Rotational atherectomy for left anterior descending artery septal perforator stenosis.

Stenosis in large septal perforators can result in significant clinical ischemia. The distribution of the septal arteries is as large as many more commonly treated branch vessels. The interventricular septal blood supply has been ignored as a target for revascularization due to its inaccessibility for surgical revascularization, and the elastic recoil associated with balloon angioplasty in this location. Rotational atherectomy is a new therapeutic option for revascularization in this previously difficult location. The septal perforator ostium is the most common site of lesions and is functionally a branch ostial stenosis. We describe four cases in which rotational atherectomy was performed in patients with reversible ischemia due to septal artery stenosis. The acute angiographic results were stable, without evidence for immediate recoil. By debulking, facilitated angioplasty can yield stable acute results in this location. The small size of most septal branches and their angulated origin make rotational atherectomy challenging, and cases must be selected carefully. This previously ignored lesion location can be considered for revascularization in patients with suitable lesion and vessel morphology.

Acute and late clinical outcome after rotational atherectomy for complex coronary disease.

Rotational atherectomy is effective acutely in treating complex coronary disease, but less is known about its long-term clinical outcome. We examined the acute results and late clinical outcome in 178 patients undergoing treatment with this device. Rotational atherectomy was used to treat 240 lesions in 178 individual patients. Nineteen percent had multilesion or staged multivessel procedures, and 71% had AHA-ACC Type B2/C lesions. The procedure was completed successfully in 94% of patients. Major complications occurred in 6% (death 1%, Q-MI 2.8%, and emergency bypass surgery 2.2%). Clinical follow-up was available for 167 (94%) patients at 13+/-6 months. Thirty-five percent required additional catheterization because of recurrent symptoms or an abnormal stress test. Clinical restenosis was confirmed in 18%, and an additional 2.2% of patients had progression of disease in previously untreated segments. At the end of 1 year, 14% had undergone repeat target vessel revascularization. Cumulatively at follow-up, approximately 80% had avoided an acute major complication and repeat revascularization for restenosis. Rotational atherectomy provides excellent acute and good late clinical results. At 1 year follow-up, the likelihood of developing clinical restenosis or significant progression of disease was 1 in 5, and patients had a 1 in 7 chance of requiring revascularization because of restenosis. These findings are encouraging and indicate that rotational atherectomy can be performed safely and with a high degree of acute and late clinical success in complex coronary disease characterized by multivessel or multilesion involvement and a predominance of B2 and C lesions.

Rapid reversal of no-reflow using Abciximab after coronary device intervention.

The no-reflow phenomenon is a reduction in epicardial coronary artery blood flow without mechanical vessel obstruction. Early descriptions of this syndrome involved reperfusion after myocardial infarction. More recently, the no-reflow phenomenon has been recognized after brief ischemic times associated with coronary interventions. It is clearly a negative prognostic indicator. The proposed mechanism is multi-factorial and may involve small vessel vasospasm and potentially platelet-mediated loss of capillary autoregulation. Because of the potential role of platelets in the genesis of the no-reflow state, we administered Abciximab to two patients with no-reflow phenomenon following catheter interventions. In both of these settings, rapid distal runoff was reestablished within minutes after treatment with the platelet glycoprotein 2B/3A inhibitor.

External jugular vein approach for percutaneous right ventricular biopsy.

A technique of external jugular venous cannulation for right ventricular endomyocardial biopsy is described. This often underused approach for venous access warrants consideration in patients at high risk for bleeding complications, pneumothorax, or difficult internal jugular access who require biopsy.

Acute congestive heart failure. The need for aggressive therapy.

Immediate management of congestive heart failure (CHF) is directed at reduction of preload and afterload and augmentation of forward blood flow and cardiac output. A variety of pharmacologic agents (e.g., diuretics, positive inotropic agents, vasodilators, vasopressors) are available for use in the intensive care unit. For patients in cardiogenic shock after acute myocardial infarction, pharmacologic measures coupled with direct reperfusion therapy using percutaneous revascularization can be lifesaving. Unfortunately, many survivors of acute CHF require longterm therapy. Current drug therapy cannot cure CHF, but a search for useful and safe oral positive inotropic agents continues, with the hope of improving both the quantity and quality of patients' lives. Heart transplantation is an alternative for some patients with severe ventricular dysfunction.

Improved technique for use of half-stents remounted on a stent delivery system.

The use of half-length intracoronary Johnson & Johnson stents has been described in a number of settings. Half-stents are useful for very short lesions, avoidance of bifurcations or side-branches, ostial stenosis, covering gaps between adjacent stents, and for dissection adjacent to stents caused by postdilatation. Previously described methods for use of half-stents have involved bare stents, or significant manipulation of either the stent or the delivery sheath for remounted half-stents. We describe a method for half-stent preparation and delivery that does not involve distortion of the stent or the delivery sheath. The risk of stent loss, as can occur with bare stents, is diminished. The geometry of the stent is preserved since it is not expanded and then recrimped, and the end of the delivery sheath is not flared or distorted, which may interfere with stent delivery.

Bail-out stenting for flow limiting dissections after rotational atherectomy in complex coronary lesions.

Flow limiting dissection may occur after rotational atherectomy and require urgent management. Important questions about the safety and effectiveness of bail-out stenting in this setting remain to be answered. We have observed that emergent stenting after rotational atherectomy can be accomplished successfully in most patients, high pressure stent dilatation is both necessary and well tolerated, and lesion debulking facilitates movement of stents into diseased arterial segments.

High-speed rotational atherectomy for chronic total coronary occlusions.

Treatment of chronic total occlusions remains a limitation of percutaneous revascularization and is associated with lower immediates success and higher long-term restenosis rates compared to less severe stenoses. While part of the problem in dealing with total occlusions relates to successfully passing a wire across the occluded segment, most chronic occlusions contain large plaque burdens. Balloon dilatation sometimes falls to restore antegrade flow and often yields suboptimal angiographic results in these situations. Rotational atherectomy has proven useful in treating calcified and diffusely-diseased vessels and appears attractive for debulking lesions with large atheromatous plaques. We report our experience using rotational atherectomy in treating chronic total occlusions.

Effect of atrial septal occlusion on mitral area after Inoue balloon valvotomy.

The purpose of this study was to examine the influence of the atrial communication created during transseptal passage of the Inoue balloon catheter on calculated mitral valve area after balloon valvotomy for severe mitral stenosis. Even in the absence of oxymetric evidence for a shunt, atrial septal puncture may result in left-to-right shunting of blood with reported spurious increases in postvalvotomy mitral valve area calculations ranging from 16-29% in prior studies. Occlusion of the septal puncture site after double balloon valvotomy has previously been shown to result in decreased postvalvotomy mitral valve area determinations. We evaluated 20 patients undergoing mitral dilation. Each patient had three postvalvotomy measurements made: (1) with the Inoue balloon catheter positioned across the septum, (2) during septal occlusion with a 7F balloon-tip catheter, and (3) without any catheters across the septum. With the Inoue catheter across the septum after successful valvotomy, the cardiac output was 4.6 +/- 1.5 L/min and the calculated mitral valve area was 1.7 +/- 0.5 cm2. No difference was found in either cardiac output or valve area when the septum was unobstructed by catheters. During septal occlusion, however, the postvalvotomy cardiac output decreased to 4.3 +/- 1.3 L/min (P < 0.001) and the calculated mitral area decreased by 12% to 1.5 +/- 0.5 cm2 (P < 0.001). The calculated mitral valve areas determined with the Inoue catheter in place after valvotomy were in agreement with echo derived data. Although statistically significant differences in post-Inoue valvotomy cardiac output and calculated mitral valve area were found during septal occlusion, these differences were small.(ABSTRACT TRUNCATED AT 250 WORDS)

Peripheral arterial angioplasty balloons as adjuncts to percutaneous coronary revascularization.

Although PTCA balloon technology has improved dramatically since the first catheters were introduced over a decade ago, some limitations remain. The largest conventional balloon size available is 4.0 mm diameter. Larger size balloons are sometimes necessary for saphenous vein graft dilatation or in very large native coronary arteries. Also, adjunctive balloon angioplasty is used frequently after atherectomy and other coronary device therapy. Current generation balloons are not always necessary in this setting, since a large lumen has already been established. Thus, it has become useful in our laboratory to use peripheral arterial angioplasty balloons for both large coronary vessel dilatation, and also for adjunctive dilatation after device use. We describe our initial experience with peripheral arterial angioplasty balloons as adjuncts to percutaneous coronary revascularization.

Maximum ultrafiltration rates during peritoneal dialysis in rats.

It has been suggested that filtration pressure equilibrium could occur in peritoneal capillaries during peritoneal dialysis with very hypertonic exchanges. Rats were exposed to peritoneal dialysis solutions using 16 ml instillations, 30 minute cycles, and dextrose concentrations from 1.4 to 20 g%. There was a plateau in ultrafiltration per exchange at mean osmotic gradients above 360 mOsm/kg H2O near 12.5 ml/ex (0.42 ml/min). The findings are also compatible with filtration pressure equilibrium predictions at an effective capillary plasma flow of 0.84 ml/min and a filtration fraction near 50%. Studies with cardiovascular drugs (norepinephrine i.v., nitroprusside i.p., and dobutamine i.v.) showed no effects on the maximum ultrafiltration rates. This might indicate that flow is rather fixed because of known microcirculatory effects of solutions themselves.