Cutting balloon angioplasty and stent implantation for aorto-ostial lesions: clinical outcome and 1-year follow-up.

BACKGROUND: Percutaneous interventions for aorto-ostial narrowing of native coronary arteries are challenging because of early elastic recoil after the procedure and the high restenosis rate. Cutting balloon angioplasty may reduce this complication. HYPOTHESIS: The purpose of the study was to evaluate the clinical outcomes of cutting balloon angioplasty and stent implantation for aorto-ostial lesions with a 1-year clinical follow-up. METHODS: All patients with aorto-ostial lesions in our laboratory underwent cutting balloon angioplasty and were followed for approximately 1 year. RESULTS: Forty-eight patients underwent balloon angioplasty; 36 of whom had lesions in the ostial right coronary artery, and 12 of whom had lesions in the left main coronary artery (LMCA). Thirty-five patients (73%) had a stent implanted. Procedural success was achieved in all patients. The in-hospital rate of major adverse cardiac events (MACEs) was 2.1% because of the death of 1 patient following urgent bypass surgery. Mean clinical follow-up was 11.6 +/- 7 month. Twelve patients (27%) required repeat coronary angiography, and restenosis was found in 7 patients (16%). Six patients (13.6%) had MACEs. CONCLUSIONS: Cutting balloon angioplasty in combination with bare metal stent (BMS) implantation has a good clinical outcome. This technique should be compared with implantation of drug-eluting stents (DESs) in a controlled study.

Clinical and echocardiographic predictors of morbidity and mortality in infective endocarditis: the significance of vegetation size.

BACKGROUND: Infective endocarditis is a common disease with significant morbidity and mortality. OBJECTIVES: To define clinical and echocardiographic parameters predicting morbidity and in-hospital mortality in patients with infective endocarditis hospitalized in a tertiary hospital from 1991 to 2000. METHODS: All patients with definite infective endocarditis diagnosed according to the Duke criteria were included. We examined relevant clinical features that might influence outcome. RESULTS: The study group comprised 100 consecutive patients, 77 with native valve and 23 with prosthetic valve endocarditis. The overall in-hospital mortality rate was 8%. There was a higher mortality in the PVE group compared to the NVE group (13% vs. 7%, P = 0.07). The mortality rate in each group, with or without surgery, was not significantly different. Clinical predictors of mortality were older age and hospital-acquired endocarditis. The presence of vegetations and their size were significant predictors of major embolic events and mortality. Staphylococcus aureus was a predictor of mortality (25% vs. 5%, P < 0.005) and abscess formation. Multivariate logistic analysis identified vegetation size and S. aureus as independent predictors of mortality. CONCLUSIONS: Mortality is higher in older hospitalized patients. S. aureus is associated with a poor outcome. Vegetation size is an independent predictor of embolic events and of a higher mortality.

Predictors for successful angioplasty of chronic totally occluded coronary arteries.

AIMS: Reevaluation of clinical and angiographic predictors for percutaneous recanalization of coronary chronic total occlusion (CTO) using current techniques with conventional PTCA wires and balloons. METHODS AND RESULTS: We studied 253 consecutive patients with 283 lesions who underwent attempted PTCA of CTO (mean time since occlusion 33 months, range 3-150 month). Immediate procedural success rate was 84.8% (95% CI = 80.3%-88.6%). Multiple clinical and angiographic characteristics were evaluated as possible predictors of success/failure. Multiple logistic regression analysis revealed that a tapered morphology (P < 0.001, OR = 6.1; 95% CI = 2.1-18.2),

Balloon angioplasty versus bypass grafting in the era of coronary stenting.

BACKGROUND: Patients with multivessel coronary artery disease are candidates for either angioplasty and stenting or coronary artery bypass grafting. A prospective randomized study designed to compare the both methods included only a minority of the eligible patients. OBJECTIVE: To compare coronary artery bypass grafting to angioplasty plus stenting in patients with multivessel disease who declined randomization to a multicenter study (the ARTS). METHODS: During 1997-98 we prospectively followed 96 consecutive patients who were eligible according to the ARTS criteria but refused randomization. Of these patients, 50 underwent angioplasty + stenting and 46 underwent coronary bypass surgery. We compared the incidence of major adverse cardiac and cerebral events, chest pain recurrence, quality of life and procedural cost during the first 6 months. RESULTS: All procedures were completed successfully without mortality or cerebral events. The rate of Q-wave myocardial infarction was 2% in the AS group vs. 0% in the CABG group (not significant). Minor complications occurred in 7 patients (14%) in the AS group and in 21 patients (45%) in the CABG group (P < 0.01). At 6 months follow-up the incidence of major cardiac and cerebral events was similar in both groups (11% and 4% in the AS and CABG groups respectively, P = NS). Seventeen patients (36%) in the AS group required repeat revascularization compared to only 3 (7%) in the CABG group (P = 0.002). Nevertheless, quality of life was better, hospitalization was shorter and the cost was lower during the first 6 months after angioplasty. CONCLUSION: Angioplasty with stenting compared to coronary bypass surgery in patients with multivessel disease resulted in similar short-term major complications. However, 36% of patients undergoing angioplasty may need further revascularization procedures during the first 6 months.

Clinical and angiographic results with the NIR stent: First International NIR Endovascular Stent Study (FINESS-II).

BACKGROUND: Although safety and efficacy of the NIR trade mark stent have been reported, the long-term angiographic and clinical outcomes have yet to be investigated. The FINESS-II study (First International NIR Endovascular Stent Study) was designed to assess the procedural safety of single 9 and 16 mm NIR stent implantation, the six-month restenosis rate and finally the six- and 12-month clinical outcome of patients treated with this novel coronary stent. METHODS: Patients with angina and a single de novo lesion in a native coronary artery of >3 and <5 mm diameter were included in this multicentre, prospective, observational trial. Clinical follow-up was obtained at one, six and 12 months. Angiography was performed before and after the stent implantation and at six months. The primary endpoint included major adverse cardiac events (death, myocardial infarction and target lesion revascularization) within 30 days after the procedure. Major bleeding complications and subacute stent thrombosis within the first 30 days were also reported as specific endpoints. Secondary endpoints were major cardiac-event-free survival at six- and 12-month follow-up and angiographic restenosis at six months. RESULTS: A total of 156 patients (81% male, mean age 60 +/- 10 years), with stable (54%), unstable (40%) angina pectoris or silent ischemia (6%) were enrolled. The target vessel diameter was 2.94 +/- 0.54 mm. The minimal lumen diameter pre, post and at follow-up was 1.04 +/- 0.32 mm, 2.64 +/- 0.42 mm and 1.88 +/- 0.63 mm, respectively. Restenosis rate according to the >50% diameter stenosis criterion at six month follow-up was 19% (26/136). At 12 months, the event-free survival rate was 83% (two deaths, one Q-wave and three non-Q-wave myocardial infarctions, four bypass surgery and 17 target lesion revascularizations), while 87% of the patients were free of angina pectoris. CONCLUSION: the outcome of the FINESS-II trial is comparable to those observed in previous stent trials (Benestent II), indicating that the coronary NIR stent is safe and effective as a primary device for the treatment of native coronary artery lesions in patients with (un)stable angina pectoris.

Permanent Cardiac Pacing in Octogenarians.

A significant percentage of patients in need of a permanent pacemaker are older than 80 years. The implantation policy may be determined either by the patient's physical activity or by chronologic age. The trend in pacemaker implantation in patients over 80 during the last 10 years in our institution was evaluated and compared with the trend in the patients younger than 80 at the time of implantation. Of 519 patients who had primary pacemaker implantation, 152 (29%) were older than 80 at the time of the procedure. Another 189 patients had second implantation procedures, and 80% of them were older than 80 years. Complete atrioventricular block was the indication for pacing in 44 Â+/- 11% and sick sinus syndrome in 25 Â+/- 7%. The tendency to implant dual-chamber pacemakers increased from 0% during 1985 to 76% in 1994, including 69% DDD and 31% DDDR, but the transition was faster in the younger group. By 1994, there was no difference in the incidence of advanced pacing systems in the 2 age groups. During 1985, only VVI pacemakers were replaced, and during 1994, less than 10% were replaced with simple ventricular pacing units. Pacing system upgrading was frequent during the second half of the decade. The success and complication rate of implantation did not differ in the 2 groups.

Percutaneous Transluminal Coronary Angioplasty in Octogenarians.

Revascularization is a theoretically ideal technique for treating repeated angina pectoris in elderly patients. Coronary angioplasty is an attractive option if it can be performed safely. In this report, we describe our experience with 80 angioplastic procedures in 72 patients older than 80 years. Seventy-two of these procedures (90%) were performed after 1990 using the currently available, improved angioplasty equipment. A third of these patients did not have any risk factors for coronary artery disease and 45% had only 1 risk factor. A history of previous myocardial infarction or coronary bypass surgery was present in 48 (67%) patients. In most patients (72%), angioplasty was performed during an admission for unstable angina or acute myocardial infarction. Single-vessel disease was present in 22% of patients. Successful angioplasty was performed in 92% of patients and major complications occurred in 8% of patients. Four patients (6%) died; in all of them, angioplasty was performed emergently to treat cardiogenic shock. None of 68 patients who underwent elective angioplasty for stable angina or a semielective procedure for unstable angina died during the hospitalization. We conclude that angioplasty can be performed safely in the carefully selected octogenarian. There is a low-risk subgroup of patients with limited disease in whom angioplasty is an attractive treatment strategy.