A randomized comparison of elective high-pressure stenting with balloon angioplasty: six-month angiographic and two-year clinical follow-up. On behalf of AS (Angioplasty or Stent) trial investigators.

BACKGROUND: Previous randomized trials have shown beneficial effects of coronary stenting on restenosis and event-free survival rates. However, it has not yet been fully established if routine high-pressure stenting with an antiplatelet regimen can show similar results. METHODS: We compared the 6-month angiographic restenosis rate and 2-year event-free survival rate in 400 patients randomly assigned to stent or angioplasty. Aspirin and ticlopidine were prescribed in both groups. RESULTS: The procedural success rate did not significantly differ between the stent and angioplasty groups (97.92% vs 97.45%, P = not significant). No stent thrombosis was found. The 6-month restenosis rate was lower in the stent group (18. 18% vs 24.87%, P =.055). At 2 years target lesion revascularization rate was 17.19% in the stent group and 25.51% in the angioplasty group (P =.02, 33% reduction). No significant differences with regard to death and myocardial infarction were observed. Event-free survival rate at 6, 12, and 24 months was 86.77% vs 78.84%, 84.13% vs 76.70%, and 83.07% vs 73.54% for stent and angioplasty groups, respectively (P =.0172). CONCLUSIONS: The 6-month angiographic and 2-year clinical outcomes were better in patients who received stent than in those after balloon angioplasty. The difference in 2-year event-free survival rate was explained by a reduction in target lesion revascularization rate in the stent group.

High-Pressure Bail-out Coronary Stenting Without Anticoagulation: Early Outcome and Follow-up Results.

PURPOSE:The purpose of this study is to assess the immediate outcome and long-term results of high pressure bail-out coronary stenting without subsequent anticoagulation. PATIENTS AND METHODS: Between June 1994 and September 1996, 32 consecutive patients (males 24, mean age 55 +/- 9.3 years) underwent bail-out stenting at a mean deployment pressure of 15.5 +/- 2.3 mmHg because of complicated PTCA. A total of 54 stents (Palmaz-Schatz, Micro, Gianturco Roubin and Wiktor) were implanted, from one to four stents into each vessel. After the procedure all patients were treated with ticlopidine 500 mg/day and acetylosalicylic acid 300 mg/day only. RESULTS: Stents were successfully delivered in all patients. In the cath lab procedural success was 96.9%. During the in-hospital phase, there was one (3.1%) acute stent thrombosis followed by urgent bypass surgery (CABG). Four (12.5%) non-Q wave myocardial infarctions occurred. There were no subacute stent thrombosis or hemorrhagic complications. Six month angiographic restudy in 28 patients showed restenosis in 13 (46.4%): 9 patients were treated successfully by rePTCA. At one year 13 (40.6%) major adverse cardiac events occurred: eleven (34.4%) target lesion revascularizations (9 PTCA, 2 CABG), one (3.1%) elective CABG surgery and one (3.1%) late cardiac death. Event-free survival was 93.8% at one month, 65.6% at six months, and 59.4% at one year. CONCLUSIONS: High pressure bail-out coronary stenting with antiplatelet regimen is an effective and safe procedure for treating complicated PTCA. Although the restenosis rate is high, in most cases in-stent restenosis can be treated by rePTCA. In 60% of patients clinical course at one year was uneventful.

[Early and long-term outcome after coronary artery patency]. / Wczesne I odlegle wyniki po udroznieniu tetnic wiencowych.

The role of percutaneous transluminal coronary angioplasty (PTCA) in the management of chronically occluded coronary arteries is still controversial. Percutaneous transluminal coronary angioplasty of chronic total occlusion is associated with relatively low success rates and a high incidence of restenosis. The purpose of this analysis was to determine, from the records of our institution, the efficacy and long-term outcome of angioplasty performed for chronic total occlusion defined as complete occlusion (Thrombolysis in Myocardial Infraction [TIMI] grade 0). PTCA was performed in 212 consecutive patients with chronically occluded coronary arteries and was successful in 125 (59%) patients. Complications were not observed. Successful initial PTCA was related to the clinical duration of occlusion and the type of guidewire (the primary success rate with the conventional guidewire was 49 (48%) versus 76 (69.1%) with Magnum Meier System p < 0.01). Repeat angiography was performed for 65 (52.0%) consecutive patients with successful initial PTCA and demonstrated restenosis in 34 (52.3%). 17 patients were successfully treated by a second PTCA. Restenosis or reocclusion was not clearly related to the residual stenosis post PTCA. In addition, the grade of collateral supply was not different in the vessels with and without restenosis.

Long term follow up after percutaneous mitral commissurotomy with the Inoue balloon-incidence of restenosis.

UNLABELLED: The long term outcome of 300 consecutive patients following percutaneous mitral commissurotomy (PMC) with the Inoue balloon was analyzed with regard to the incidence of restenosis. There were 256 females and 44 males (mean age 44.4 +/- 9.9 years, range 18-69 years), 52 had previous surgical commissurotomy, 96 were in atrial fibrillation, and 16 had a history of embolism. PCM was carried out with a success rate of 84% (no significant mitral regurgitation and mitral valve area (MVA) > 1.5 cm2). Two hundred and seventy patients were available for clinical and serial echocardiographic studies at six months, 12 months and once a year thereafter (18 patients operated on for mitral regurgitation less than six months after PMC, three patients lost to follow up, nine patients refused to return). MVA increased with PMC from 1.18 cm2 +/- 0.3 to 2.0 +/- 0.3 cm2 and then decreased to 1.8 +/- 0.3 at a mean follow up of 24.0 +/- 13.5 months (range 6-55). Echocardiographic restenosis (RS) (MVA at follow up < 1.5 cm2 with a 50% loss of the initial gain) was found in 38 patients (14%). Twenty-five (66%) of them remained in NYHA class I or II. Restenosis free survival according to the Kaplan-Mayer curve was 93%, 86%, 77% and 73% at 12,24,36 and 55 months respectively. None of the 24 clinical, hemodynamic, echocardiographic or procedural variables used on the Cox proportional hazard regression analysis identified predictors of restenosis free survival. CONCLUSIONS: The overall incidence of echocardiographic restenosis post PMC is low (12.6%) in patients followed for a mean period of two years and often occurs without worsened clinical symptoms. It may be difficult to define clinical, echocardiographic or procedural factors as significant predictors of restenosis free survival.

Reversal of ischaemic systolic and diastolic left ventricular dysfunction by successful coronary angioplasty in patients with non-Q wave anterior myocardial infarction.

The effect of PTCA on global and regional left ventricular systolic function, isovolumic relaxation, chamber and muscle stiffness were studied in 30 patients with angina pectoris, previous non-Q wave anterior myocardial infarction (AMI) and significant stenosis of the left anterior descending coronary artery (LAD). In 11 of the 30 patients the condition was stable, but it was unstable in 19. Left ventricular angiograms were obtained before and 4.85 +/- 3.67 months after PTCA. The RAO was in the 30 degree projection, with the silhouette of the left ventricle sliced into 90 regions; changes in left ventricular volume, pressure and anterior wall thickness during the full cardiac cycle, together with dp/dt were demonstrated. After PTCA, global ejection fraction increased from 68.77 +/- 5.96% to 76.57 +/- 3.18%, P < 0.001. Impaired contractility was found in 29/90 (32.2%) regions before PTCA and in 5/90 (5.6%) after PTCA, P < 0.001. The time constant of the isovolumic pressure fall decreased after PTCA (52.56 +/- 17.40 ms vs 39.61 +/- 11.26 ms, P < 0.01). Elastic chamber stiffness coefficient decreased (0.022 +/- 0.003 vs 0.008 +/- 0.004, P < 0.001) and peak rate of left ventricular filling increased (319.0 +/- 107.9 ml.min-1 vs 396.8 +/- 201.4 ml.min-1, P < 0.05) after PTCA. The muscle stiffness coefficient was within normal values before and did not change after PTCA. The study findings show that in patients with persistent angina pectoris after non-Q wave AMI, complex systolic and diastolic ischaemic dysfunction occurs. This dysfunction can be reversed after successful PTCA of LAD.

[Coronarography in 1000 consecutive patients--clinical aspects]. / Koronarografia u 1000 kolejnych chorych--aspekty kliniczne.

Between 1984 and 1987 1000 consecutive patients with stated or suspected ischemic heart disease underwent selective coronarography and left ventriculography. Patient's age ranged from 23 to 70 years (mean - 47 yrs). Atherosclerotic lesions in three main coronary arteries: left anterior descending, circumflex and right coronary artery were assessed. Stenosis exceeding 50% of a vessel lumen was considered as a significant one. Changes were evaluated in the whole group of patients and in two subgroups in relation to patients age (younger and older than 40 years). Besides assessment of atherosclerotic changes in coronary arteries a presence of IHD risk factors, family occurrence, disease progress and methods of further therapy were analyzed. 60.9% of patients had a documented history of myocardial infarction in the post. Unchanged coronary arteries were found in 77 patients (7.7%), one isolated coronary artery stenosis in 145, single coronary artery stenosis with nonsignificant atherosclerotic lesions in other arteries in 328. Two significantly narrowed arteries were found in 285 patients and 101 subjects had significant changes in three coronary arteries. Analysis of further therapy revealed following results: 520 patients underwent PTCA or CABG (270 - PTCA and 250 - CABG), 439 were conservatively treated and only 41 did not need further cardiological care. Comparing atherosclerotic changes in patients younger and older than 40 years, a statistically significant correlation between patient's age and a number of coronary artery stenosis was stated. Diffuse coronary atherosclerosis more frequently occurred in patients more than 40 years. In youngers changes mainly concern a single coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complex hemodynamic analysis of left ventricular systole in hypertrophic cardiopathy--clinical implications]. / Kompleksowa analiza hemodynamiczna skurczu lewej komory w kardiomiopatii przerostowej--implikacje kliniczne.

Hypertrophic cardiomyopathy is characterized by hemodynamic disturbances concerning left ventricular systole and diastole. Both of them are probably connected with abnormal structure of myocardium. The aim of the study was to assess left ventricular sufficiency, LV contractility and answer the question: if there is relationship between hemodynamic disturbances and clinical state. Estimation of verapamil influence on evaluated parameters was performed in the second part of the study. 20 patients (13 M, 7 F) aged 16-59 years (mean age 33, 25 yrs) with various type of hypertrophic cardiomyopathy were studied. Catheterization of the right and left heart and coronarography were performed in each patient. The first pressure derivative (d/P/dt) was recorded simultaneously with left ventricular pressure recording. Left ventricular angiography was performed in RAO 30 degrees and LAO 60 degrees projections. Analysis of the angiographic image of the whole heart cycle every 40 ms was performed to evaluate the changes in the left ventricular volume and LV wall thickness. Relationships between left ventricular pressure and volume were defined using computer PDP 11/24. To define verapamil influence, 6 patients received 10 mg of the drug intravenously, 14 patients received verapamil directly into left coronary artery 0.02 mg/kg of 0.5 mg/min. Control blood pressure measurements were performed after 5 and 10 minutes, and ventriculography after 15 min. Obtained results were compared with the control group consisted of 10 patients with normal hemodynamic data. Left ventricular contractility was estimated using V max and power/volume relationship (stress/volume). Both indices showed decreased left ventricular muscle contractility in hypertrophic cardiomyopathy. Verapamil had no significant effect on left ventricular contractility in our patients. Ejection period was studied using few indices. Ejection volume and net work (strokework) of the left ventricle were found to be decreased significantly, what means decreased mechanical preformance. The most significant were differences concerning mechanical performance which did not change after verapamil administration whereas circumferential fibre shortening velocity (VCF) was found to be decreased. If was probably related to increased afterload which could be caused by ventricular kinetics change. Midsystolic stress and the afterload index, significantly lower in cardiomyopathic patients. Preload was similar in both groups. Ejection indices of decreased afterload and normal preload proved decreased contractility. If above changes were primary, hypertrophy might be the compensating mechanism of decreased myocardial sufficiency in patients with hypertrophic cardiomyopathy. Which proved Hiroto's and Furabayashi's. The lack of negative effect verapamil on LV contractility in the group of our patients was very interesting, and could be partially related to beneficial effects in diastole.(ABSTRACT TRUNCATED AT 400 WORDS)

[Use of photogrammetry for evaluating the effectiveness of percutaneous transluminal coronary angioplasty]. / Zastosowanie fotogrametrii do oceny skutecznosci zabiegów przezskórnej sródnaczyniowej koronaroplastyki (PTCA).

In 16 patients which underwent PTCA of a right or left coronary artery, analysis of coronarographic image using the stecometer (a precise instrument measuring background coordinates) was performed. Segment of a coronary artery in which PTCA was performed, was estimated in projections: RAO 30 degrees and LAO 60 degrees with a cranial 30 degrees-45 degrees view before and after the procedure. Totally, 72 arteriograms were evaluated. Measurements data were processed by a computer under a written program. Obtained results were presented digitally as a coordinates list and graphically as automatically plotted by Digigraf, drawings in the scale of 10:1 or 20:1. Obtained results were convergent with the hitherto applied method of coronary arteries stenoses approximate assessment.