The pesticides use and the risk for head and neck cancer: A review of case-control studies.

BACKGROUND: Tobacco, alcohol consumption, and HPV infection are the most common risk factors for head and neck cancer (HNC). Despite of this, recent evidences are growing on the association between long-term exposure to pesticides and the risk of chronic diseases, including different types of cancer. The present review evaluated in current literature evidence of an association between exposure to pesticides and the occurrence of HNCs. MATERIAL AND METHODS: A literature search of the case-control studies was conducted in the PubMed, Web of science and Cochrane databases. Methodological quality of each study was rated with the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. RESULTS: One thousand and thirty-five studies were identified and twelve met all criteria and, therefore, considered for quality assessment and data extraction. According to SIGN 50 criteria, six studies received an overall high-quality. All the studies considered of high quality found a positive association between exposure to pesticides and different HNC sites, including larynx, pharynx and nasal cavity. In addition, the increased risk was associated with the frequency of exposure. CONCLUSIONS: Finally, improving pesticide users' awareness of their risks and proper handling, as well as adopting protective measures such as the use of personal protective equipment, appear to be effective in reducing human health damage.

Awareness on oral cancer among patients attending dental school clinics in Brazil.

BACKGROUND: Oral cancer is considered a public health problem worldwide. Dental schools may play an important role in educating patients about oral cancer. This study aimed at evaluating the knowledge of patients attending clinics at two dental schools in Brazil. MATERIAL AND METHODS: From March 2017 to April 2017, 251 patients who were attending clinics at two dental schools in Recife, Brazil, were included in the study. Patients were contacted in the waiting rooms of the clinic. Each participant completed a self-administered questionnaire, which consists of 21 questions, including socio-demographic and specific information on the disease. Data were analyzed using descriptive statistics, and a chi-square test (with a 5% significance level) was used to assess the correlation between the variables, education and family income and other variables. RESULTS: Most participants were women (64.9%) with a mean age of 42.72 years. Most participants were knowledgeable about oral cancer and identified tobacco use (48.6%), alcohol consumption (25.1%), and solar radiation (12%) as the primary risk factors for the disease. Only 36.7% of the participants reported having received counselling on oral cancer, of which 18.3% received the information from a dentist. All patients with an income higher than six minimum wages were aware about oral cancer (p = 0.001). CONCLUSIONS: These findings emphasize the importance of educational programs in dental schools as well providing integrated services for patients seeking care at school clinics, including population's awareness on oral cancer.

[Transcatheter aortic valve replacement]. / Remplacement valvulaire aortique percutané.

After more than ten years of development, A. Cribier accomplished in 2002 the first percutaneous aortic valve replacement (AVR), which is a curative procedure for severe aortic stenosis and an alternative to surgery for high risk patients. With material improvements over time, the procedure has evolved to become a purely percutaneous intervention in most centers. Currently, two different valve systems, the CoreValve Revalving system and the Edwards SAPIEN valve, have each been implanted in more than 1,500 patients. Careful patient selection, including consideration of vascular access, associated cardiomyopathies and annulus size, remains critical. Although this technique has generated great enthusiasm, conventional surgery remains the gold standard in late 2008.

Randomized, double-blind, multicenter study of the Endeavor zotarolimus-eluting phosphorylcholine-encapsulated stent for treatment of native coronary artery lesions. Clinical and angiographic results of the ENDEAVOR II Trial.

AIM: The use of the Endeavor stent might reduce restenosis and stent thrombosis at 9 months. METHODS: Patients (n =1,197) treated for single coronary artery stenosis were enrolled in a prospective, randomized, double-blind study and randomly assigned to receive the Endeavor zotarolimus-eluting phosphorylcholine polymer-coated stent (n= 598) or the same bare metal stent but without the drug or the polymer coating (n=599). RESULTS: The 2 groups were well matched in baseline characteristics. Diabetes was present in 20.1% of patients; the mean reference vessel diameter was 2.75 mm; and the mean lesion length was 14.2 mm. The primary end point of target vessel failure at 9 months was reduced from 15.1% with the bare metal stent to 7.9% with the Endeavor (P=0.0001), and the rate of major adverse cardiac events was reduced from 14.4% with the bare metal stent to 7.3% with the Endeavor (P=0.0001). Target lesion revascularization was 4.6% with Endeavor compared with 11.8% with the bare metal stent (P=0.0001). The rate of stent thrombosis was 0.5% with the Endeavor, which was not significantly different from 1.2% with the bare metal stent. In 531 patients submitted to angiographic follow-up, late loss was reduced from 1.03+/-0.58 to 0.61+/-0.46 (P<0.001) in stent and from 0.72+/-0.61 to 0.36+/-0.46 (P<0.001) in segment. The rate of in-segment restenosis was reduced from 35% to 13.2% with Endeavor (P<0.0001). There was no excessive edge stenosis, aneurysm formation, or late acquired malposition by intravascular ultrasound imaging. Differences in clinical outcome were maintained at 12 and 24 months (P<0.0001). CONCLUSIONS: Compared with bare metal stents, the Endeavor stent is safe and reduces the rates of clinical and angiographic restenosis at 9, 12, and 24 months.

Influence of postangioplasty beta-irradiation on endothelial function in porcine coronary arteries.

BACKGROUND: Postangioplasty (PTCA) intracoronary radiation therapy (ICRT) has been demonstrated to limit restenosis. The consequences of these procedures on coronary reactivity are unknown. METHODS AND RESULTS: Porcine coronary arteries were studied after PTCA immediately (n=5) and 6 weeks (n=5) after ICRT (n=5 and 5, respectively), after combined PTCA+ICRT (n=5 and 7, respectively), and after no intervention (n=11). A 3-cm-long source train of Sr/Y(90) was used in vivo to deliver 16 Gy at a depth of 2 mm from the source center, as used in clinical trials. Arterial rings were mounted on myographs to record isometric tension. After achieving steady-state contraction to depolarizing physiological solution containing 40 mmol/L KCl, measured baseline tension was significantly elevated immediately after all interventions. It returned to normal levels 6 weeks after PTCA and ICRT alone but was significantly reduced if combined. Active contractions induced by 40 mmol/L KCl were maintained after combined therapy both immediately after and at 6 weeks. In these depolarizing conditions, nitric oxide-dependent relaxation to substance P was trivial after PTCA+ICRT and reduced after ICRT, whereas in the presence of physiological solution and N(omega)-nitro-L-arginine, substance P-induced relaxation was reduced after PTCA and abolished after PTCA+ICRT 6 weeks after intervention. In rings without endothelium, the relaxation mediated by sodium nitroprusside (0.1 micromol/L) was reduced immediately after PTCA and at 6 weeks. CONCLUSIONS: PTCA+ICRT altered the passive mechanical properties of porcine coronary arterial wall. Furthermore, at 6 weeks, receptor-operated release of endothelium-derived nitric oxide and endothelium-derived hyperpolarizing factor was reduced by ICRT and PTCA alone, respectively, and was prevented by their combination.

High-dose intravascular beta-radiation after de novo stent implantation induces coronary artery spasm.

BACKGROUND: Intracoronary brachytherapy is effective in preventing restenosis after coronary interventions. However, in vitro and animal studies have shown that irradiation produces immediate and sustained endothelial dysfunction. This study assesses the clinical relevance of impaired vasomotoric function induced by brachytherapy. METHODS AND RESULTS: We analyzed the occurrence of postradiation coronary artery spasms in 1 animal study and 2 clinical trials investigating the effects of high-dose intracoronary beta-radiation after de novo coronary artery stenting. Irradiated segments (IRSs) proximal and distal to the stent were studied by quantitative coronary angiography after stenting, after radiation, and at the end of the procedure. There was an 67% overall incidence of coronary artery spasm in the IRSs immediately after beta-radiation compared with 9% after sham treatment (P<0.001). Whereas in most cases this phenomenon was only minor or moderate, in 12 cases, 4 (22%) animals and 8 (28%) patients, severe coronary spasm (>90% diameter stenosis) with significant ECG-changes or hemodynamic instability was observed. Relief of spasms was protracted (mean time until complete relief of spasm 423+/-122 seconds) and required repetitive intracoronary administration of nitroglycerin (mean dose: 1.2+/-0.6 mg). CONCLUSIONS: Vasoconstriction is a frequent reaction of coronary arteries after high-dose intracoronary beta-radiation, necessitating repetitive administration of vasodilators.

Randomized comparison of elective stent implantation and coronary balloon angioplasty guided by online quantitative angiography and intracoronary Doppler. DESTINI Study Group (Doppler Endpoint STenting INternational Investigation).

BACKGROUND: The purpose of this study was to compare long-term outcomes of coronary stenting in all lesions (elective stenting) or only in lesions with inadequate morphological and functional results after balloon angioplasty (guided PTCA). METHODS AND RESULTS: Treatment of multivessel disease, with any lesion length and vessel size, was allowed provided that all lesions were suitable for stent implantation. Patients were randomized to elective stent implantation (n=370) or guided PTCA (n=365). An optimal PTCA result (residual diameter stenosis 2.0, absence of threatening dissections) was achieved in 166 lesions (43%). The remaining 218 lesions underwent stent implantation (provisional stenting). Final residual diameter stenosis was lower in the elective and provisional stent groups (9.3% and 10.2%) than in the optimal PTCA group (24.8%, P:<0. 00001). On an intention-to-treat analysis, the probability of >/=1 major adverse cardiac event at 12 months was 17.8% in the elective stenting group and 18.9% in the guided PTCA group (20.1% for optimal PTCA and 18.0% for the provisional stenting subgroup, P:=NS). The incidence of repeat target lesion revascularization at 1 year was 14. 9% in the elective stent group and 15.6% in the guided PTCA group (17.6% for optimal PTCA and 14.1% for the provisional stenting subgroup, P:=NS). CONCLUSIONS: When balloon angioplasty is guided by online quantitative angiography and Doppler-derived coronary flow reserve, with provisional stenting reserved for suboptimal results, early and late clinical outcomes are comparable to those achieved by elective stenting of all patients.

The effects of intracoronary brachytherapy on the natural history of postangioplasty dissections.

OBJECTIVES: The aim of this study was to determine the natural history of postangioplasty intravascular ultrasound (IVUS)-detected dissections and to assess the influence of intracoronary beta-radiation on dissection resolution. BACKGROUND: Intracoronary radiotherapy is considered to impair exaggerated vessel healing. Conversely, excessive healing impairment may increase the risk of complications due to unhealed dissection. Alternatively, residual dissection may represent an innocent marker of adequate therapy. METHODS: Immediate postangioplasty and six-month follow-up IVUS studies of 94 patients in the IVUS substudy of the MultiVitamins and Probucol (MVP) trial and 26 nonstented patients in the Beta Energy Restenosis Trial (BERT) were analyzed for the presence or absence of dissection. RESULTS: Of the 28 patients with postangioplasty dissections in MVP, only one had evidence of residual dissection at six months (95% confidence interval [CI] for failure rate 0.2%; 20.2%). Conversely, 9 of 16 dissections had healed in BERT (95% CI for failure rate 30.6%; 79.2%) (p < 0.0002). Nevertheless, an index based on dissection arc and length demonstrated improvement in the irradiated patients. Irradiated patients with residual dissections showed significant increase in lumen area at six-months (5.10 +/- 0.98 to 7.11 +/- 2.61 mm2, p < 0.02) not noted when there was resolution of the dissection (6.03 +/- 2.38 to 6.36 +/- 3.33 mm2, p = NS). In both groups the external elastic membrane area was unchanged at follow-up. CONCLUSIONS: Resolution appears to be the natural history of IVUS-detected dissections in most cases. Significant resolution of dissection occurs following intracoronary beta-radiation as reflected in reduced dissection index at six-months in these patients, although significant impairment of vessel wall healing was noted.

Percutaneous mitral valvuloplasty in surgical high risk patients.

Among 126 consecutive patients undergoing percutaneous mitral valvuloplasty, 34 were judged to be at high risk for surgery on the basis of age greater than 70 years (n = 13), New York Heart Association functional class IV (n = 11), ejection fraction less than or equal to 35% (n = 3), severe pulmonary hypertension (n = 7), need for associated coronary bypass (n = 4) or additional valve surgery (n = 20) or severe pulmonary disease (n = 3). Baseline features of the high risk group were substantially worse than those of the other patients: age (65 +/- 11 versus 49 +/- 12 years; p = 0.0001) and echocardiographic score (9.4 +/- 1.8 versus 8.2 +/- 1.5; p = 0.005) were higher, whereas cardiac output (2.9 +/- 0.9 versus 4.1 +/- 1.2 liters/min; p = 0.0001) and mitral valve area (0.9 +/- 0.4 versus 1.1 +/- 0.3 mm2; p = 0.002) were lower. Three high risk patients experienced technical failures and three others had major complications. Among the remaining 28 patients, 18 (65%) had a complete hemodynamic success, 4 (14%) an incomplete success and 6 (21%) hemodynamic failure. Stepwise logistic regression analysis retained echocardiographic score as the only factor independently predictive of success. The percent increase in mitral valve area also correlated with echocardiographic score (r = 0.51, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Four-year follow-up of patients undergoing percutaneous balloon mitral commissurotomy. A report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry.

OBJECTIVES: This study reports the long-term outcome of patients undergoing percutaneous balloon mitral commissurotomy who were enrolled in the National Heart, Lung, and Blood Institute (NHLBI) Balloon Valvuloplasty Registry. BACKGROUND: The NHLBI established the multicenter Balloon Valvuloplasty Registry in November 1987 to assess both short- and long-term safety and efficiency of percutaneous balloon mitral commissurotomy. METHODS: Between November 1987 and October 1989, 736 patients > or = 18 years old underwent percutaneous balloon mitral commissurotomy at 23 registry sites in North America. The maximal follow-up period was 5.2 years. RESULTS: The actuarial survival rate was 93 +/- 1% (mean +/- SD), 90 +/- 1.2%, 87 +/- 1.4% and 84 +/- 1.6% at 1, 2, 3 and 4 years, respectively. Eighty percent of the patients were alive and free of mitral surgery or repeat balloon mitral commissurotomy at 1 year. The event-free survival rate was 80 +/- 1.5% at 1 year, 71 +/- 1.7% at 2 years, 66 +/- 1.8% at 3 years and 60 +/- 2.0% at 4 years. Important univariable predictors of actuarial mortality at 4 years included age > 70 years (51% survival), New York Heart Association functional class IV (41% survival) and baseline echocardiographic score > 12 (24% survival). Multivariable predictors of mortality included functional class IV, higher echocardiographic score and higher postprocedural pulmonary artery systolic and left ventricular end-diastolic pressures (p < 0.01). CONCLUSIONS: Percutaneous balloon mitral commissurotomy has a favorable effect on the hemodynamic variables of mitral stenosis, and long-term follow-up data suggest that it is a viable alternative with respect to surgical commissurotomy in selected patients.

Restenosis and progression of coronary atherosclerosis after coronary angioplasty.

The relation between restenosis and progression of atherosclerosis in other coronary segments after angioplasty was studied in 98 consecutive patients with 110 coronary stenoses successfully treated with angioplasty. At early angiographic restudy (5 +/- 2 months after angioplasty) 37 patients (38%) had restenosis (defined as a stenosis greater than or equal to 50% of the luminal diameter or loss of greater than or equal to 50% of the gain achieved by angioplasty); progression of atherosclerosis was observed in 4 patients with and 7 without restenosis (13 versus 11%, p = NS). Ninety of the 98 patients underwent a late angiographic restudy a mean of 34 +/- 11 months after angioplasty. Late restenosis was found in one patient. Progression of coronary artery disease (defined as a greater than or equal to 20% decrease in the diameter of a vessel initially narrowed by greater than or equal to 50% or a greater than or equal to 30% decrease when the initial stenosis was less than 50%) was examined in relation to restenosis in 85 of the 90 patients. It occurred in 9 of 27 patients with and 22 of 58 patients without restenosis (33 versus 38%, p = NS). Restenosis developed more rapidly than did progression of disease. Diameter stenosis increased from 35 +/- 8 to 73 +/- 11% at the early restudy in lesions with restenosis; in lesions with disease progression it increased from 9 +/- 18 to 20 +/- 28% (p less than 0.001) at the early restudy to 53 +/- 21% (p less than 0.001) at the late restudy.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple coronary angioplasty: a model to discriminate systemic and procedural factors related to restenosis.

To assess the interrelation of clinical and procedural factors responsible for restenosis, 119 patients undergoing coronary arteriography were studied a mean of 5.8 +/- 3 months after successful multiple percutaneous transluminal coronary angioplasty. In all clinical, angiographic and procedural variables, the 119 patients undergoing repeat catheterization were similar to the 87 patients that did not. Overall, restenosis occurred in 74 (34%) of 215 lesions. Sixty-three patients had no restenosis, 44 had at least one restenosis and 12 had restenosis at all angioplasty sites. The statistical distribution of restenoses did not follow a binomial model, suggesting that restenosis is more than a lesion-specific phenomenon. Of all the clinical and procedural variables assessed by multivariate logistic regression analysis, only percent stenosis before angioplasty (p less than 0.01), diabetes mellitus (p less than 0.01) and percent stenosis after angioplasty (p less than 0.05) were predictive of restenosis in the entire group. Patients with no restenosis and patients with restenosis at all sites were not different with respect to procedural variables; however, patients with restenosis at all sites more often (p less than 0.05) had diabetes and recent onset angina. In contrast, patients with no restenosis differed from patients with isolated restenosis with respect to procedural variables: severity of stenosis before and after angioplasty, balloon/artery lumen ratio and maximal inflation pressure. Thus, procedural factors may be more related to isolated restenosis, but patient-related factors such as diabetes and recent onset angina may play a more important role in patients with multiple restenoses.

Low molecular weight heparin (reviparin) in percutaneous transluminal coronary angioplasty. Results of a randomized, double-blind, unfractionated heparin and placebo-controlled, multicenter trial (REDUCE trial). Reduction of Restenosis After PTCA, Early Administration of Reviparin in a Double-Blind Unfractionated Heparin and Placebo-Controlled Evaluation.

OBJECTIVES: The specific objective of the REDUCE trial was to evaluate the effect of low molecular weight heparin on the incidence and occurrence of restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Unfractionated heparin and its low molecular weight fragments possess antiproliferative effects and have been shown to reduce neointimal smooth muscle cell migration and proliferation in response to vascular injury in experimental studies. METHODS: The REDUCE trial is an international prospective, randomized, double-blind, multicenter study. Twenty-six centers in Europe and Canada enrolled 625 patients with single-lesion coronary artery obstructions suitable for PTCA. Three hundred six patients received reviparin as a 7,000-U bolus before PTCA, followed by 10,500 U as an infusion over 24 h and then twice-daily 3,500-U subcutaneous application for 28 days. The 306 patients in the control group received a bolus of 10,000 U of unfractionated heparin followed by an infusion of 24,000 U over 24 h. These patients then underwent 28 days of subcutaneous placebo injections. The primary end points were efficacy (defined as a reduction in the incidence of major adverse events [i.e., death, myocardial infarction, need for reintervention or bypass surgery]), absolute loss of minimal lumen diameter and incidence of restenosis during the observation period of 30 weeks after PTCA. RESULTS: Using the intention to treat analysis for all patients, 102 (33.3%) in the reviparin group and 98 (32%) in the control group have reached a primary clinical end point (relative risk [RR] 1.04, 95% confidence interval [CI] 0.83 to 1.31, p = 0.707). Likewise, no difference in late loss of minimal lumen diameter was evident for both groups. Acute events within 24 h occurred in 12 patients (3.9%) in the reviparin group and 25 (8.2%) in the control group (RR 0.49, 95% CI 0.26 to 0.92, p = 0.027) during or immediately after the initial procedure. In the control group, eight major bleeding complications occurred, and in the reviparin group, seven were observed within 35 days after PTCA. CONCLUSIONS: Reviparin use during and after coronary angioplasty did not reduce the occurrence of major clinical events or the incidence of angiographic restenosis over 30 weeks.

First international new intravascular rigid-flex endovascular stent study (FINESS): clinical and angiographic results after elective and urgent stent implantation. The FINESS Trial Investigators.

OBJECTIVES: The purpose of this study was to determine the feasibility, safety and efficacy of elective and urgent deployment of the new intravascular rigid-flex (NIR) stent in patients with coronary artery disease. BACKGROUND: Stent implantation has been shown to be effective in the treatment of focal, new coronary stenoses and in restoring coronary flow after coronary dissection and abrupt vessel closure. However, currently available stents either lack flexibility, hindering navigation through tortuous arteries, or lack axial strength, resulting in suboptimal scaffolding of the vessel. The unique transforming multicellular design of the NIR stent appears to provide both longitudinal flexibility and radial strength. METHODS: NIR stent implantation was attempted in 255 patients (341 lesions) enrolled prospectively in a multicenter international registry from December 1995 through March 1996. Nine-, 16- and 32-mm long NIR stents were manually crimped onto coronary balloons and deployed in native coronary (94%) and saphenous vein graft (6%) lesions. Seventy-four percent of patients underwent elective stenting for primary or restenotic lesions, 21% for a suboptimal angioplasty result and 5% for threatened or abrupt vessel closure. Fifty-two percent of patients presented with unstable angina, 48% had a previous myocardial infarction, and 45% had multivessel disease. Coronary lesions were frequently complex, occurring in relatively small arteries (mean [+/-SD] reference diameter 2.8 +/- 0.6 mm). Patients were followed up for 6 months for the occurrence of major adverse cardiovascular events. RESULTS: Stent deployment was accomplished in 98% of lesions. Mean minimal lumen diameter increased by 1.51 +/- 0.51 mm (from 1.09 +/- 0.43 mm before to 2.60 +/- 0.50 mm after the procedure). Mean percent diameter stenosis decreased from 61 +/- 13% before to 17 +/- 7% after intervention. A successful interventional procedure with < 50% diameter stenosis of all treatment site lesions and no major adverse cardiac events within 30 days occurred in 95% of patients. Event-free survival at 6 months was 82%. Ninety-four percent of surviving patients were either asymptomatic or had mild stable angina at 6 month follow-up. CONCLUSIONS: Despite unfavorable clinical and angiographic characteristics of the majority of patients enrolled, the acute angiographic results and early clinical outcome after NIR stent deployment were very promising. A prospective, randomized trial comparing the NIR stent with other currently available stents appears warranted.

Reno, a European postmarket surveillance registry, confirms effectiveness of coronary brachytherapy in routine clinical practice.

PURPOSE: To assess, by a European registry trial, the clinical event rate in patients with discrete stenotic lesions of coronary arteries (de novo or restenotic) in single or multiple vessels (native or bypass grafts) treated with beta-radiation. MATERIALS AND METHODS: Between April 1999 and September 2000, 1098 consecutive patients treated in 46 centers in Europe and the Middle East with the Novoste Beta-Cath System were included in Registry Novoste (RENO). RESULTS: Six-month follow-up data were obtained for 1085 patients. Of 1174 target lesions, 94.1% were located in native vessels and 5.9% in a bypass graft; 17.7% were de novo lesions, 4.1% were restenotic, and 77.7% were in-stent restenotic lesions. Intravascular brachytherapy was technically successful in 95.9% of lesions. Multisegmental irradiation, using a manual pullback stepping maneuver to treat longer lesions, was used in 16.3% of the procedures. The in-hospital rate of major adverse cardiac events was 1.8%. At 6 months, the rate was 18.7%. Angiographic follow-up was available for 70.4% of the patients. Nonocclusive restenosis was seen in 18.8% and total occlusion in 5.7% of patients. A combined end point for late (30-180 days) definitive or suspected target vessel closure was reached in 5.4%, but with only 2% of clinical events. Multivariate analysis was performed for major adverse cardiac events and late thrombosis. CONCLUSIONS: Data obtained from the multicenter RENO registry study, derived from a large cohort of unselected consecutive patients, suggest that the good results of recent randomized controlled clinical trials can be replicated in routine clinical practice.

Predictive factors of restenosis after multivessel percutaneous transluminal coronary angioplasty.

To evaluate the rate and predictive factors of restenosis after multivessel percutaneous transluminal coronary angioplasty (PTCA), 122 consecutive patients with multivessel PTCA performed in the same setting were included in a prospective study. Systematic angiographic control at 6 months was performed in 112 patients (92%). Restenosis (increase > 20% and stenosis > 50%) was found in 62 patients (55%) and 82 of 254 segments (32%) were dilated. Statistical analysis identified the number of successfully dilated segments as the only predictor of restenosis by patient (2.4 +/- 0.7 vs 2.0 +/- 0.7; p < 0.03), and the greater degree of residual stenosis as the only predictor of restenosis by lesion (30 +/- 14% vs 23 +/- 12%; p < 0.005). Twenty-two of 62 restenosed patients (35%) were asymptomatic (group 1). Baseline clinical and angiographic characteristics of these patients were similar to those with symptomatic restenosis (n = 40; group 2) and without restenosis (n = 50; group 3). Repeat revascularization for restenosis was used only in symptomatic patients (re-PTCA in 36; bypass surgery in 4). After a mean follow-up of 75 +/- 24 months, clinical status, and rates of cardiac death and myocardial infarction were similar in the 3 groups. Medical care was similar in groups 1 and 3, and higher in group 2. However, the rate of repeat revascularization for progression of disease was similar in the 3 groups (29%). In conclusion, restenosis is a frequent event after multivessel PTCA and is strongly related to the number of successfully dilated segments.(ABSTRACT TRUNCATED AT 250 WORDS)

Five- to ten-year outcome after multivessel percutaneous transluminal coronary angioplasty.

The early and late outcome of patients who underwent multivessel percutaneous transluminal coronary angioplasty (PTCA) in a 1-stage procedure are described, and the predictors for clinical event and new revascularization procedure are identified. Of 1,937 patients treated by PTCA between 1981 and 1986, 203 (10.4%) had multivessel PTCA in a 1-step procedure. A follow-up extending to 71 +/- 23 months was obtained in 195 patients (96%). Primary success was achieved in 91% of 494 attempted sites, and complete revascularization in 65% of 203 patients. There were no in-hospital deaths. Acute complications occurred in 13 patients (6.4%), including non-Q-wave (n = 8) and Q-wave (n = 5) infarction, and urgent coronary artery bypass surgery (n = 3). Before PTCA, 126 patients (62%) were in class III or IV of the Canadian Cardiovascular Society classification; at follow-up, 84% were angina-free or in class I. Death occurred in 14 patients and nonfatal myocardial infarction in 18. Angiographic restenosis was diagnosed in 37.2% of dilated lesions in 96 patients (60% of 159 restudied). A repeat revascularization procedure for restenosis or progression of disease, or both, was needed in 92 symptomatic patients (47%). The survival rate at 7 years without the need for surgery or PTCA was 53%, and cardiac survival without myocardial infarction was 85.5%. The only independent predictor of cardiac death was ejection fraction (p < 0.001). The rate of restenosis per patient was primarily determined by the number of segments dilated, whereas progression of disease was related to the number of nonsignificant coronary artery stenoses (< 50%) at baseline (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon mitral commissurotomy in patients aged > or = 70 years.

Of 280 patients treated by balloon mitral commissurotomy (BMC) between 1987 and 1991, 28 (10%) were > or = 70 years old. Two patients with associated significant aortic stenosis were excluded from the study. Older patients more often were in New York Heart Association class III or IV (84 vs 67%; p < 0.007) and atrial fibrillation (61 vs 36%; p < 0.0001), and had a higher echocardiographic score (9.3 +/- 2 vs 8 +/- 1.6; p < 0.0004) and a lower baseline cardiac index (2.1 +/- 0.6 vs 2.4 +/- 0.6 liters/min/m2; p < 0.03) than younger ones. Baseline mean pulmonary pressure (37 +/- 11 vs 34 +/- 12 mm Hg), transmitral gradient (14 +/- 4 vs 14 +/- 5 mm Hg) and valve area (1.0 +/- 0.4 vs 1.1 +/- 0.3 cm2) were not different between older and younger patients (p = NS). Acute complications during the procedure (including cardiac perforation, embolism, severe mitral regurgitation and surgical atrial shunt), and 30-day mortality after BMC were more frequent in older than younger patients (27 vs 9% [p < 0.01], and 12 vs 0.8% [p < 0.005], respectively). A complete success, defined as a mitral valve area increase > 25% and postmitral valve area > 1.5 cm2 was obtained in 16 of the 22 older patients (72%) with the completed procedure (compared with 81% of younger ones; p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Ergonovine testing in a coronary care unit.

This study describes the results of ergonovine testing in 100 consecutive patients who underwent this procedure in a coronary care unit. All patients had recently undergone coronary arteriography. A bolus injection of ergonovine was administered at 5 minute intervals in the following doses (mg): 0.0125, 0.025, 0.05, 0.1, 0.2, 0.3 and 0.4. The criterion for a positive test was the appearance of S-T elevation greater than 1 mm. The test was positive in all 17 patients known to have variant angina and in 18 (40 percent) of 45 patients who had a history of chest pain judged strongly suggestive of variant angina but who had no electrocardiogram recorded during pain. Of 38 patients with a history of chest pain classified as not entirely typical of variant angina, only 1 (2.6 percent) had a positive test. Of the 64 patients with a negative ergonovine test, 47 had chest pain and 25 had nausea but none had more serious complications. Ventricular arrhythmia accompanied S-T elevation in 18 of the 36 patients with a positive test but occurred in only 4 of the 64 with a negative test (p < 0.0005). No patient needed treatment with antiarrhythmic drugs. Four of the 36 patients with a positive test had serious complications: severe transient hypotension (2 patients), recurrent episodes of angina with S-T elevation (1 patient) and a subendocardial infarction (1 patient). Thus, ergonovine testing is useful in patients with a typical clinical history of variant angina but without an electrocardiogram recorded during pain. In this study, a small but definite incidence of serious complications occurred during a positive test.

Coronary anatomic and procedural characteristics of patients randomized to coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI).

The Bypass Angioplasty Revascularization Investigation (BARI) is a randomized multicenter clinical trial that compares a strategy of initial coronary angioplasty to initial coronary bypass surgery for patients with multivessel coronary artery disease. The purpose of this report is to describe the coronary anatomic characteristics of the 915 patients assigned to the angioplasty arm of the trial and the manner in which angioplasty was performed. Patients were eligible for BARI if they demonstrated multivessel coronary artery disease, had a clinical indication for revascularization, and were suitable for both coronary angioplasty and bypass surgery. Clinical and technical features of angioplasty procedures were systemically recorded. Coronary cineangiograms obtained before and during the angioplasty were interpreted by a central radiographic laboratory. Angioplasty was performed in 904 (98.8%) of the 915 patients assigned to that initial strategy. Of 6,530 coronary arterial lesions identified, 3,427 (52.5%) were significant (> 50% diameter reduction). The majority of patients had 2-6 significant lesions, with 3 being most common. Angioplasty was attempted in 92.2% of the lesions for which it was intended. Lesions most frequently attempted ranged between 50% and 79% in severity. Multilesion angioplasty was performed in 77.5% of patients and 69.7% had multivessel angioplasty. Factors that influenced whether a lesion was attempted included lesion severity, clinical significance, and complexity. For lesions presenting as total occlusions, a history of recent infarction and postinfarction angina favored attempting angioplasty. Patients assigned to the angioplasty arm of BARI had evidence of extensive multilesion and multivessel coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)