Technetium-99m-sestamibi SPECT to detect restenosis after successful percutaneous coronary angioplasty.

UNLABELLED: This study evaluated the accuracy of 99mTc SPECT in predicting restenosis after primary successful PTCA. METHODS: Thirty-seven patients with equivocal symptom-limited exercise stress testing were evaluated. All patients underwent separate day exercise-rest 99mTc-sestamibi SPECT. The perfusion studies were evaluated using three different methods of analysis: visual inspection, semiquantitative and quantitative polar map analysis. The perfusion studies were interpreted in absence of a pre-PTCA scan. All patients underwent a control coronary angiography within 1 mo. RESULTS: Sensitivity and specificity of 99mTc-sestamibi SPECT in predicting restenosis were 87.5-78%, 50-65% and 75-74% for visual inspection, semiquantitative and quantitative polar map analysis, respectively. Sensitivity and specificity related to the vascular territories were: LAD territory 93-73% (qualitative analysis), 53-60% (semiquantitative analysis), 80-67% (quantitative analysis); LCX territory 83-100% (qualitative analysis); and 33-100% (semiquantitative analysis), 67-100% (quantitative analysis); and RCA territory 67-80% (qualitative analysis), 67-60% (semiquantitative analysis), 67-80% (quantitative analysis). CONCLUSION: These data suggest that 99mTc-sestamibi SPECT is a useful noninvasive tool in the follow-up evaluation of patients who have undergone angiographically successful coronary angioplasty even in the absence of a pre-PTCA perfusion study.

Invasive and echocardiographic evaluation of non-Q myocardial infarction with isolated stenosis of descending anterior coronary artery.

Prognostic and clinical characteristics of acute myocardial infarction (AMI) can usually justify surgical and/or angioplastic approach if the residual ventricular function is still good. Multivessel disease frequently complicates results interpretation. We studied with 2D echocardiography and coronary angiography two groups of patients with one vessel stenosis located on anterior descending (AD) and previous AMI (means 19 days): 23 patients with spontaneous non-Q infarction (group 1), and 23 patients with Q infarction. Left ventricular function was better in group 1. Percent occlusion of AD was lower in group 1 and angiographic AD caliber was significantly higher. Differences between groups were much more evident in subgroups with proximal stenosis of AD: patients of non-Q subgroups had very good left ventricular function but frequently had post-AMI instable angina (88%). Our results underline the usefulness of aggressive diagnostic and therapeutic approach in non-Q AMI, because of higher amount of myocardium at risk.

Effects of transcatheter aortic valve implantation on left ventricular mass and global longitudinal strain: tissue Doppler and strain evaluation.

INTRODUCTION: Transcatheter aortic valve implantation is the option of choice for high surgical risk patients suffering from symptomatic aortic stenosis. We aimed to evaluate the influence of baseline global longitudinal strain on left ventricular mass regression after the procedure. METHODS: We enrolled 23 patients with pure symptomatic severe aortic stenosis who underwent CoreValve prosthesis (Medtronic, Minneapolis, MN) implantation. Everyone had echocardiography registration before the procedure and after six months in order to analyze two-, three-, and four-chamber peak longitudinal strain and global longitudinal strain. RESULTS: After the procedure New York Heart Association class, peak and mean aortic valve gradients (p<0.001 for all) improved. Interventricular septum and posterior wall thicknesses decreased (p<0.001 for both). Moreover, left ventricular mass index for body surface area changed from 190±44 to 143±30 g/m(2), (p<0.001). Finally, global longitudinal strain significantly increased (from 9.4±0.9 to 11.5±0.8%; p<0.001), as well as its components. Baseline global longitudinal strain correlated with left ventricular mass regression (r=0.560; p=0.005; 2-sided) and predicted it at linear regression analysis (B=23.707; p=0.005; adjusted R(2)=0.281). CONCLUSIONS: Global longitudinal strain and its components improved six months after the procedure. Moreover, baseline global longitudinal strain seemed to predict left ventricular mass regression in patients with pure aortic stenosis undergoing transcatheter aortic valve implantation. This finding could be related to the extent of myocardial fibrosis which is also responsible for lack of left ventricular mass regression and poorer prognosis.

[Isolated tricuspid valve prolapse and meso-telesystolic click. Echocardiographic diagnosis (author's transl)]. / Prolasso tricuspidale isolato e click meso-telesistolico. Diagnosi ecocardiografica.

A 9-year-old girl in whom tricuspid valve prolapse was confirmed by echocardiogram is presented. The patient had a non ejection systolic click, but the echocardiogram of the mitral valve demonstrated no prolapse of either leaflet of the mitral. No other abnormality of the heart was seen.

[Echocardiography in the evaluation of ventricular function]. / Die Echokardiographie in der Beurteilung der Ventrikelfunktion.

The ultrasonic beam used for quantitative assessment of left ventricular (LV) function traverses the heart in a projection similar to the familiar angiographic left anterior oblique projection. It crosses the anterior wall of the right ventricle, the right ventricular cavity, the interventricular septum, the LV cavity and the posterior wall of the left ventricle. Whereas the cyclic changes of the right ventricular diameter are rarely clearly determined by echocardiography, the easily assessed cyclic changes of the LV endocardial transverse diameter are useful measure of LV FUNCTION. Of practical importance are the percentage of systolic shortening of the LV diameter (%Sh) and the mean velocity of circumferential fiber shortening (VCF). There are several factors, such as placing of the ultrasonic transducer, the shape and size of the LV cavity and rotational movements of the heart as a whole, that influence echocardiographic determination of the transverse LV diameter. In patients with asynergic contraction, %Sh and VCF cannot be used as measures of overall LV performance, but localized contraction disturbances of the septum and the posterior wall may be detected from the reduced extent of wall motion in a given LV segment during a full sweep from the base to the apex. The most important indications for echocardiographic assessment of LV function are valvar diseases with chronic LV pressure or volume overload, and congestive cardiomyopathy. Echocardiography has proved useful in serial evaluation of LV function in patients undergoing valvar heart surgery. Assessment of LV volume by standard echocardiography using the cubic formula is not satisfactory. More accurate determination of volumes is provided by formulas that include the actual ratio of the LV long axis to the minor axis.

[Post-traumatic tricuspid insufficiency. Hemodynamic and echocardiographic study of one case (author's transl)]. / Insufficienza tricuspidale traumatica. Studio emodinamico ed ecocardiografico di un caso.

The case of a patient, aged 63, with isolated post-traumatic tricuspid insufficiency is described. In this patient the correct diagnosis was made immediately after a non penetrating chest trauma. Physical examination, electrocardiogram, phonocardiogram, chest roentgenogram, hemodynamic and angiocardiographic investigations are reported. The usefulness of echocardiographic examination is emphasized and a comparison with the fail valve syndrome of the mitral valve is made. According to previous reports no immediate surgery was considered and the patient is still under follow up.

[Stable angina: long-term results]. / Angina stabile: risultati a lungo termine.

We report on 345 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) for stable angina in a 5-year period, with an average follow-up of 34 months (range 12-72). The primary success rate was 94.5%. The late mortality and incidence of myocardial infarction were 1.5% and 2.1% respectively. The rate of recurrence of angina was 34.5% and required PTCA (28.5%) and/or coronary artery bypass grafting (7%). At the end of follow-up 79.5% of patients were free from angina and a further 10% had improved. Our data confirm the importance of PTCA in stable angina.

[Coronary angioplasty in chronic total occlusion: angiography results, complications, and predictive factors]. / L'angioplastica coronarica nelle occlusioni totali croniche: risultati angiografici, complicanze e fattori predittivi.

The results of coronary angioplasty of chronic total occlusions are still controversial. We examined baseline clinical and angiographic parameters and the success and complication rates of 142 consecutive procedures of coronary angioplasty of chronic occlusions selected among 1084 total procedures performed between January 1989 and May 1993. Procedural success was obtained in 109 procedures (77%) with 4 major cardiac complications (2.8%) consisting in one cardiac death caused by left main artery occlusion following an attempt of dilatation of an occluded left anterior descending artery, two non Q wave myocardial infarctions caused by distal embolization and one cardiac tamponade following artery perforation, successfully treated by pericardiocentesis. Extensive coronary dissection occurred in 24 procedures (17%): 5 caused vessel reocclusion and 19 were successfully treated by prolonged balloon inflation and/or use of long balloons or stent implantation. Among 15 baseline clinical and angiographic variables, none was predictive of cardiac complications or coronary artery dissection. In contrast, procedural success was significantly related with absence of bridging collaterals, duration of occlusion < 3 months and a tapered or thrombotic morphology of occlusion. Presence or absence of collaterals was the most significant variable selected by multivariate discriminant analysis. When patients with bridging collaterals were excluded from the analysis, occlusion morphology was the most important determinant. Success rates were 95% and 82% in patients with a tapered morphology lesion with < 3 months and > 3 months duration, respectively (ns); in contrast, success rates were 79% and 36% in patients with abrupt occlusion morphology of < and > 3 months duration (p = 0.001).

[Lower myocardial infarct with depression of the ST segment in anterior precordial leads. Correlation of the electrocardiogram, coronarography and ventriculography performed in the acute phase]. / Infarto inferiore con sottoslivellamento del tratto ST nelle derivazioni precordiali anteriori. Correlazione fra elettrocardiogramma, coronarografia e ventricolografia eseguiti in fase acuta.

We report on 11 pts affected by acute inferior myocardial infarction (group A: 4 pts without precordial ST-segment depression; group B: 7 pts with ST precordial ST-segment depression). These pts underwent left and right coronarography and left ventriculography in the course of intracoronary thrombolysis. We did not observe, in the group B pts, an involvement of the LAD branch of the left coronary, neither contractility abnormalities of the left ventricular anterior wall. ST depression in the precordial leads was associated with severe and extensive abnormalities of left ventricular inferior wall contractility.

[Effectiveness and duration of action of nifedipine in effort angina (author's transl)]. / Efficacia e durata d'azione della nifedipina nell'angor da sforzo. Somministrazione acuta.

The anti-anginal activity of nifedipine was studied after a dosage of 10 and 20 mg in nine patients suffering from a typical, stable effort angina pectoris. The effectiveness and the duration of action of nifedipine was evaluated by serial cycloergometer exercise testing repeated after the administration of the two dosage of nifedipine, for six hours. Nifedipine significantly increased exercise tolerance before angina pectoris, with an action lasting at least two hours after 10 mg and six hours after 20 mg. We also evaluated the changing of hemodynamic parameters (heart rate, blood pressure, double product) before and after the drug in the same day.

[Coronary angiographic study of patients with non-Q myocardial infarct: correlations with the initial electrocardiographic aspect and prognosis]. / Studio coronarografico nei pazienti con infarto miocardico non-Q: correlazioni con l'aspetto elettrocardiografico iniziale e la prognosi.

The purpose of our study was to evaluate, during the early phase, the coronary anatomy of the patients who suffered from an acute non-Q myocardial infarction (non-Q MI) and to correlate it with the ECG findings and with clinical evolution. We studied 76 patients (pts.), mean age 56 +/- 9 years, who had their a first non-Q MI (reinfarctions non included). They all underwent angiographic examination within an average period of 18 days (range 5-30 days). In the whole group of patients it is worthwhile noting: A) the elevated occurrence of left main lesions (11% of pts.) and multivessel disease (60%); B) the great percentage (41%) of patients with open infarct-related vessel but with very critical residual stenosis (above 90% of total lumen); C) the presence of collateral vessels in almost all the pts. (91%) with totally occluded infarct-related artery. During the 12 month follow-up, in all groups was a high occurrence (above 70%) of coronary events (postinfarction angina, reinfarction, aortocoronary by pass or PTCA). Furthermore, it is possible to identify a subgroup of patients presenting ST-segment depression with very unfavourable coronary anatomy (80% had multivessel disease, 30% of which had a left main critical stenosis) and high prognostic risk (90% occurrence of coronary events). In the subgroup with ST-segment elevation there was an elevated percentage (65%) of open infarct-related vessel, but with an important residual stenosis. Considering the advantages of revascularization interventions in these high risk patients with extensive residual jeopardized myocardium, we conclude that it is important that all patients with non-Q MI undergo early coronary angiography.

[Prognosis in patients with myocardial infarction and angiographically normal coronaries]. / La prognosi nei pazienti con infarto miocardico e coronarie angiograficamente normali.

From a survey on 8,000 coronary angiographic studies performed in our Institute between January 1980 and June 1990, 105 patients were identified as having angiographically normal coronary arteries and myocardial infarction (MI). Coronary arteries considered as normal were subdivided in completely normal (Group I), or slightly abnormal, with minimal lesions resulting in less than 30% narrowing of a major artery, defined as mild coronarosclerosis (Group II). Thirty-five patients were excluded from the study, because of the lack of complete follow-up data; the remaining 70 patients represent the study group we examined. The following parameters were examined: sex, age at the time of acute MI, family of ischemic heart disease, hypertension, dyslipidemia, diabetes, smoking, stable or unstable angina before MI, location of the MI, ejection fraction (EF), presence of completely normal coronary arteries or mild coronarosclerosis. Follow-up was obtained by contacting the patients or their families; post infarction angina, reinfarction, sudden death or cardiac death were noted. The subjects were divided in 2 groups, according to the coronary anatomy; Group I consisted of 41 patients with completely normal coronary arteries and Group II consisted of 29 patients with mild coronarosclerosis. No significant statistical difference was noted between the 2 groups regarding age, sex and coronary risk factors (except for dyslipidemia which was significantly more prevalent in the subjects with mild coronarosclerosis). Prevalence of left ventricular impairment (EF < 45%) and coronary events (angina, reinfarction and death) were significantly higher in Group II. There was no significant difference in age or clinical risk factor prevalence between patients with complicated and non complicated clinical course.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic and cardioangiographic evaluation of non-Q infarction with isolated stenosis of the anterior descending artery]. / Valutazione ecocardiografica e cardioangiografica dell'infarto non Q con stenosi isolata dell'arteria discendente anteriore.

We studied with two-dimensional echocardiography and coronary angiography 2 groups of patients with one-vessel stenosis located on anterior descending (IVA) and previous acute myocardial infarction (AMI; means 19 days): 23 patients with spontaneous non-Q infarction (Group I), and 23 patients with Q infarction (Group II). Left ventricular function was better in Group I (echo score: 2.04 +/- 2.64, angiographic ejection fraction: 65.65 +/- 9.7 in Group I, echo score: 4.78 +/- 3.14, angiographic ejection fraction: 49.47 +/- 9.1 in Group II, p less than 0.001). Percent occlusion of IVA was lower in Group I and angiographic IVA caliper was significantly higher (p less than 0.05). Differences between groups were much more evident in subgroups with proximal stenosis of IVA: patients of non-Q subgroup had very good left ventricular function but frequently had post-IMA unstable angina (78%). Our results underline usefulness of aggressive diagnostic and therapeutic approach in non-Q AMI, because of higher amount of myocardial a risk.

Combined invasive and noninvasive study of left ventricular systolic and diastolic function following acute administration of cicloprolol to subjects with normal cardiac function.

Cicloprolol is a new beta-blocking agent with high selectivity for beta 1 receptors and high intrinsic sympathomimetic activity. We studied the acute hemodynamic effects of cicloprolol in nine subjects with no evidence of left ventricular dysfunction who underwent cardiac catheterization for the evaluation of chest pain. All patients had normal coronary angiography and left ventriculography. Left ventricular pressure was determined throughout the cardiac cycle using a Millar 8Fr Minotip catheter; an echocardiogram, phonocardiogram, and ECG were simultaneously recorded to obtain left ventricular pressure-diameter loops. All the measurements were repeated before and after the intravenous administration of cicloprolol. Cicloprolol was administered at increasing doses of 0.05, 0.10, and 0.25 mg/kg until a cardiac output increase of at least 15% over basal values was achieved. A decrease of mean arterial pressure or cardiac output after cicloprolol was not observed in any patient. Cicloprolol administration significantly increased cardiac output (24%), stroke volume (22%), and peak positive dP/dt (25%); no significant changes in heart rate, systemic blood pressure, right atrial pressure, or pulmonary artery pressures were observed. No significant change in the echocardiographic parameters occurred. Among the indices of left ventricular diastolic function, the time constant of isovolumetric relaxation was significantly decreased (-43%) after cicloprolol; moreover, the left ventricular pressure-diameter loop in the protodiastolic phase was shifted to the left following cicloprolol infusion. This study confirms that in subjects with normal left ventricular function cicloprolol can improve resting left ventricular systolic function, and it shows that this action can also be attended by a more rapid isovolumetric relaxation, similar to what has been observed with other sympathomimetic amines.

[The Registry for Angioplasty in Infarction (RAI): brief preliminary report on the main indicators and process of acute outcome]. / Registro per l'Angioplastica nell'Infarto (RAI): breve report preliminare dei principali indicatori di processo e di esito acuto. Conto di Tutti i Ricercatori del RAI.

BACKGROUND: Emergency coronary angioplasty can be the treatment of choice in selected patients with acute myocardial infarction in centers with adequate facilities and organization. METHODS: A multicenter observational study in patients with high-risk acute myocardial infarction was conducted to evaluate the quality of emergency angioplasty treatment according to process, acute and long-term outcome, and use of resources. RESULTS: The RAI registry included 345 patients with high-risk acute myocardial infarction who were admitted to six participating centers over a thirteen-month period. Emergency coronary angiography was performed in 261 patients (76%) and was followed by immediate angioplasty in 236 of them (68%). Mean door-to-procedure time was 58 +/- 47 min. Severe left ventricular failure was present at admission in 35 (13%) of the 261 patients with emergency coronary angiography; and 29 of them were in cardiogenic shock (11%). Overall, in-hospital mortality for patients with angioplasty was 7.6%; i.e., 43% and 3.7% for patients with and without shock, respectively. CONCLUSIONS: Despite logistical limitation, in centers with emergency angioplasty programs this treatment can be performed with favorable process and acute outcome characteristics in patients with high-risk myocardial infarction.