 26%). Two of the 15 instances of cardiac tamponade (13%) were delayed, occurring within 24 hours after dismissal from the catheterization laboratory. CONCLUSION: The incidence of perforation, while low, is increased with new devices. Women and the elderly are at highest risk. The clinical risk after perforation can be classified angiographically, but even low-risk perforations occasionally have poor clinical outcome. Patients should be observed for delayed cardiac tamponade for at least 24 hours.

Coronary artery disease in women: a risk-factor analysis.

BACKGROUND: Risk factor modification is important in preventing coronary artery disease; however, risk factors for coronary artery disease have been studied mostly in men, not women. OBJECTIVE: To examine risk factors for coronary artery disease in women. METHODS: We retrospectively reviewed the records of all adult women who underwent their first-ever cardiac catheterization at our institution in 1983. Risk factors in women with angiographic evidence of coronary atherosclerosis were compared with risk factors in women without angiographic evidence of coronary artery disease. RESULTS: Risk factors identified included age, diabetes mellitus, hypertension for more than 5 years, hyperlipidemia, smoking, and familial coronary artery disease. CONCLUSIONS: Risk factors for coronary artery disease in women are similar to those of men.

Coronary artery disease in young women: risk factor analysis and long-term follow-up.

BACKGROUND: Heart disease in the leading cause of death in women of all ages in the United States, but data on coronary disease in young women remains sparse. OBJECTIVE: To identify and follow up a cohort of young women referred for the evaluation of coronary disease. METHODS: Retrospective review of the medical records. RESULTS: Thirty-two women younger than 31 years met the entry criteria. The average age was 28 +/- 2.4 years, 28% had insulin-dependent diabetes mellitus, 38% had hypertension, 6% had congenital heart disease, 38% had a family history of coronary artery disease, 72% were smokers, and 28% used oral contraceptives. Serum cholesterol levels were > 5.17 mmol/L (200 mg/dL) in 71%, and the mean cholesterol level was 6.70 +/- 2 mmol/L (259 +/- 78 mg/dL). Resting electrocardiographic results were abnormal in 28 women (88%), 22 of whom had evidence of transmural myocardial infarction. Follow-up averaged 9.8 +/- 6.4 years. Five patients died, all of whom had hypertension, and 4 of whom had diabetic nephropathy and required dialysis. CONCLUSIONS: Risk factors for coronary disease in young women include hypertension, hypercholesterolemia, diabetes mellitus, familial coronary disease, and smoking. Long-term prognosis is excellent for those without advanced diabetes mellitus and renal failure.

Assessment of reperfusion after thrombolytic therapy for myocardial infarction.

The benefits of thrombolytic therapy in reducing the mortality associated with acute myocardial infarction are well documented. Presumably, this is on the basis of a patent IRA, although other mechanisms may be involved. Because there is a 25% to 30% failure rate for thrombolytic therapy that is associated with a significantly worse prognosis, it is crucial to document reperfusion in a timely fashion. In cases of failure to reperfuse, the patient could be considered a candidate for secondary mechanical intervention. While coronary arteriography is presently the "gold standard" to document reperfusion, this is an invasive procedure associated with small but defined risks for the patient. A noninvasive marker that is readily available and highly accurate is most desirable. There are a number of methods currently used to document coronary reperfusion noninvasively. This review discusses the advantages and disadvantages of each method, and the need for continued evaluation and refinement in noninvasive modalities to identify patients who are candidates for further intervention.

Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter.

The need for prophylactic anticoagulation to prevent embolism before direct current cardioversion is performed for atrial fibrillation or atrial flutter is controversial. To examine this issue further, a retrospective review was undertaken to assess the incidence of embolic complications after cardioversion. The review involved 454 elective direct current cardioversions performed for atrial fibrillation or atrial flutter over a 7 year period. The incidence rate of embolic complications was 1.32% (six patients); the complications ranged from minor visual disturbances to a fatal cerebrovascular event. All six patients had atrial fibrillation, and none had been on anticoagulant therapy (p = 0.026). The duration of atrial fibrillation was less than 1 week in five of the six patients who had embolic complications. Baseline characteristics of patients with a postcardioversion embolic event are compared with those of patients who did not have an embolic event. There was no difference in the prevalence of hypertension, diabetes mellitus or prior stroke between the two groups, and there was no difference in the number of patients who were postoperative or had poor left ventricular function. Left atrial size was similar between the two groups. No patient in the embolic group had valvular disease. No patient with atrial flutter had an embolic event regardless of anticoagulant status; therefore, anticoagulation is not recommended for patients with atrial flutter undergoing cardioversion. Prophylactic anticoagulation is pivotal in patients undergoing elective direct current cardioversion for atrial fibrillation, even those with atrial fibrillation of less than 1 week's duration.

Early and late results of coronary angioplasty and bypass in octogenarians.

Early and late results were evaluated for octogenarians undergoing first time revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The study group consisted of 142 patients with CABG and 53 with PTCA. The groups with PTCA and CABG differed with respect to number of patients with angina class III to IV (92 and 67%, respectively; p less than 0.001), number with 3-vessel disease (34 and 77%, respectively; p less than 0.001), presence of left main trunk disease (2 and 24%, respectively; p less than 0.001) and number with normal or mildly impaired left ventricular function (82 and 65%, respectively; p less than 0.034). The groups with PTCA and CABG had similar procedural complications, including myocardial infarction (6 and 4%, respectively) and stroke (0 and 4%, respectively). Hospital mortality was low (6% with CABG and 2% with PTCA). Three year survival, excluding hospital mortality, was 87% in patients with CABG and 81% in those with PTCA (p = 0.493). Octogenarians underwent revascularization procedures with relatively low morbidity and mortality. In regard to the excellent long-term survival, "very" elderly patients with severe coronary artery disease should be considered for revascularization despite advanced age.

Right heart failure after chemotherapy.

Cardiotoxicity associated with chemotherapeutic agents used in the treatment of cancer is well-documented. Usually this cardiotoxicity presents as a distinct syndrome in which the left ventricle is more seriously affected than the right ventricle. A case of severe right-sided ventricular dysfunction shortly after an aggressive cycle of chemotherapy for metastatic colon carcinoma is presented.

Retrospective analysis of patients undergoing one- or two-stage strategies for myocardial revascularization and implantable cardioverter defibrillator implantation.

Internal defibrillation leads were placed at time of coronary revascularization in 79 patients. In 34, an implantable cardioverter defibrillator (ICD) was placed simultaneously (group I). A two-stage strategy (selective implantation of the ICD in patients with postoperative spontaneous or inducible ventricular tachycardia [VT]) was followed in 45 patients (group II). Group I patients had failed more antiarrhythmic drug trials (2.9 +/- 1.6 vs 1.5 +/- 1.6; P = 0.02), including amiodarone (62% vs 20%; P less than 0.001). There were four operative deaths in each group. Postoperatively, VT was present in 27 group II patients (60%), 25 of whom received an ICD (two refused device implantation). Patients with postoperative VT had a lower left ventricular ejection fraction than those without VT (33 +/- 9 vs 47 +/- 16; P = 0.01). Actuarial survival at 1, 2, and 3 years was 88 +/- 6, 88 +/- 7, and 88 +/- 10 in group I; and 83 +/- 6, 76 +/- 7, and 76 +/- 11 in group II (NS). No patient without an ICD (based on the postoperative electrophysiological study [EPS]) died suddenly. Five patients (6%) had ICD system infection. Sudden death was largely prevented by either strategy, but relatively high rates of operative mortality and ICD system infection were observed. Prospective studies should identify patients more likely to benefit from one or another strategy.

Safety of external cardioversion/defibrillation in patients with internal defibrillation patches and no device.

Placement of prophylactic epicardial defibrillation patches at time of open-heart surgery in patients at risk for postoperative arrhythmias has been strongly questioned. Concern has centered on the ability to safely perform subsequent external defibrillation if needed. From 61 patients who were treated with a two-stage strategy we identified 17 who, while wearing epicardial patches and no generator, received external cardioversion/defibrillation for 20 episodes of hemodynamically unstable ventricular arrhythmias. All the patients had one small and one large patch. Eighteen of the episodes were induced during electrophysiological testing (with transthoracic shocks delivered via pad electrodes oriented in an apex-posterior configuration) and two were spontaneous. The episodes occurred at 21 +/- 27 days from patch implant. Thirteen episodes (65%) were converted with one shock at an energy level of 185 +/- 65 J. Seven (35%) required a second shock at 351 +/- 22 J. The accumulated energy requirement was 286 +/- 205 J. No adverse outcomes were noted. The number of episodes requiring more than one shock and the energy requirements were not different from those in a control group of 20 similar arrhythmias treated with the same equipment. Under these conditions, external cardioversion/defibrillation in patients with one large and one small epicardial defibrillation patch was uniformly successful. Further data is needed in the out-of-hospital setting and on the results of external defibrillation in patients with two large patches.

Corynebacterium endocarditis. Difficult diagnosis in an elderly woman.

Physicians have been reminded repeatedly of the many faces of bacterial endocarditis. In this case, Corynebacterium endocarditis presented as an occult malignancy and eluded diagnosis for six months. The coryneform isolates found in cultures are often considered to be contaminants because of their ubiquitous nature, sometimes causing a delay in diagnosis. Patients with culture-negative endocarditis or Corynebacterium "contamination" should be treated as having Corynebacterium endocarditis pending results of microbiologic isolation tests.