Timing of surgery in aortic stenosis.

Aortic valve stenosis (AVS) usually results from three distinct processes (degenerative-calcific, rheumatic, and congenital), with a final common pathway of significant aortic outflow tract obstruction. The stenotic lesion tends to progress slowly, but once symptoms develop clinical deterioration can ensue rapidly. Chest pain, dyspnea, and syncope are the most common symptoms of significant AVS. Detection of symptoms, subtle or obvious, is critical to the management of AVS because their presence portends a worse overall prognosis and is an indication for intervention. There are several special clinical scenarios that require added consideration, including individuals with concomitant coronary artery disease, the presence of a relatively small transvalvular pressure gradient in the setting of low cardiac output (so-called low-gradient AVS), and elderly with severe AVS. Surgical aortic valve replacement (AVR) is the mainstay treatment for relief of obstruction in patients with symptomatic AVS. Percutaneous balloon valvuloplasty is reserved for the small minority of patients who are not surgical candidates and is associated with a high restenosis rate. Percutaneous AVR is a new technology that is being tested in a few select centers on patients who are not operative candidates.

Comparison of bare metal stents versus drug-eluting stents on clinical decision making in patients with previous percutaneous coronary intervention admitted for suspected acute coronary syndrome.

To determine whether the decreased rate of restenosis observed with drug-eluting stents (DES) has changed the treatment of patients with recurrent symptoms after stent placement, we compared patients hospitalized with presumed cardiac symptoms within 1 year after placement of either a DES or a bare metal stent (BMS). In this retrospective, single-center study, cases were identified from consecutive patients who received a DES from March 2003 to July 2004 or a BMS from August 2001 to June 2002. No differences were noted in the rate of hospitalization, hospitalization for presumed cardiac symptoms, use of coronary angiography in patients hospitalized for presumed cardiac symptoms, or average interval to hospitalization. In contrast, restenosis and the need for additional revascularization procedures were higher in the BMS group. The primary indication for additional revascularization was restenosis in the BMS group and progression of coronary artery disease in the DES group. In the DES group, the need for revascularization was significantly higher in patients with multi- versus single-vessel coronary artery disease (26% vs 7%, p < 0.05). In conclusion, the rate of hospitalization and use of coronary angiography in patients with recurrent symptoms were similar in patients who received a BMS or DES, despite the decreased rates of restenosis and additional revascularization procedures observed with DESs.

Idiopathic dilated cardiomyopathy: a common but mystifying cause of heart failure.

While researchers try to elucidate the origins of idiopathic dilated cardiomyopathy, clinicians continue to face the challenges of identifying and treating the causes of this condition to improve symptoms and survival. We review classification schemes for dilated cardiomyopathy and the current range of diagnostic and therapeutic options and treatment goals.