Revascularization procedures in patients with transplant coronary artery disease.

OBJECTIVE: To assess the efficacy of revascularization in cardiac transplant patients who developed de novo coronary artery disease. METHODS: Eighteen patients underwent one or more of four methods of revascularization: percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revacularization (TMLR). Eleven PTCA procedures were performed in 10 patients 55.3 +/- 6.6 months after transplantation. Six patients underwent PTCRA 83.3 +/- 11.2 months after transplantation. Five patients underwent CABG 54.0 +/- 12.6 months after transplantation; the mean left ventricular ejection fraction was 49.6 +/- 16.9 (20-65%); hypertrophy was present in two of these patients. One patient with distal coronary artery disease and New York Heart Association class IV symptoms underwent TMLR only. One patient underwent both CABG and TMLR because of triple vessel proximal disease, diffuse distal disease, and New York Heart Association class IV symptoms. RESULTS: PTCA was successful in 10 procedures with decrease in mean stenosis from 87.7 +/- 2.7 to 24.3 +/- 6.0%. Follow-up, at 16.9 +/- 4.0 months, showed restenosis in two patients. PTCRA was successful in all patients with a decrease in mean stenosis from 83.4 +/- 4.4 to 11.7 +/- 1.9%. Short-term follow-up did not reveal reocclusion. Two CABG patients who had hypertrophy died of heart failure 2 and 9 days after their operations. One CABG patient with excellent cardiac function died after 15 days because of pulmonary failure. In one patient, left ventricular ejection fraction improved from 35 to 50%, and he is alive 64 months later. Six months after TMLR, the New York Heart Association class in one patient improved from IV to II, and his left ventricular ejection fraction improved from 29 to 42%. The ejection fraction in the patient who underwent both CABG and TMLR improved from 20 to 56% but the patient expired 7 weeks later. CONCLUSIONS: It appears that revascularization procedures can be effective in patients with coronary artery disease after cardiac transplantation and that coronary angioplasty or atherectomy would be a therapy of choice for single proximal lesions. CABG should be used cautiously and only reserved for patients with multi-vessel disease without hypertrophy. Laser revascularization with or without bypass grafting has potential to become the therapy of choice for transplant coronary artery disease.

High-risk coronary angioplasty assisted by active hemoperfusion. A feasibility study.

We assessed the effectiveness of distal hemoperfusion support during gradual, prolonged balloon inflation during percutaneous transluminal coronary angioplasty in high-risk patients. The patients were identified as having a poor left ventricular ejection fraction ( < 35%), > 50% of viable myocardium at risk percutaneous coronary balloon angioplasty, or both. A total of 64 procedures were performed in 61 patients. Angiographic success was achieved in 83 of 86 (96.5%) lesions treated with hemoperfusion support. Hospital complications included 1 patient who had a non-Q-wave infarction, 1 who had to undergo redo percutaneous coronary balloon angioplasty, and 5 who required coronary artery bypass operations. The hospital mortality was 7.8% (5 patients). This preliminary study indicates that hemoperfusion support can enable expeditious, simple, economical, and effective percutaneous transluminal coronary balloon angioplasty in a subset of labile patients in whom procedural failure frequently leads to sudden death.

Coronary angioplasty of anomalous left anterior descending artery with the left coronary artery originating from the right coronary sinus of Valsalva.

Percutaneous transluminal coronary angioplasty of anomalous coronary arteries presents several technical challenges to interventional cardiologists. Choosing the best guiding catheter and other equipment is crucial to the technical success of the procedure. We performed successful coronary angioplasty of an anomalous left anterior descending artery lesion in a 51-year-old man who had a left coronary artery originating from the right coronary sinus. We review his case, along with this rare anomaly and the technical considerations for successful percutaneous transluminal coronary angioplasty in such a patient.

High-dose thrombolytic therapy and angioplasty for thrombosis in a subacute femoropopliteal bypass graft.

The rate of success in reoperation for thrombosed infrainguinal grafts is unimpressive, particularly in patients with disease of distal vessels. In certain cases, combining high-dose urokinase and angioplasty appears to offer a safe and effective alternative. We describe the successful use of this combined treatment in a patient with a recently occluded femoropopliteal bypass graft.

Indications and choices in pacemaker therapy.

During their 33-year history of clinical use, cardiac pacemakers have evolved from devices primarily intended to save lives into complex systems designed to improve the cardiac patient's overall quality of life. To help physicians cope with this rapidly changing field, this review outlines current indications for pacemaker therapy and examines the wide range of options available. After describing the standard nomenclature for identifying the various systems, the author discusses pacemaker selection on the basis of cardiac rhythm alone, as well as rate-modulated therapy.

Echocardiographic swinging heart motion in loculated anterior pericardial effusion.

A patient in chronic renal failure presented with cardiomegaly. Echocardiography and cardiac scan demonstrated loculated anterior pericardial effusion. Another unusual echocardiographic feature was the presence of swinging heart motion, usually seen only with large nonlocalized pericardial effusion. When dialysis led to substantial regression of cardiac size, the echocardiographic abnormalities disappeared.

Electrocardiographic pseudo-infarction pattern: appearance with a large posterior pericardial effusion after cardiac surgery.

Two patients with a large posterior pericardial effusion after cardiac surgery presented with electrocardiographic precordial Q waves without evidence of myocardial infarction. Resolution of the pericardial fluid resulted in the disappearance of the Q waves. Changes in conductivity and orientation of the heart within the pericardial space, along with a decrease in QRS voltage, could lead to the loss of initial R waves in the precordial leads, eventually resulting in a QS complex. Care should be taken in interpreting the electrocardiogram after cardiac surgery in patients with a large posterior pericardial effusion. The clinical course along with serial electrocardiographic and echocardiographic tracings should be helpful in identifying this false infarction pattern.

Permanent pacemaker implantation in infants, children, and adolescents. Long-term follow-up.

Twenty-four patients in the pediatric age range who underwent implantation of a cardiac pacemaker for treatment of complete atrioventricular (A-V) block were followed for an average of five years (range 1-12 years). The etiology of the A-V block was surgical in 13 cases, congenital in nine, and acquired in two. Twenty patients had symptoms of cerebrovascular insufficiency and four had congestive heart failure. To date, 18 of the 24 patients studied are alive and well. Death occurred in six patients, five of whom had complex congenital heart defects, and one of whom had Refsum's disease. Death probably was caused by complete heart block despite pacemaker treatment in four patients, and congestive heart failure in two. In 18 of the 24 children with disabling complete A-V block, pacemaker therapy provided relief of symptoms and prolonged life.