[Revascularization in patients with prior coronary bypass surgery]. / Revascularização em pacientes com cirurgia prévia de bypass coronário.

UNLABELLED: Increasingly over the past several years, patients have returned after coronary surgery for reintervention procedures. This reflects immediate postsurgical complications and the relentless progression of coronary artery disease in the native circulation and in the bypass grafts. Although there are randomized comparative data for coronary bypass surgery (CABG) versus percutaneous transluminal coronary angioplasty (PTCA) and medical therapy, these trials have always excluded patients with previous (GABG). OBJECTIVES: We attempted to compare the risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). METHODS AND RESULTS: This study examines follow up data (15.4 +/- 11.0 months) from 130 patients with previous CABG, who required either PTCA (Group A, n = 73) or re-CABG (Group B; n = 57) at a single center from 1994 to 1997. Follow up data were obtained from subsequent office visits and telephone calls. The PTCA and re-CABG groups were similar with respect to gender (86% vs 94% males), mean age (62 +/- 9 vs 59 +/- 10 years), angina CCS classes 3 and 4 (73% vs 69%), diminished left ventricular function (23% vs 26%), risk factors such as diabetes (19% vs 17%), hypercolesterolemia (49% vs 45%) and smoking (48% vs 39%) and three-vessel native coronary artery disease (67% vs 72%). The symptomatic status prior to the revascularization procedure was similar in both groups. Complete and functional revascularization was achieved in 85% of the PTCA group and in 92% of those with re-CABG (p = NS). During the hospital stay the complication rates were lower in the PTCA group. Actuarial survival was different at follow up (p = 0.04). Both PTCA and re-CABG groups resulted in equivalent event-free survival (freedom from death, myocardial infarction, unstable angina and urgent revascularization). The need for repeat revascularization at follow up was significantly higher in the PTCA group (PTCA 28% vs re-CABG 10%, p < 0.01). CONCLUSIONS: In this non-randomized study of patients with previous CABG requiring revascularization procedures, PTCA resulted in lower procedural morbidity and mortality risks. At follow up, both PTCA or CABG were similar for event-free survival; PTCA offered lower overall mortality, although it is associated to a greater need for subsequent revascularization procedures.

[Total occlusion of the left common coronary artery--a case report]. / Oclusão do tronco comum da coronária esquerda--a propósito de um caso clínico.

Total chronic occlusion of the left main coronary artery is an unusual finding. After a review of the literature, the authors present a case report of a patient with stable angina and total occlusion of the left main coronary artery, right coronary with atherosclerotic lesions and normal ventricular function.

[Predictive value of coronarography in the localization of arterial lesions responsible for future infarcts of the myocardium]. / Valor preditor da coronariografia na localização da lesão arterial responsável por futuro enfarte do miocárdio.

OBJECTIVES: To evaluate the capability of coronary angiography, when performed in stable conditions, to predict which arterial segment will be responsible for future acute myocardial infarction. POPULATION: 17 patients (15 men and 2 woman), mean age 52 +/- 12 years, who suffered a myocardial infarction (AMI), and had been previously submitted to coronary angiography. After the myocardial infarction all the patients had a new angiography. METHODS: The coronary angiographies performed before and after the AMI were compared, by simultaneous visualization of the films, and the segment related to the AMI was determined with the help of ECG and ventriculography. Among the arterial segments with in the coronary angiography performed before the AMI and who were found to be related with it, three Groups were considered: A-with no angiographic lesion; B-with less then 70% lesion; C-with a lesion equal or superior to 70% (angiographically significant). RESULTS: In nine patients the arterial segment related to AMI belonged to group A. In four patients it belonged to group B and in four to C. Segments with angiographically significant lesions were responsible for AMI in less then one fourth of the patients. CONCLUSIONS: Coronary angiography, when performed in stable conditions, has a low predictive value to determine the localization of the arterial segment related to future AMI.

[The evolution of the arterial pressure during a stress test in patients with hypertrophic myocardiopathy]. / Evolução da pressão arterial durante a prova de esforço, em doentes com miocardiopatia hipertrófica.

OBJECTIVES: To study the exercise blood pressure response in patients with hypertrophic cardiomyopathy (HC) and its relationship with sudden death. DESIGN: Retrospective study. POPULATION: We studied 51 patients (P) with HC: 18 women and 33 men. Their average age was 45 +/- 14 years, with a mean follow-up of 55 +/- 37 months. METHODS: Every patient had been subjected to a treadmill stress-test, a 24-hour Holter monitoring and an echocardiographic examination. Particular emphasis was given to blood pressure increments (BPI) during stress-test, the existence of premature ventricular contractions with a frequency of 10 or more per hour (PVC > or = 10), the occurrence of couplets (C) and/or non-sustained ventricular tachycardia (NSVT) on a 24-hour Holter. Finally, the finding of systolic anterior motion (SAM) of the mitral valve, in the routine echocardiogram, was valued. RESULTS: Four patterns of BPI were identified: "1": normal evolution (27 P); "2": plateau type increment (16 P); "3": fall in blood pressure during exercise (6 P); "4": abnormal BPI during recovery (2 P). Two groups were considered: group N-normal BPI, group A-patients with abnormal blood pressure responses. There were no significant differences among therapeutic agents, between the two groups, when the stress-test was performed. SAM was found in 21 P. Only 8 P registered ventricular arrhythmias, half of them with NSVT. No statistical relations were found between BPI and P age, the presence of SAM, PVC > or = 10, C, or NSVT. We found 78% of P in group N in NYHA class I. In contrast, in group A only 46% were in class I (p = 0.04). Only one death, of non cardiac cause, occurred (group A). CONCLUSIONS: There is a large number of patients with HC and abnormal BPI. This is, seemingly, not influenced either by a dynamic left ventricular gradient or by ventricular ectopic beat occurrence. However, a relation appears to exist between the abnormal response and functional class, not explained by the usual (noninvasive) clinical tests.

Comparison of the effects of a controlled-release formulation of isosorbide-5-mononitrate and conventional isosorbide dinitrate on exercise performance in men with stable angina pectoris.

Thirty-three men with stable exercise-induced angina pectoris entered a randomized, double-blind, crossover study in which controlled-release isosorbide-5-mononitrate 60 mg once daily was compared with conventional isosorbide dinitrate 20 mg 3 times daily. Each drug was given for 2 weeks. Twenty-eight patients completed the study and data on exercise variables are available in 23 patients. Treatment with either drug resulted in significant antianginal effects, when measured 6 hours after a single dose and after 2 weeks of therapy compared with baseline placebo; however, there were significantly fewer signs of myocardial ischemia during treatment with isosorbide-5-mononitrate. There was no evidence of tolerance to either drug treatment but a significant attenuation of resting blood pressure (but not of exercise blood pressure) was observed with both drugs. Headache was the only clinically significant adverse event during therapy and it occurred more frequently in the isosorbide dinitrate treatment group (p less than 0.05 vs placebo); 3 such patients had to withdraw from the study because of headache. Thus, once-daily, controlled-release isosorbide-5-mononitrate appears as effective as conventional isosorbide dinitrate 3 times daily in patients with stable angina pectoris. The once-daily administration is convenient and improves patient compliance.

[Percutaneous mitral valvotomy]. / Valvulotomia mitral por via percutânea.

We report the first percutaneous mitral valvotomy performed in Portugal in October 19th 1987. The valvotomy was attempted successfully in a 34 year old man, with calcific mitral stenosis, in NYHA class III, with functional mitral valve area less then 1 cm2. The intervention was performed using the transseptal technique with two balloons (20 and 18 mm in diameter), placed in the mitral valve annulus through two long transseptal sheaths (14F). The procedure resulted in a marked decrease in the diastolic transmitral gradient, and an increase in mitral valve area superior to 100%. No immediate or late complications were observed, namely mitral regurgitation or left to right shunt through the atrial septum. One year later the patient is in NYHA class I, with a mitral valve area of 1.7 cm2.