Paraprosthetic leak unmasked by thrombolysis for thrombosed mitral valve.

Prosthetic valve thrombosis (PVT) is classically a cardiothoracic surgical emergency. Case series, however, report thrombolysis as first line management for PVT. A case of mitral PVT treated successfully with thrombolysis is described. Immediately after thrombolysis a trivial paraprosthetic leak noted on pretreatment transoesophageal echocardiography had increased significantly in severity. The paraprosthetic leak subsequently required repeat mitral valve replacement. It is speculated that the thrombolytic treatment interfered with the usual healing process by disrupting the fibrin deposited at the valve ring margin. This suggests that fibrin is important in the formation of the annular seal of the prosthetic valve and that patients receiving thrombolysis should be monitored for this complication.

Platelet IIb/IIIa antagonists followed by delayed stent implantation. A new treatment for vein graft lesions containing massive thrombus.

The percutaneous treatment of saphenous vein graft lesions containing angiographically massive thrombus is associated with a high risk of distal embolisation and no-reflow. The optimal management for these lesions remains unclear and a challenge to the interventional cardiologist. Five cases are described in whom the risks of percutaneous angioplasty were felt to be excessive owing to a high thrombus load. Each case was treated with a bolus and infusion of abciximab (ReoPro; Eli Lilly-a platelet glycoprotein IIb/IIIa receptor antagonist) at least 24 hours before further angiography. Repeat angiography of the culprit vein graft, following treatment with abciximab alone, demonstrated a major reduction in the thrombus score and the presence of TIMI 3 flow in each case. Immediately following repeat angiography, angioplasty with stent insertion was performed successfully with no distal embolisation or no-reflow phenomenon. This staged approach, with abciximab used alone to reduce thrombus load, is a new treatment for vein graft lesions containing massive thrombus.

Instantaneous lead entrapment: successful percutaneous removal using the cook workstation.

An unusual complication of transvenous endocardial lead placement is reported in which an electrode became entrapped within the vicinity of the tricuspid valve apparatus, resisting all initial attempts at removal. The lead was subsequently successfully removed percutaneously via the right femoral vein.

Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease.

BACKGROUND: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease. METHODS: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group. RESULTS: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62). CONCLUSIONS: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.

Objective assessment of "cardioprotective" efficacy as a prognostic guide to management of mildly symptomatic revascularizable coronary artery disease.

OBJECTIVES: The concept of "cardioprotection" based on ejection fraction was tested to see whether patients with coronary artery disease in whom medical treatment fails to be cardioprotective can be distinguished from those in whom it is safe to continue such treatment. BACKGROUND: Ejection fraction is of fundamental prognostic importance. Its modification by anti-ischemic medication may allow assessment of cardioprotection from adverse outcome. METHODS: Exercise ejection fraction and the change in ejection fraction from rest to exercise were measured by radionuclide ventriculography with and without background medication in 102 mildly symptomatic patients with coronary artery disease suitable for revascularization but initially treated medically. RESULTS: Over 20 months, 23 patients experienced an adverse event. With medication, exercise ejection fraction increased in patients with and without events. By contrast, the ejection fraction response to exercise improved significantly in the event-free group only; the group with events had a persistent decrease in ejection fraction. By Cox analysis, the ejection fraction response to exercise performed with medication made the most significant independent contribution to event-free survival. Comparison of areas under receiver operating characteristic curves suggested that this index is the most useful clinical measure of cardioprotection. CONCLUSIONS: An exercise-induced decrease in ejection fraction despite anti-ischemic medication implies failure of cardioprotection and a greater short-term risk of adverse outcome and crossover to revascularization in patients initially treated medically. Conversely, a preserved left ventricular performance confers a satisfactory prognosis while continuing with that treatment. Thus, the effect of medication on the ejection fraction response to exercise--a reasonable estimate of its cardioprotective efficacy--may influence the choice of continuing with such treatment or performing early revascularization.

Exercise testing without interruption of medication for refining the selection of mildly symptomatic patients for prognostic coronary angiography.

OBJECTIVE: To examine how exercise testing on background medical treatment affects the ability of the test to predict prognostically important patterns of coronary anatomy in patients with a high clinical probability of coronary artery disease but who are well controlled on medication. DESIGN: Prospective study. SETTING: Regional cardiothoracic centre and referring district general hospital. PATIENTS: 84 patients with a history of typical angina or definite myocardial infarction and mild symptoms who had been placed on the waiting list for prognostic angiography. INTERVENTION: Maximal exercise electrocardiography and radionuclide ventriculography performed off and on medication, followed by angiography within three months. MAIN OUTCOME MEASURE: Prognostically important coronary artery disease for which early surgery might be recommended purely on prognostic grounds, irrespective of symptoms. RESULTS: Coronary artery disease was present in 71/84 (85%) patients; in 28/84 (33%) patients this was prognostically important. When the result was strongly positive, the predictive accuracy for prognostically important disease was 0.46 off and 0.62 on medication for the exercise electrocardiogram and 0.71 off and 0.82 on medication for exercise radionuclide ventriculography. The likelihood ratio was 1.00 off and 1.36 on medication for exercise electrocardiography and 2.54 off and 10.5 on medication for exercise radionuclide ventriculography. In stepwise logistic regression, the test identified as the strongest predictor of prognostically important disease was exercise radionuclide ventriculography on medication for which the improvement chi 2 was 28 (p < 0.0001). With the regression model, the probability of important disease is 92% if exercise radionuclide ventriculography on medication is at least strongly positive, compared with 16% if the result is normal or just positive. CONCLUSION: In patients likely to have coronary disease, exercise testing should be performed without interruption of medication to optimise its ability to identify those with prognostically important disease, and to help to avoid unnecessary or premature angiography in those who are well controlled on medical treatment.

Suppression of inducible painless myocardial ischemia by conventional medical therapy: effect on short-term outcome and left ventricular systolic function.

To test the hypothesis that abolition of exercise-induced painless myocardial ischemia by anti-ischemic medication improves prognosis in patients with medically treated coronary artery disease, we studied such patients with painless ischemia during exercise radionuclide ventriculography performed after temporary discontinuation of medication. The test was repeated while patients received conventional medical therapy that rendered angina no worse than New York Heart Association class I. The relative risk of adverse cardiac events was reduced by > 5-fold when painless ischemia was abolished by symptom-dictated therapy. Thus, the abolition of exercise-induced painless ischemia by conventional medical therapy carries a better short-term prognosis in medically treated coronary artery disease, suggesting that therapeutic efficacy may need to be assessed by titration against ischemia and not angina. In patients without overt cardiac events, there were no significant differences between baseline and 12-month measurements of ejection fraction at rest, peak exercise, and the change in ejection fraction from rest to exercise. Thus, in those who remain asymptomatic and event-free, painless ischemia that is easily inducible at baseline despite medication does not lead per se to deterioration of left ventricular systolic function at rest or during exercise over 12 months. Such an effect, if evident as early as at 12 months, would favor a strategy of early revascularization over medical treatment in asymptomatic patients who have inducible painless ischemia despite medication.

Long-term effect of inducible silent ischaemia on left ventricular systolic function.

Silent myocardial ischaemia is readily detected by exercise radionuclide ventriculography in patients with coronary artery disease. In those who remain asymptomatic and event-free, it is not known whether silent ischaemia which is inducible despite anti-ischaemic medication exerts an insidious detrimental effect on left ventricular function. To study this, 34 medically treated patients (mean age 57; 26 men) underwent prospective measurement of left ventricular ejection fraction (LVEF) during rest and exercise radionuclide ventriculography without interruption of anti-ischaemic medication at baseline and 12 months later. There was no significant mean (standard deviation, 95% confidence interval) deterioration from baseline to 12 months in LVEF at rest (50% v 49%, SD 5; 95% CI = -3 to +1), peak exercise (44% v 45%, SD 8; 95% CI = -1 to +4) and the change in LVEF from rest to exercise (-6% v -4%, SD 7; 95% CI = -1 to +5). Thus, in coronary artery disease patients who remain asymptomatic and event-free on medical therapy, silent myocardial ischaemia which is readily inducible at baseline despite medication does not lead per se to deterioration of left ventricular systolic function at rest or exercise over 12 months.

Novel approach to the interpretation of long-term "deterioration" in ejection fraction in individual patients with coronary artery disease.

OBJECTIVE: The long-term predictability of left ventricular ejection fraction (LVEF) measurements was evaluated with particular emphasis on the assessment of deterioration in individual patients whose coronary artery disease was initially treated medically. DESIGN: Prospective pilot study. SETTING: Regional cardiac centre. PATIENTS: 60 minimally symptomatic patients with coronary artery disease who, after arteriography, were initially treated medically. INTERVENTION: Measurement of LVEF by first pass exercise radionuclide ventriculography at baseline and six months later without interruption of usual anti-ischaemic medication. Baseline and six-month studies were analysed independently of each other. MAIN OUTCOME MEASURE: Based on 51 patients who remained event free, 95% prediction intervals were derived for prognostic LVEF indices to suggest the minimum change from baseline that might be considered clinically important in the individual patient, alerting clinicians to the need for closer review. RESULTS: At six-month ventriculography, 22 patients showed apparent deterioration in exercise LVEF or the change in LVEF with exercise (delta LVEF). Only two patients had six-month values below the lower limit of 95% prediction intervals, compared with 15 when 95% group confidence intervals (z = 3.33, p < 0.001) were used. When delta LVEF = 0 at baseline, the lower limit of 95% prediction intervals allowed for an exercise induced fall at six months of < or = 13%. For a baseline exercise LVEF of 50% (just normal), the lower limit of 95% prediction intervals was 38%--that is, the exercise LVEF could be measured as low as 38% > or = six months later without necessarily indicating or missing true deterioration. CONCLUSION: In the follow up of minimally symptomatic patients with coronary artery disease, serial long-term changes, in particular "deterioration," in prognostic LVEF indices may be interpreted more meaningfully with reference to 95% prediction intervals.

Left ventricular volume calculation using a count-based ratio method applied to first-pass radionuclide angiography.

Most count-based radionuclide methods for calculating left ventricular volume rely on measurement of radioactivity in a peripheral blood sample and a measurement of ventricle to collimator distance. We have developed a method which requires neither a blood sample nor a distance measurement and which is applicable to first-pass radionuclide angiography. The parameters used to calculate volume are the area of pixel, the total counts in the left ventricle and the maximum pixel count. The equation was used to calculate the volumes in 50 patients who had both resting first-pass radionuclide angiography (25 patients with a single crystal and 25 patients with a multicrystal camera) and contrast ventriculography on the same day. Correlation coefficients for end-diastolic and end-systolic volumes showed r ranging 0.93-0.98 and standard error of estimate ranging 23-35 ml for end-diastolic volume (14%-17% of mean end-diastolic volume) and 16-23 ml for end-systolic volume (18%-21% of mean end-systolic volume). Image processing software for extracting the needed values is generally available on most commercial nuclear medicine imaging systems and the additional time for the calculations is short. Although the theory is based on multiple assumptions, the volume calculation appears to be reasonably accurate and clinically applicable.

High-risk coronary angioplasty with elective intra-aortic balloon pump support.

Percutaneous transluminal coronary angioplasty was attempted with elective percutaneous intra-aortic balloon pump support in 21 patients (mean age 60 years, range 40-82; 18 males) with unstable angina (n = 2), multivessel coronary disease requiring multivessel angioplasty (n = 2), severe left ventricular dysfunction (ejection fraction 10-30%; n = 16) or ventricular fibrillation at diagnostic angiography (n = 1). Fourteen patients had 3-vessel disease (1 with vein grafts also diseased), 6 had 2-vessel disease and 1 had isolated left anterior descending disease. Twenty-five procedures were performed (one in 18 patients, two in 2 patients and three in one patient) on 42 lesions in 34 vessels/grafts. There was no angioplasty-related death. Successful dilatation was achieved in 38/42 lesions (90%) in 21/25 procedures (84%) without major complication. Three procedures were complicated: one by major coronary dissection without sequelae, one by haemodynamic deterioration due to distal occlusion and one by an unstable residual stenosis in the attempted vessel necessitating urgent bypass surgery. The only complication related to the intra-aortic balloon pump was local haematoma in 2 patients. In conclusion, elective intra-aortic balloon pump support may be safely used to stabilise high-risk patients undergoing coronary angioplasty, leading to a satisfactory primary success rate.