Enhanced detection of ischemic myocardium by transesophageal dobutamine stress echocardiography: comparison with simultaneous transthoracic echocardiography.

The diagnostic accuracy of dobutamine stress echocardiography is limited in patients with poor transthoracic acoustic windows. Transesophageal echocardiography (TEE) overcomes these limitations and thus may increase the clinical usefulness of dobutamine stress echocardiography. The present study was designed to compare the diagnostic accuracies of transesophageal and transthoracic dobutamine stress echocardiography for the identification of coronary artery disease (CAD) in a cohort of patients with a higher incidence of poor acoustic windows. Forty-two male patients (mean age, 66 +/- 9 years) underwent dobutamine stress echocardiography with simultaneous transesophageal and transthoracic imaging. Coronary arteriography was performed in 28 patients (67%). Transesophageal imaging adequately visualized 99.6% of left ventricular segments compared with 76.2% visualized by transthoracic imaging (P < 0.0001). There was substantial agreement between the two techniques for segmental wall motion analysis at baseline (kappa 0.76; 95% CI, 0.70-0.82); however, at peak dobutamine dose, agreement was significantly reduced (kappa 0.62; 95% CI, 0.55-0.69). The sensitivity (88% vs 75%), specificity (100% vs 75%), and positive predictive value (100% vs 80%) for the identification of CAD were all superior for transesophageal imaging. Transesophageal imaging correctly identified 11 of the 12 patients (92%) with multivessel disease compared with 5 patients (42%) identified by transthoracic imaging (P < 0.03). There were no major complications. Transesophageal dobutamine stress echocardiography is a safe, feasible, and accurate technique for the identification and risk stratification of patients with CAD. Transesophageal imaging appears to be superior to transthoracic imaging for identifying both the presence and extent of CAD, specifically in patients with poor acoustic windows.

Abrupt vessel closure: changing importance, management, and consequences.

Percutaneous coronary interventions have been performed for 20 years. Despite the success and progress of these interventions, abrupt vessel closure has been a dramatic adverse event of coronary interventions. Closure has frequently led to the major complications of death, myocardial infarction, and emergency coronary artery bypass. Because of the fear of this adverse event and its subsequent complications, the applicability of coronary interventions is sometimes limited. The pathologic characteristics of abrupt vessel closure have been recognized as predominantly caused by dissection, with vessel recoil and thrombus formation playing important secondary roles. The recognition of the lesions at risk for abrupt vessel closure has led to a strategy of lesion-specific device therapy to reduce complications. Similarly the role of antiplatelet and antithrombotic therapies have reduced complications. The earliest methods of dealing with abrupt closure was emergency coronary artery bypass surgery with significant rates of morbidity and mortality. With the advent of second-generation devices and techniques, particularly stents, the management of abrupt vessel closure has been simplified and alternatives to emergency coronary bypass are more available. This article will review the history and current status of the prevention and management of abrupt vessel closure and demonstrate that anticipation and management of this complication have been facilitated with reduction of subsequent complications and increased applicability of coronary interventions.

Gender differences in percutaneous interventional therapy of coronary artery disease.

To determine what differences exist in angiographic parameters between men and women undergoing revascularization therapy for coronary heart disease that may indicate a gender difference, a retrospective review of patients admitted to one hospital for diagnosis of cardiac ischemic syndrome, and undergoing coronary arteriography, percutaneous interventional procedure, or coronary bypass surgery, was performed. Demographic, clinical, and angiographic parameters were evaluated in men and women, including body surface area, distribution of coronary lesions, size of target coronary vessels, and results of interventional procedures. Men and women undergoing percutaneous revascularization did not differ in regard to distribution or size of vessels or outcome. Previous data support the contention that women may undergo coronary arteriography and coronary artery bypass surgery less frequently than men. No evidence of differences existed in selecting patients for percutaneous intervention from those patients who underwent coronary arteriography. Men and women who underwent percutaneous intervention had similar baseline angiographic characteristics, yet men were more likely to receive a new device.

Gender differences in clinical evaluation and triage in coronary artery disease.

BACKGROUND: Women undergo evaluation and treatment for cardiac diseases less frequently than men with similar symptoms. The purpose of this study was to determine what differences exist in clinical evaluation and treatment between men and women presenting with coronary heart disease that may indicate a gender bias. METHODS: A single hospital retrospective review of patients admitted with the diagnosis of cardiac ischemic syndrome, undergoing stress testing, coronary arteriography, percutaneous interventional procedure, or coronary bypass surgery was performed, including an evaluation by gender of the demographic, clinical, and angiographic parameters of 1 year of patients undergoing hospital admission, evaluation, or revascularization therapy for coronary heart disease in a single university hospital. RESULTS: Women admitted to the coronary care unit with a coronary diagnosis were less likely to undergo coronary arteriography than men. Women having a positive stress test result were as likely to undergo coronary arteriography as men with similar findings. Women undergoing coronary arteriography were as likely as men to undergo percutaneous transluminal coronary angioplasty, but less likely to undergo coronary artery bypass surgery. CONCLUSIONS: A gender-based selection bias exists in choosing patients to undergo coronary arteriography and coronary artery bypass grafting.

Left main coronary artery disease: assessment, diagnosis, and therapy.

This article reviews and updates the current literature concerning the assessment, diagnosis, and therapy of coronary disease involving the LMCA. Included is recent information regarding the natural history, congenital abnormalities, noninvasive diagnostic studies, and role of coronary bypass surgery and percutaneous coronary interventions in treating disease of the LMCA. At present, it remains that the LMCA is a difficult segment to assess angiographically. The use of noninvasive imaging does not specifically distinguish LMCA from other types of coronary disease. Coronary bypass surgery has a proven benefit in the treatment of disease of the LMCA. Currently, interventional procedures are limited by significant risks, and surgical treatment with coronary bypass surgery remains the therapy of choice.

Transluminal extraction catheter for the treatment of diseased saphenous vein grafts: a multicenter experience.

To evaluate the efficacy, safety, and long-term results of atherectomy using the Transluminal Extraction catheter (TEC), patients with diseased saphenous vein grafts were enrolled in a prospective nonrandomized trial. Patients were followed to hospital discharge for acute complications and underwent routine 6-mo reevaluation with repeat cardiac catheterization to assess restenosis. Atherectomy was performed on 650 graft lesions in 538 consecutive patients (male 81%; mean age 66 yr; range 37-81). Mean graft age was 8.3 yr; (range 0.3-20) with 85% of grafts > 3 yr of age. Complex lesion morphology included thrombus (28%), ulceration (13%), and eccentricity (50%). Lesion success was achieved in 606 lesions (93%) with clinical success in 479 patients (89%). Lesion success was achieved in 90% of thrombus containing lesions, 97% of ulcerated lesions, and 97% of grafts > 3 yr. Complications included nonfatal myocardial infarction in 4 (0.7%) of patients, emergency bypass surgery in 2 (0.41%), and in-hospital death in 17 patients (3.2%). Angiographic follow-up at 6 mo was obtained from 268 lesions in 227 patients. The overall lesion angiographic restenosis rate was 60%. TEC atherectomy can be performed in patients with diseased saphenous vein grafts with high primary success and low complication rates. It is suitable for use in aged grafts, particularly in the presence of thrombus and ulcerations, and may be superior to balloon angioplasty alone in this group of patients.

Contrast-induced nephrotoxicity in patients undergoing cardiac catheterization.

Contrast-induced nephrotoxicity (CIN) is a common concern among angiographers. The causes of CIN are not well understood and the identification and preparation of patients at risk are important. This report reviews the literature concerning the causes and identification of patients at risk and documents the studies that are available to improve the safety of cardiac catheterization and cardiac interventions by reducing the risk of CIN.

National Registry for Supported Angioplasty: results and follow-up of three years of supported and standby supported angioplasty in high-risk patients.

The National Registry of Supported Angioplasty was formed in 1988 to collect data on patients undergoing supported angioplasty. The Registry was expanded to include patients also undergoing standby supported angioplasty. In 3 years the Registry collected data on 801 patients undergoing supported or standby supported angioplasty. The data indicate that in patients with low ejection fractions and/or > or = 50% of jeopardized myocardium at risk can have an interventional procedure performed with a 6.9% risk of mortality with prophylactic or standby support, but patients with < or = 20% ejection fraction do better with prophylactic support. In addition, patients with LMCA stenosis and age > or = 70 years are at higher risk. The Registry also demonstrates good long-term results for patients who have undergone the procedure.

Coronary angioplasty in high-risk patients with left main coronary stenosis: results from the National Registry of Elective Supported Angioplasty.

To assess the outcome of PTCA in circulatory supported patients with left main coronary artery (LMCA) stenosis, the National Registry of Elective Supported Angioplasty data bank was searched. Patients entered in the registry were considered high-risk PTCA and the PTCA was performed using percutaneous cardiopulmonary bypass (PCPB). Criteria for high risk was left ventricular ejection fraction less than or equal to 25% or a target lesion supplying greater than or equal to 50% of functioning myocardium. Of 455 patients entered in the registry, 61 (13.3%) had LMCA stenosis greater than or equal to 60%. There were 42 patients in whom the PTCA target vessel was the LMCA (PTCA-LMCA) and 19 in whom it was vessel(s) other than the LMCA (PTCA-OTHER). The mean age was similar in the 2 groups (65 +/- 10 vs. 68 +/- 9 yrs, p = ns). The left ventricular ejection fraction (LVEF) was higher in PTCA-LMCA than in PTCA-other (38 +/- 16% vs. 27 +/- 16%, p less than 0.05). The number of vessels dilated/patient was higher in PTCA-LMCA than in PTCA-OTHER (2.1 +/- 1.0 vs. 1.1 +/- 0.3, p less than 0.001). There were a total of 10 in-hospital deaths (16%) in patients with LMCA greater than or equal to 60% stenosis. This exceeds the mortality of the patients with less than 60% LMCA stenosis entered in the registry (4.5%, p less than 0.001). There were 6 in-hospital deaths (14%) in PTCA-LMCA and 4 (21%) in PTCA-OTHER (p = ns).(ABSTRACT TRUNCATED AT 250 WORDS)