Long-term mortality in patients unsuitable for surgical revascularization undergoing elective left main coronary artery angioplasty.

AIM: Elective percutaneous coronary intervention (PCI) of left main coronary artery disease remains an important challenge in interventional cardiology. Nonetheless, this procedure is useful for patients with significant left main stenosis who are candidates for revascularization but unsuitable for coronary artery bypass graft. In this study the Authors sought to evaluate the safety and long-term mortality of PCI of left main coronary artery disease. Secondary endpoints were to analyse long-term mortality in various categories (patients<75 years vs patients<75 years, males vs females, drug eluting stents [DES] vs bare metal stents [BMS]). METHODS: Between January 2003 and December 2006, 131 patients who consecutively under-went PCI on left main stem were reviewed. The mean follow-up time was 14.0+/-10.8 months. Survival curves were plotted with the Kaplan-Meier method and compared with the Log-rank test. RESULTS: The Kaplan-Meier curves did not show statistically significant differences in terms of all-cause mortality at follow-up between protected and unprotected left main coronary disease (12% vs 14% respectively, P=0.67). In the protected left main group, there was a significantly higher use of DES compared with unprotected left main group (59% vs 43%, P=0.02). CONCLUSION: The data show that PCI for left main coronary disease is feasible, safe and with an acceptable long-term mortality rate in patients at high-surgical risk unsuitable for surgical revascularization.

Prospective clinical evaluation and follow-up of a cohort of consecutive VT/VF patients, using a staged-care protocol, including coronary arteriography, programmed electrical stimulation and cardiac surgery.

The prospective evaluation and follow-up of 39 consecutive subjects with VT/VF, 6 of whom, with cardiac arrest (CA), are reported. Patients were enrolled in a specific staged-care approach protocol, which included coronary arteriography (CAR) and ventriculography (VC), in order to exclude the need of cardiac surgery, including coronary artery bypass graft (CABG), with and without left ventricular aneurysmectomy (LVA). The protocol included inducibility of VT/VF, which was verified by programmed electrical stimulation (PES) in control conditions and after antiarrhythmic therapy (ADT), to assess persistent inducibility and mainly to verify the hemodynamic sequelae of VT. VT that showed poor hemodynamic tolerance was treated with ICD, while well-tolerated VT was treated by ADT or ablation when indicated. Furthermore, PES was obtained after surgical procedures. As a first step, the patients were assigned to receive amiodarone (AMIO) (200-400 mg/daily) in the presence of EF% < 30% or contraindication to sotalol, (Group A), or sotalol (SOT) (80-140 mg/daily) in the presence of EF > or = 31%. (Group C). Conversely, in case of recurrences, patients were assigned to receive AMIO (200-300 mg/daily) plus metoprolol (MET) (20-100 mg/daily), (Group B) or, in case of intolerance to beta-blockers, to AMIO plus mexiletine (MEX) (200 mg/daily) (Group D). The four groups were similar for the type of VA, with recurrent ventricular tachycardia (RVT) being the most frequent one. The most frequent underlying cardiac disease of VA in this study was post-AMI CAD, with a rate of over 60% in all four groups. Single- and two-vessel lesions were found at CAR in various patients in all four groups, in 5/13 (38%) in Group A, in 8/14 (57%) in Group B, in 5/7 (71%) in Group C, and in 3/5 (60%) in Group D. Cardiac surgery was performed in a similar and limited number of patients in all four groups, in 4/13 (30%) in Group A, in 4/14 (35%) in Group B, in 2/7 (28%) in Group C, and in 2/5 (40%) in Group D. In 8/39 (20.5%) of the patients who underwent CABG, there was no operative or late mortality; 4/39 (10.2%) received CABG and LVA, and two died. For the amiodarone plus metoprolol and sotalol patients only, PES showed a lower residual inducibility, in comparison to the amiodarone and amiodarone + mexiletine groups. In the entire group, 7 out of 26 (27%) were still inducibile at PES while in 19/26 (64%) of the patients, an apparently effective treatment could be found, documenting the relative usefulness of PES. Recurrence rate was the highest in the amiodarone + mexiletine group and in patients with previous CA. Our data show the potential utility and limitations of ADT, even using the most effective antiarrhythmic drugs and association of drugs, mainly because of the high recurrence rate of VT observed in the present study, even in non-inducible patients [14/39 (36%)]. In conclusion, in a prospective and staged-care approach protocol of management of VT/VF patients, only a few patients with VT/VF benefited from cardiac surgery. PES could still play a role in the evaluation of the most effective ADT. Amiodarone + metoprolol seems to be the most effective ADT in these patients. Nevertheless, a high recurrence rate was observed in this patient population, even with an aggressive protocol, in the short follow-up period of 12 +/- 8 months, confirming recent data on the superiority of ICD to ADT, in patients with frequent recurrences or hemodynamically poorly-tolerated VT. In these patients, ICD therapy should definitively be preferred to ADT.

[Surgical treatment of saccular aneurysm of the left anterior descending coronary artery]. / Trattamento chirurgico di aneurisma sacciforme della coronaria discendente anteriore.

We report a case of a 74 old man presenting unstable angina and history of previous myocardial infarction. Coronary angiography showed significant stenoses of the left main and right coronary arteries and saccular aneurysm of the left anterior descending coronary artery. The patient underwent surgical treatment consisting in coronary artery bypass grafts and aneurysm resection. This procedure appears indicated, in author's opinion, when coronary aneurysm is saccular as in the described case.

Clinical significance of coronary artery disease in hypertrophic cardiomyopathy.

The role of coronary artery disease (CAD) in hypertrophic cardiomyopathy (HC) has not been thoroughly clarified. To assess the clinical and prognostic significance of these 2 coexistent diseases, 96 patients with HC (62 men, mean age 45 years) who underwent coronary arteriography and 2-dimensional echocardiography were studied. Significant stenosis (greater than 70%) of 1 or more coronary arteries was detected in 11 patients, all aged greater than 45 years. This group, compared with the other group without significant CAD (n = 85), was characterized by an older age (59 +/- 7 vs 42 +/- 15 years; p less than 0.05), a greater prevalence of previous myocardial infarction (24 vs 0%; p less than 0.001), complex ventricular arrhythmias (100 vs 50%; p less than 0.05), non-obstructive forms (82 vs 46%; p less than 0.05), dilated (45 vs 7%; p less than 0.02) and hypocontractile left ventricle (36 vs 6%; p less than 0.01) and higher mortality (36 vs 8%; p less than 0.05) during a mean follow-up of 3.6 years. It is concluded that CAD associated with HC is a complex clinical syndrome, difficult to diagnose clinically, that can reliably be recognized by coronary angiography. CAD seems to play an important role in modifying the pathophysiology, the natural history and the prognosis of HC.

[Efficacy of verapamil in the prevention of ventricular fibrillation in the acute phase of myocardial infarction]. / Efficacité du vérapamil dans la prévention de la fibrillation ventriculaire à la phase aiguë de l'infarctus du myocarde.

The effectiveness of verapamil in preventing ventricular fibrillation caused by coronary occlusion or reperfusion has been well demonstrated in animal studies, but these experimental data have not yet been confirmed in man. In this study we evaluated the prevalence of ventricular arrhythmias (fibrillation, sustained tachycardia and frequent extrasystoles) in patients hospitalized for myocardial infarction and treated with or without verapamil. The records of patients admitted to our Coronary Intensive Care unit during a 5-year period were analyzed retrospectively. Strict selection criteria enabled us to divide our patients into two homogeneous groups. The control group (group A) consisted of 106 patients who received only continuous infusions of heparin. The treated group (group B) comprised 89 patients who received exclusively verapamil by intravenous injections followed by continuous infusions. The prevalence of ventricular arrhythmia of all types was significantly lower in group B (22 p. 100) than in group A patients (71 p. 100; p less than 0.001). Episodes of ventricular fibrillation, in particular, were considerably less frequent in group B patients (1 p. 100) than in group A patients (13 p. 100; p less than 0.001). It would appear from these results that verapamil is highly effective in preventing death due to cardiac arrhythmia in the acute phase of myocardial infarction.

[Tricuspid endocarditis caused by Staphylococcus aureus in AIDS. Discussion of a case]. / Endocardite tricuspidale da Stafilococco aureus in AIDS. Discussione di un caso.

Right-sided staphylococcal endocarditis has been described in drug-addict, but not in association with an Acquired Immunodeficiency Syndrome. A case of a 26 years old drug-addict woman with AIDS related complex is reported. Antibiotic therapy, produced a favourable evolution on the illness. This case support the usefulness of two-dimensional echocardiography for detecting one of the possible complications associated with AIDS.

[Acute isolated infarct of the right ventricle with an unusual hemodynamic and electrocardiographic pattern]. / Infarto acuto isolato del ventricolo destro con inusuale quadro emodinamico ed elettrocardiografico.

The Authors reports on a case of isolated infarction of the right ventricle, with electrocardiographic pattern of non-transmural anterior myocardial infarction and haemodynamic profile suggestive of important diastolic disfunction. Clinical, angiographic and haemodynamic data are discussed along with review of the literature.

[Anomalous origin of the left coronary from the trunk of the pulmonary artery. Description of a clinical case]. / Origine anomala della coronaria sinistra dal tronco dell'arteria polmonare. Descrizione di un caso clinico.

The case of a 32 year old woman with anomalous origin of the left coronary artery from the pulmonary trunk is reported, in whom, for technical difficulties, the surgical correction has been limited to artery ligation. After surgery, there was a complete clinical improvement and normalization of the stress electrocardiogram. Nevertheless, radioisotopic studies--exercise Thallium 201 scintigraphy and radionuclide ventriculography--disclosed a poor left ventricular function. It is possible to suppose that the prolonged perfusion deficit resulted in an extensive area of myocardial fibrosis.

[Experimental characterization of propafenone. Hemodynamic effects]. / Caratterizzazione sperimentale del propafenone. Effetti emodinamici.

We studied the haemodynamic effects of Propafenon in a group of 20 subjects who had a coronary arteriography and a left ventriculography. The drug was been administered in doses of 1 mg/kg b.w. i.v. in 5 minutes. The haemodynamic parameters were measured in basal conditions and after 10 and 20 minutes. The basal data and those obtained after 20 minutes were analyzed and compared statistically. Our results show that Propafenon administered acutely i.v. in therapeutic doses causes a very small depression of cardiac inotropism. The same results were obtained in subjects whose basal haemodynamic parameters were abnormal. Our data show that the drug can be used safely also in subjects with mild heart failure.

[Selective coronary scintiscanning]. / La scintigrafia coronarica selettiva.

30 patients, undergoing coronary angiography for diagnostic and/or bypass surgery evaluation, have been studied also by intracoronary scintigraphy (IS). Scintigraphic and angiographic data have been compared: --21 cases had concordant results: normal in 2 patients (quite normal coronary system); pathological in 19, accounting for a damage both of the principal coronary artery branches and the arteriolar-capillary system: --6 cases had a pathological angiography with a normal IS: an indication of a normal myocardial perfusion; --in 3 cases a normal angiography was coupled with a pathological IS, pointing out a damage of the arteriolar-capillary system. On the basis of these results and of the literature, the AA. emphasize that the IS, allowing an exact evaluation of the myocardial perfusion, complete the essential morphological informations of the coronary angiography and it is specifically useful: --in the candidates to bypass coronary surgery; a viable myocardium is important both for surgery indication and results; --in bypassed patients to assess patency and the actual blood delivery (also for the low reliability of e.v. Thallium); --in patients with typical angina and positive stress test but with normal coronary angiography, to establish an organic lesion of the arteriolar-capillary system.

[Changes on release of MB isoenzyme of creatine kinase by propranolol in acute myocardial infarction (author's transl)]. / Modificazioni indotte da propranololo sulla liberazione dell'isoenzima MB della creatin-chinasi nell'infarto acuto del miocardio.

MB isoenzyme of creatine kinase was measured every 3 hours during the first 24 hours of admission to C.C.U. and successively every 4-6 hours in the next 24-48 hours in 42 patients with acute transmural myocardial infarction. The pain-C.C.U. admission time interval was less than 6 hours in all cases. 22 patients were treated by propranolol (2 mg bolus followed by 0.1 mg/Kg/die for the next 48 hours in continuous i.v. infusion), 20 patients served as a control. Cumulated activity, peak plasma value, rate of release and total duration of release of MB-CK did not differ significantly between the two groups. In patients treated within 3 hours from pain onset (n = 12) cumulated activity, peak plasma value and rate of release of MB-CK were significantly inferior than control group. In patients treated between the 3rd and 6th hour from pain onset (n = 10) the total duration of release of isoenzyme was significantly prolonged. No treated patients developed clinical or radiologic signs of cardiac insufficiency. The incidence of ventricular arrhythmias was 17% in the treated group vs. 62% in the control group (P < 0.05). The data show that propranolol, if started early in the course of acute myocardial infarction, reduces significantly infarct size and slows down the evolution of necrotic process.

[Acute myocardial infarction in a case of obstructive cardiomyopathy of the left ventricle (author's transl)]. / Infanto acuto del miocardio in un caso di cardiomiopatia ostruttiva del ventricolo sinistro.

A case of acute myocardial infarction in 64 year old man with idiopathic hypertrophic obstructive cardiomyopathy of left ventricle is described. The Authors emphasize the rarity of association and that the diagnosis of obstructive cardiomyopathy in the elderly is always almost misinterpreted. This depends on the poor specificity of clinical and phonocardiographic findings, both basal and under pharmacological tests. The Authors point out that in adult patients with left ventricular idiopathic obstructive cardiomyopathy who must be operated also selective coronary angiography should be performed.