Comparison of patients with either < 70% diameter narrowing or > or = 70% narrowing of the right coronary artery when performing rotational atherectomy on > or = 1 narrowing in the left coronary arteries.

This study compares the complication rates of patients undergoing rotational atherectomy of the left coronary system who had either minimal or significant narrowing of the right coronary artery (RCA). A series of 1,872 patients from a multicenter registry who were treated for left coronary artery disease were divided into <70% diameter stenosis (mild) and > or = 70% stenosis (severe) of the RCA. The patient demographics, lesion characteristics, and frequency of procedural complications for each group were compared. Of the 1,872 patients undergoing rotational atherectomy of the left coronary system, 86.3% (n = 1,616) had mild RCA disease and 13.7% (n = 256) had severe RCA disease. Comparing the mild and severe groups, death (0.8% vs 3.1%, p <0.005), non-Q-wave myocardial infarction (5.1% vs 8.6%, p <0.04), and bypass surgery (2.7% vs 5.8%, p <0.02) were increased in the severe group. Within the severe group, 7 of 8 deaths were in the 128 patients with total occlusion of the RCA. Multivariate analysis demonstrated that RCA stenosis increases the risk of death by 4.9, bypass surgery by 2.6, and non-Q-wave myocardial infarction by 1.8. Patients treated for left coronary disease who have > or = 70% stenosis of the RCA have increased complications during rotational atherectomy.

High speed rotational atherectomy: outcome in calcified and noncalcified coronary artery lesions.

OBJECTIVES: This study sought to determine the success and complication rates of high speed rotational coronary atherectomy in calcified and noncalcified lesions. BACKGROUND: Percutaneous transluminal coronary angioplasty and directional coronary atherectomy of calcified lesions are associated with reduced procedural success and increased complications. Rotational atherectomy using the Rotablator catheter abrades noncompliant plaque and may improve outcome in calcified lesions. METHODS: Data from the completed Multicenter Rotablator Registry of 2,161 rotational atherectomy procedures in single lesions were analyzed to determine the relative efficacy of rotational atherectomy for 1,078 calcified and 1,083 noncalcified lesions. The power of the study was 0.86 to detect a significant difference in outcome, if the true success rates in the noncalcified and calcified lesions were 96% and 93%, respectively. RESULTS: Patients with calcified lesions were older (mean [+/- SD] age 66.2 +/- 10.3 vs. 60.5 +/- 11.0 years, p = 0.0001) than those with noncalcified lesions. Calcified lesions were more frequently new (75% vs. 64%, p = 0.0001), angulated (27% vs. 22%, p = 0.02), eccentric (75% vs. 64%, p = 0.0001) and long (32% vs. 27%, > 10 mm in length, p = 0.01). They were also more often complex (57% vs. 46%, p = 0.001) and located in the left anterior descending coronary artery (51% vs. 44%, p = 0.001). Adjunctive coronary angioplasty was used in 82.9% of calcified and 66.9% of noncalcified lesions. Procedural success, defined as < 50% residual stenosis without major complications, was achieved in 94.3% of calcified and 95.2% of noncalcified lesions (p = 0.32). Major complication rates were 4.1% in calcified and 3.1% in noncalcified lesions (p = 0.24). Non-Q wave myocardial infarction was documented in 10.0% of calcified and 7.7% of noncalcified lesions (p = 0.054). Mean postprocedural residual stenosis was 21.6 +/- 13.9% in calcified and 23.3 +/- 15% in noncalcified lesions (p = 0.39). CONCLUSIONS: In this review of data from a large multicenter registry, the success rate of rotational atherectomy was not reduced by calcification despite the more frequent complex nature of the calcified lesions. The Rotablator catheter is likely to be the device of choice for percutaneous intervention in calcified lesions, but definitive conclusions await the results of randomized trials.

Rotational atherectomy multicenter registry: acute results, complications and 6-month angiographic follow-up in 709 patients.

OBJECTIVES: The purpose of this study was to describe data collected for an industry-sponsored multicenter registry of rotational atherectomy. BACKGROUND: Several new devices are in use or under development for coronary atherectomy. The clinical role for each is in part defined by descriptive registry data. METHODS: We describe results in 709 consecutive patients undergoing 743 procedures representing 874 lesions. The majority of lesions were in the left anterior descending coronary artery. Lesion morphology was described as eccentric (61.1%), calcified (32%), tortuous (26.6%) and long (24.9%), with previous intervention in 32.7%. RESULTS: Overall procedural success rate, including lesions treated with rotational atherectomy alone and with balloon angioplasty was 94.7% and did not vary between lesion type, location, characteristics or severity. Previously treated lesions had a significantly higher success rate (97.4%, p = 0.04) than new lesions. Major complications, including death 0.8% (95% confidence interval [CI] 0.3% to 1.7%), Q wave myocardial infarction 0.9% (95% CI 0.4% to 1.9%) and emergent coronary artery bypass surgery 1.7% (95% CI 0.9% to 3.0%), were similar to other reported devices and were associated with length and number of lesions treated. Non-Q wave myocardial infarction occurred in 3.8% of patients and was significantly associated with female gender and history of previous myocardial infarction. Abrupt occlusion occurred in 3.1% of patients and was significantly associated with bifurcated lesions and the use of adjunctive therapy. Angiographic evidence of dissection was seen in 10.5% (95% CI 8.3% to 12.7%) of patients and was significantly associated with more complex lesions, such as eccentric, long, calcified and American College of Cardiology/American Heart Association type C lesions. Overall restenosis rate was 37.7%, determined with 6-month angiography, representing 64% of treated lesions. Higher restenosis rates were associated only with poorer initial treatment outcome, diabetes and lower follow-up angiographic rate per reporting center. CONCLUSIONS: Rotational atherectomy appears to be a safe method of treatment with a high success rate in a broad spectrum of lesion types, with restenosis rates similar to other techniques. Further conclusions will require randomized trials.

Rotational ablation of coronary artery lesions using single, large burrs.

Previous clinical use of the Rotablator in coronary artery disease has involved a sequential increase in burr sizes up to 2 mm in diameter and has often utilized balloon adjunct to achieve an optimal result. We report our experience and describe our technique using a single, large burr (2.25, 2.5, or 2.75 mm diameter) without balloon assistance. The burr size was selected to approximate 70-90 percent of the apparent normal lumen diameter. Thirty-one patients with 36 lesions of complex morphology (eccentric, irregular, calcified, ulcerated, at bends, at bifurcations, completely occluded, as well as balloon failures) were successfully treated with the Rotablator. Results were assessed by computerized quantitative angiography. The percent diameter stenosis (mean +/- SD) for the group was reduced from 69.8 +/- 11.3% to 30.9 +/- 10% (p less than 0.001). The mean absolute diameter stenosis increased from 0.9 +/- 0.3 mm to 2.2 +/- 0.3 mm (p less than 0.001). Angiographically visible dissections were seen in 4 patients and were uncomplicated in 2. One patient had a non-Q-wave myocardial infarction. A fourth patient had a presumed acute occlusion 36 hr after the procedure, necessitating emergency bypass surgery, but without Q waves on the electrocardiogram or wall-motion abnormalities on the echocardiogram. Nitroglycerin was infused through the Rotablator catheter and has considerably lowered the degree and frequency of spasm. No other acute complications occurred. The mean procedure time using a single burr was shorter than when multiple burrs were used: 56.5 vs. 97.3 min, respectively (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

High speed rotational coronary atherectomy for patients with diffuse coronary artery disease.

High speed rotational coronary atherectomy was undertaken using the Rotablator in 42 patients who were suboptimal candidates for balloon angioplasty. Most patients (71%) had diffuse coronary artery disease, defined as a stenosis greater than 1 cm in length. Previous restenosis after balloon angioplasty was present in 21% and 10% had an ostial lesion. Adjunctive balloon angioplasty was not used to reduce residual stenosis after atherectomy. The procedure was successful in 76% of patients. Procedural success was achieved in 92% of patients with a lesion less than or equal to 1 cm in length, but in only 70% of patients with a lesion greater than 1 cm in length (p less than 0.01). One patient sustained abrupt closure of the target vessel, resulting in emergency bypass surgery and death. Small non-Q wave myocardial infarction occurred in eight patients (19%) and was associated with a longer lesion. The mean peak creatine kinase value in patients with non-Q wave myocardial infarction was 683 U/liter. Transient regional wall motion abnormalities were noted on the postatherectomy left ventricular angiogram in four of the eight patients with non-Q wave myocardial infarction. Follow-up angiography (at a mean interval of 6.2 +/- 2.6 months) was performed in 91% of patients and revealed restenosis (greater than 50% narrowing) in 59% The resistance rate was 22% for short lesions (less than or equal to 1 cm) and 75% for long lesions (greater than 1 cm) (p less than 0.05). In this study, the results of high speed rotational coronary atherectomy were strongly influenced by lesion length.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of mitral valve prolapse in normal children.

Although echocardiography has become the standard noninvasive method of diagnosing mitral valve prolapse, the diagnostic criteria have been established without clearly defining the range of normal patterns for mitral valve closure. The current study reports the analysis of mitral valve closure patterns in 193 children (aged 5 days to 18 years) making scheduled visits for well child care who were screened by history and physical examination to exclude structural heart disease. Mitral valve systolic leaflet position was analyzed for the appearance of any portion of either leaflet superior to the plane of the anulus. Superior systolic motion was noted in 13% of the overall study group; this pattern was uncommon in infants but more frequent in older children, with a prevalence of 35% in the 10 to 18 year age group. There was no statistically significant difference between male and female children at any age. The prevalence of superior systolic motion decreased markedly if consideration was given to its presence in more than one echocardiographic view (1%) or to displacement of the coaptation point of the mitral valve leaflets (0.5%). Superior systolic motion occurs with such frequency in normal children as to call into question the reliability of this pattern of mitral valve closure as a standard for the diagnosis of mitral valve prolapse. More restrictive diagnostic criteria which consider the degree of leaflet displacement or its presence in multiple echocardiographic views may be necessary to identify those subjects whose mitral valve closure patterns truly fall outside the range of normal.

A new method to calculate aortic valve area without left heart catheterization.

Assessment of the severity of aortic stenosis remains a commonly encountered clinical problem. Noninvasive evaluation has to date not proven sufficiently accurate in most cases to permit clinical decision making in the individual patient. Therefore, cardiac catheterization and measurement of the valve area with use of the Gorlin equation remains the standard approach in patients with suspected aortic stenosis. Doppler ultrasound allows direct measurement of blood velocity in cardiac chambers. This technique was used to study 16 patients with suspected aortic stenosis after cardiac catheterization. Aortic valve area (AVA) was calculated with the equation AVA = CO/(SEP X mean velocity), where CO is cardiac output measured by thermodilution and SEP is the systolic ejection period derived from the Doppler tracings. The resulting value was compared with valve area calculated from cardiac catheterization data and an excellent correlation was noted (r = .99). This study demonstrates that Doppler ultrasound can be used to accurately measure aortic valve area without the need for left heart catheterization.

Insulin responsiveness of isolated perfused livers from rats with streptozotocin induced diabetes.

The ability of insulin to inhibit efflux of potassium (K) and amino acid nitrogen (AAN) from perfused livers of normal and insulin deficient rats was studied. Two groups of rats with different degrees of insulin deficiency were produced by injecting varying amounts of streptozotocin. One group, classified as being moderately diabetic (MD), had fasting plasma glucose levels between 235--425 mg%, while the other group, whose plasma glucose levels greater than 425 mg%, were considered to have severe diabetes (SD). Two other groups of rats were food restricted in order to attain body weights comparable to the two groups of diabetic rats, and livers from these animals were used for control perfusions. The results indicated that the ability of insulin to suppress efflux of K and AAN from perfused livers of rats with MD was comparable to that seen in control perfusions. On the other hand, insulin could not suppress the efflux of either K or AAN from perfused livers of rats with SD. These results indicate that normal hepatic responsiveness to insulin can be lost secondary to the production of insulin deficiency.