Immediate results of interventional devices for coronary ostial narrowing with angina pectoris.

Angioplasty of aorto-ostial lesions has had suboptimal results. This study reports on the immediate results of new debulking devices (atherectomy, excimer laser) in the treatment of aorto-ostial disease. Thirty-one vessels (29 patients) with an ostial lesion treated with a new device (group I) were compared with 15 vessels (13 patients) with an ostial lesion treated with angioplasty alone during the preceding 24 months (group II). Both groups were similar in their clinical characteristics. A larger proportion of vessels in group I (64%) compared with group II (7%) had unfavorable features for angioplasty. Procedural success was similar: 28 vessels in group I (91%) and 14 in group II (93%). Among the new devices, success was also similar: atherectomy in 8 arteries (89%), rotablator in 4 (100%) and excimer laser in 17 (94%). The acute gain was more significant with new devices: absolute reduction in percent stenosis was 66% for directional atherectomy, 67% for rotational atherectomy (p = 0.016 compared with angioplasty), 52% for excimer laser (p = 0.09) and 46% for angioplasty. In group I, 2 patients (6%) required emergency bypass surgery during our early experience; no deaths or Q-wave myocardial infarctions occurred. Group II had no complications. Therefore in aorto-ostial lesions, despite a much higher prevalence of unfavorable angiographic characteristics, new devices had (1) a success rate of > or = 90%, (2) a significantly larger acute gain compared with angioplasty alone, and (3) an acceptable complication rate. Larger studies with complete angiographic follow-up are needed to assess restenosis.

Long-term efficacy of triple-vessel angioplasty in patients with severe three-vessel coronary artery disease.

Between May 1982 and December 1988, a total of 103 patients underwent angioplasty of all three major coronary arteries at a single institution. Angiographic success was achieved in 334 of 352 vessels (95%) and in 441 of 460 lesions (96%). No patients required urgent bypass surgery, and none died during the procedure; six had non-Q wave infarctions. The mean length of follow-up time was 49 +/- 15 months (range 28 to 107 months). There have been 11 deaths, and one patient has undergone cardiac transplantation. Thirty-six patients had a clinical recurrence; 30 had repeat angioplasty and five had bypass surgery. Another nine patients eventually had bypass surgery after the clinical recurrence. At 48 months actuarial event-free rates are myocardial infarction, 98%; bypass surgery, 88%; and death, 89%. Of 86 current survivors, 58 are in functional class O to I, 21 are in class II, and seven are in class III.

Frequency and predictors of left ventricular segmental dysfunction in patients with recent rest angina.

The relation between coronary artery lesion morphology and associated segmental left ventricular (LV) dysfunction in patients with unstable angina is unclear. Fifty-two patients with angina occurring at rest who underwent cardiac catheterization within 3 days of the last episode of pain and had no enzymatic evidence for myocardial necrosis were evaluated. Coronary artery narrowings deemed responsible for the ischemic episodes were analyzed with regard to the artery involved, maximal diameter of the narrowing, presence of thrombus, and complex appearance. Time to catheterization, age, sex and electrocardiographic evidence of ischemia were also noted. Segmental LV dysfunction in the territory supplied by the "culprit lesion" was present in 58% of patients. It occurred significantly more often with lesion location in the left anterior descending coronary artery, and was less frequent with lesions in the left circumflex and ramus coronary arteries. Ischemic electrocardiographic changes were more sensitive in predicting LV dysfunction with culprit lesion location in the left anterior descending or right coronary artery. LV dysfunction could not be predicted by any other parameter analyzed. It is concluded that postischemic LV dysfunction occurs frequently in rest angina, especially when the severest narrowing is in the left anterior descending coronary artery.

Intracoronary thrombolysis followed by directional atherectomy: a combined approach for thrombotic vein graft lesions considered unsuitable for angioplasty.

Eccentric complex vein graft lesions with abundant luminal thrombus have been generally considered unfavorable for balloon angioplasty. We present 3 patients in whom such lesions were successfully treated by a combined approach: intracoronary urokinase (1 million units over 1 hr) administered in the catheterization laboratory followed by directional atherectomy of the residual lesions in 2 separate procedures; with the patients maintained on heparin infusion between the 2 stages. No distal embolizations were encountered. Two of the 3 patients developed a groin hematoma without vascular compromise. This combined approach may prove to be an attractive alternative to reoperation in select patients with unfavorable vein graft lesions.

Immediate and long-term results of delayed recanalization of occluded acute myocardial infarction-related arteries using coronary angioplasty.

Recent evidence suggests that late reperfusion of an occluded infarct-related artery after acute myocardial infarction (AMI) may convey a better prognosis. The clinical outcome of percutaneous transluminal coronary angioplasty (PTCA) as a means of mechanical reperfusion in this particular setting has not been clearly delineated. Ninety-seven patients with AMI underwent PTCA of the occluded infarct-related artery after the acute phase of the AMI (48 hours to 2 weeks, mean 8 +/- 4 days). The study consisted of 72 men (74%) (mean age 56.5 +/- 12 years) and 25 women. Seventy-seven patients (79%) had a Q-wave AMI and 20 patients (21%) a non-Q-wave AMI. Seventy-six patients (79%) had angina after AMI and 4 had previously undergone coronary bypass surgery. Clinical success was achieved in 85 patients (87%). Angiographic success was obtained in 90 of the 97 occluded arteries (93%) and was similar for all 3 major vessels: right coronary 97%, left anterior descending 93% and circumflex 85% (p = not significant). Major complications (AMI, emergency bypass and death) occurred in 3 patients (3.1%). Long-term follow up (3.7 +/- 0.8 years) revealed symptomatic recurrence in 20 (23%), whereas 51 (58%) remained asymptomatic. Most recurrences (16 of 20) were in the form of restenosis rather than reocclusion, with a high success rate for repeat dilation (93%). These results indicate that mechanical reperfusion of an occluded infarct artery, performing PTCA 48 hours to 2 weeks after AMI, has a high success rate, a low complication rate and low symptomatic restenosis.

Late complications involving the ascending aorta after cardiac surgery: recognition and management.

Pseudoaneurysms and dissecting aneurysms of the ascending aorta after cardiac surgery are uncommon but important complications. Pseudoaneurysms, which result from extravasation of blood into the mediastinum, most commonly occur at the site of aortotomy or aortic cannulation. Infection may play an important role. Dissecting aneurysms after cardiac surgery usually occur at the site of aortic incision or cross clamping, especially in atherosclerotic aortas. Both conditions may be clinically silent but more frequently are seen with significant symptoms. Noninvasive techniques including CT scan, MRI, and echocardiography are very useful in the diagnosis of both complications, with contrast aortography remaining the definitive method. Surgical repair is necessary for dissecting aneurysms and for enlarging and symptomatic pseudoaneurysms, with improving morbidity and mortality.

Coronary collateral recruitment: functional significance and relation to rate of vessel closure.

Studies in animals and humans have demonstrated the anatomic presence and functional significance of coronary collaterals. The extent of collateralization varies among species and among individuals. Collateral vessels are usually adequate for preserving resting regional and global ventricular function in the face of coronary obstruction. During stress, however, collateral supply may be inadequate. Collateral development is a time-dependent process during both the initial occlusion and following transient reflow and reclosure. Therefore when a previously collateralized coronary occlusion is recanalized and then recloses, the extent of the resulting collateral recruitment will depend, at least in part, upon the period of reflow between the two occlusions. The longer the reflow period, the less enhanced will be the collateralization. This is illustrated in the cases presented and has also been demonstrated in animal studies. The exact mechanisms for this recurrent collateral recruitment need further study.