Impact of atrioventricular compliance on pulmonary artery pressure in mitral stenosis: an exercise echocardiographic study.

BACKGROUND: The decay of the pressure gradient across a stenotic mitral valve is determined by the size of the orifice and net AV compliance (C(n)). We have observed a group of symptomatic patients, usually in sinus rhythm, characterized by pulmonary hypertension (particularly during exercise) despite a relatively large mitral valve area by pressure half-time. We speculated that this discrepancy was due to low atrial compliance causing both pulmonary hypertension and a steep decay of the transmitral pressure gradient despite significant stenosis. We therefore tested the hypothesis that C(n) is an important physiological determinant of pulmonary artery pressure at rest and during exercise in mitral stenosis. METHODS AND RESULTS: Twenty patients with mitral stenosis were examined by Doppler echocardiography. C(n), calculated from the ratio of effective mitral valve area (continuity equation) and the E-wave downslope, ranged from 1.7 to 8.1 mL/mm Hg. Systolic pulmonary artery pressure (PAP) increased from 43+/-12 mm Hg at rest to 71+/-23 mm Hg (range, 40 to 110 mm Hg) during exercise. There was a particularly close correlation between C(n) and exercise PAP (r=-0.85). Patients with a low compliance were more symptomatic (P<0.025). Catheter- and Doppler-derived values for C(n), determined in 10 cases, correlated well (r=0.79). CONCLUSIONS: C(n), which can be noninvasively assessed, is an important physiological determinant of PAP in mitral stenosis. Patients with low C(n) represent an important clinical entity, with symptoms corresponding to severe increases in PAP during stress echocardiography.

The distinction between coronary and myocardial reperfusion after thrombolytic therapy by clinical markers of reperfusion.

OBJECTIVES: We sought to examine the hypothesis that rapid resolution of ST-segment elevation in acute myocardial infarction (AMI) patients with early peak creatine kinase (CK) after thrombolytic therapy differentiates among patients with early recanalization between those with and those without adequate tissue (myocardial) reperfusion. BACKGROUND: Early recanalization of the epicardial infarct-related artery (IRA) during AMI does not ensure adequate reperfusion on the myocardial level. While early peak CK after thrombolysis results from early and abrupt restoration of the coronary flow to the infarcted area, rapid ST-segment resolution, which is another clinical marker of successful reperfusion, reflects changes of the myocardial tissue itself. METHODS: We compared the clinical and the angiographic results of 162 AMI patients with early peak CK (< or =12 h) after thrombolytic therapy with (group A) and without (group B) concomitant rapid resolution of ST-segment elevation. RESULTS: Patients in groups A and B had similar patency rates of the IRA on angiography (anterior infarction: 93% vs. 93%; inferior infarction: 89% vs. 77%). Nevertheless, group A versus B patients had lower peak CK (anterior infarction: 1,083+/-585 IU/ml vs. 1,950+/-1,216, p < 0.01; and inferior infarction: 940+/-750 IU/ml vs. 1,350+/-820, p=0.18) and better left ventricular ejection fraction (anterior infarction: 49+/-8, vs. 44+/-8, p < 0.01; inferior infarction: 56+/-12 vs. 51+/-10, p=0.1). In a 2-year follow-up, group A as compared with group B patients had a lower rate of congestive heart failure (1% vs. 13%, p < 0.01) and mortality (2% vs. 13%, p < 0.01). CONCLUSIONS: Among patients in whom reperfusion appears to have taken place using an early peak CK as a marker, the coexistence of rapid resolution of ST-segment elevation further differentiates among patients with an opened culprit artery between the ones with and without adequate myocardial reperfusion.

Q wave and Non-Q wave myocardial infarction after thrombolysis.

OBJECTIVES: We studied the clinical outcome of Q wave and non-Q wave infarction after thrombolytic therapy. BACKGROUND: Controversy exists over the clinical significance of Q waves after thrombolysis. METHODS: We studied postthrombolytic angiographic results and short- and long-term clinical outcome in 150 patients with acute myocardial infarction classified as Q wave and non-Q wave on the 24-h and discharge electrocardiograms (ECGs). The results from the two groups were then compared. RESULTS: Eighty percent of patients had a Q wave and 20% a non-Q wave infarction on the 24-h ECG. The latter patients had lower peak creatine kinase (CK) levels (p < 0.001), but the two groups did not differ significantly otherwise. In 18 patients with a Q wave infarction on the 24-h ECG, pathologic Q waves disappeared. However, in seven patients with a non-Q wave infarction on the 24-h ECG, pathologic Q waves appeared throughout the hospital period. Q wave regression was associated with lower peak CK levels (p < 0.001) and an improvement in left ventricular ejection fraction (p < 0.01). Thus, only 72% of patients had a Q wave and 28% a non-Q wave infarction on the discharge ECG. Patients with a non-Q wave infarction on the discharge ECG had higher patency of the infarct-related artery (p < 0.04), lower mean peak CK levels (p < 0.0001), a higher ejection fraction (p = 0.001) and a lower incidence of heart failure (p = 0.06) than patients with a Q wave infarction on the discharge ECG. Although the 2-year incidence of reinfarction and revascularization was higher in patients with a non-Q wave infarction on the discharge ECG (p < 0.05), 2-year mortality was lower (p = 0.08). CONCLUSIONS: Although the early postthrombolytic distinction between Q wave and non-Q wave infarction conveys no significant information, during the hospital period, non-Q wave infarction is associated with a smaller infarct area, improved left ventricular function and lower mortality.

Early T wave inversion after thrombolytic therapy predicts better coronary perfusion: clinical and angiographic study.

OBJECTIVES: This study was undertaken to test the hypothesis that early inversion of T waves after thrombolytic therapy for acute myocardial infarction predicts patency of the infarct-related artery with high Thrombolysis in Myocardial Infarction (TIMI) perfusion flow and better in-hospital outcome. BACKGROUND: Although numerous studies have demonstrated a strong association between early resolution of ST segment elevation after acute myocardial infarction and successful thrombolysis, little is known about early changes in T waves after thrombolytic therapy. METHODS: Ninety-four consecutive patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA) were studied with admission and predischarge radionuclide ventriculography and with coronary angiography within 72 h of admission. Patient stratification was based on the presence or absence of early (within 24 h) T wave inversion. RESULTS: Early T wave inversion was associated with a higher patency rate of the infarct-related artery (90% vs. 65%, p < 0.02) and less severe residual stenosis ([mean +/- SD] 73 +/- 27 vs. 83 +/- 22, p = 0.06), and when only TIMI perfusion grade 3 was considered, the difference was even greater (77% vs. 41%, p < 0.001). Patients with early inversion of T waves had a lower peak creatine kinase value ([mean +/- SD] 678 +/- 480 vs. 1,076 +/- 620, p < 0.01), and although a similar percent of patients with and without early T wave inversion had a normal ejection fraction (> or = 55%) on admission, a higher percent of patients with early inversion had a normal ejection fraction at hospital discharge (71% vs. 44%, p < 0.03). Early T wave inversion anticipated a more benign in-hospital clinical course with a lower incidence of adverse cardiac events (10% vs. 33%, p < 0.02). CONCLUSIONS: Early inversion of T waves in patients with acute myocardial infarction treated with thrombolytic therapy suggests patency of the infarct-related artery, better perfusion grade and left ventricular function and a more benign in-hospital course.

The significance of persistent ST elevation versus early resolution of ST segment elevation after primary PTCA.

OBJECTIVES: To determine the prevalence and clinical significance of early ST segment elevation resolution after primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI). BACKGROUND: Despite angiographically successful restoration of coronary flow early during AMI, adequate myocardial reperfusion might not occur in a substantial portion of the jeopardized myocardium due to microvascular damage. This phenomenon comprises the potentially beneficial effect of early recanalization of the infarct related artery (IRA). METHODS: Included in the study were 117 consecutive patients who underwent angiographically successful [Thrombolysis in Myocardial Infarction (TIMI III)] primary PTCA. The patients were classified based on the presence or absence of reduction > or =50% in ST segment elevation in an ECG performed immediately upon return to the intensive cardiac care unit after the PTCA in comparison with ECG before the intervention. RESULTS: Eighty-nine patients (76%) had early ST segment elevation resolution (Group A) and 28 patients (24%) did not (Group B). Group A and B had similar clinical and hemodynamic features before referring to primary PTCA, as well as similar angiographic results. Despite this, ST segment elevation resolution was associated with better predischarge left ventricular ejection fraction (LVEF) (44.7 +/- 8.0 vs. 38.2 +/- 8.5, p < 0.01). Group B patients, as compared with those of Group A, had a higher incidence of in-hospital mortality (11% vs. 2%, p = 0.088), congestive heart failure (CHF) [28% vs. 19%, odds ratio (OR) = 4, 95% confidence interval (CI) 1 to 15, p = 0.04], higher long-term mortality (OR = 7.3, 95% CI 1.9 to 28, p = 0.004 with Cox proportional hazard regression analysis) and long-term CHF rate (OR = 6.5, 95% CI 1.3 to 33, p = 0.016 with logistic regression). CONCLUSIONS: Absence of early ST segment elevation resolution after angiographically successful primary PTCA identifies patients who are less likely to benefit from the early restoration of flow in the IRA, probably because of microvascular damage and subsequently less myocardial salvage.

From swirling to a mobile, pedunculated mass--the evolution of left ventricular thrombus despite full anticoagulation. Echocardiographic demonstration.

We describe the unusual evolution of a left ventricular thrombus following acute anterior myocardial infarction despite adequate anticoagulation. Serial echocardiographic examinations demonstrated the evolution from swirling in the left ventricle through a solid apical mass gradually dislodging into a mobile, pedunculated mass that was removed surgically to prevent embolization. This report emphasizes the need to follow echocardiographically left ventricular thrombi during treatment with anticoagulants, and to identify morphologic changes that may predict embolization. This case suggests that left ventricular thrombectomy should be considered in selected patients in whom a very high-risk thrombus morphology is detected.

Continuous rt-PA infusion as a salvage strategy to maintain patency of the infarct artery; safety of high cumulative dose and subsequent emergency coronary artery angioplasty and bypass surgery.

Acute re-occlusion of an infarct artery reperfusion attained by thrombolytic therapy may be treated by emergency coronary angioplasty or bypass surgery. Repeated infusion of a thrombolytic agent is an additional treatment strategy. Three patients with reinfarctions that occurred very early after successful reperfusion were treated with continuous infusion of recombinant tissue-type plasminogen activator (rt-PA). These patients received a rt-PA dose of 300-360 mg while they awaited emergency mechanical revascularization procedures. Two patients had coronary angioplasty immediately after receiving repeated infusions of rt-PA and one underwent coronary bypass surgery while receiving a third rt-PA infusion. There were no bleeding complications in the 2 patients who underwent coronary angioplasty, and no excessive bleeding in the patient who received coronary bypass surgery. Thus, repeated continuous rt-PA infusions can be used to maintain the patency of recurrently occluding infarct arteries until definitive mechanical revascularization can be performed.

Hemodynamic effects of oral isosorbide-5-mononitrate and dinitrate in ischemic heart failure.

Isosorbide-5-mononitrate (ISMN), the main metabolite of isosorbide dinitrate (ISDN) was recently introduced in clinical use. The hemodynamic effects of oral ISMN and ISDN, administered in equal doses, were studied in a randomized, crossover fashion in 20 patients with pump failure of ischemic etiology. Baseline hemodynamic criteria for admission into the study were: pulmonary capillary wedge pressure (PCW) of at least 20 mmHg and systolic arterial pressure (AP) above 90 mmHg. Hemodynamic parameters were serially measured and systemic vascular resistance was calculated up to 6 h postadministration of either ISMN or ISDN single dose (40 mg). Maximal effects obtained were statistically significantly different from baseline. While ISMN and ISDN appeared to be equipotent in reducing the filling pressure, with a maximum effect reached in 60-120 min, the mononitrate maintained its effects for a longer period.

[Emergency stenting for acute left main coronary artery closure during cardiac catheterization].

We report a case of acute closure of the left main coronary artery, a rare complication of diagnostic cardiac catheterization, treated by emergency stenting prior to aorto-coronary bypass surgery. We suggest encroachment of the Judkins catheter into a calcified left main ostium; with dissection and acute thrombosis of this segment, as the possible mechanism. Clinically, the patient's condition deteriorated to cardiogenic shock and loss of consciousness. Remarkably, there was no angiographic evidence of significant left main coronary artery disease, besides the presence of calcification in the proximal part of the left coronary system and ventricularization of coronary pressure at the time of engagement. We chose to slide quickly the angioplasty guidewire through the left main coronary artery, which allowed prompt mechanical recanalization and rapid restoration of coronary flow, with dramatic clinical and hemodynamic improvement. This relatively simple procedure allowed stenting the left main artery after brief predilation, and the patient came to by-pass surgery in excellent condition. The rationale for surgery in this case was the need for complete coronary revascularization because of significant 3-vessel coronary artery disease.

Bacterial and fungal meningitis in adults: a 22-year survey in a large community hospital in Israel.

The etiologic, bacteriological, clinical and therapeutic aspects of 95 cases of bacterial or fungal meningitis in adults seen in a large community hospital were reviewed. The study was limited to non-neurosurgical patients in whom positive cerebrospinal fluid cultures were obtained. Overall mortality was 40%, with no appreciable change during the 22-year period. The most common causative organism was the pneumococcus, with a 45% mortality. There were no deaths among the patients with meningococcal meningitis. Cryptococcus neoformans was the third most common single organism encountered. Meningitis due to uncommon organisms usually developed in debilitated or immunologically compromised patients, and had a poor prognosis. Advanced age, underlying debilitating disease and severly impaired consciousness on admission were associated with a high mortality. Bacterial and fungal meningitis in adults remains a serious life-threatening disease, despite advances in antibiotic therapy.

Coronary arterioluminal communications in routine angiography.

Visualization of the left ventricular cavity from coronary arterioventricular communications is rarely encountered in routine coronary angiography. We report 14 patients, of 5,500 consecutive cardiac catheterizations, in whom these communications were evident during coronary angiography. All 14 patients had angina pectoris; in each the arterioluminal communication originated from the left anterior descending coronary artery. Two patients had evidence of anterior wall ischemia despite a normal left anterior descending coronary artery, suggesting that a possible steal phenomenon is responsible for the myocardial ischemia.

Prostaglandin E1 during angioplasty as preventative therapy for coronary restenosis.

The effect of intravenous prostaglandin E ( 1 ) (PGE ( 1 ) ) on the incidence of restenosis after elective percutaneous transluminal coronary angioplasty (PTCA) was studied in a prospective, single-blind, randomized trial of 30 patients. Group I (12 patients) received only the conventional medications before and after protocol, and group II (18 patients) received intravenous PGE ( 1 ) infusion for 24 hours starting at least 2 hours before angiography after hemodynamically based titration to a mean dosage of 16 +/- 3 ng/kg/min (range, 10-20 ng/kg/min). All patients received aspirin orally, beginning 24 hours before PTCA and continuing for 6 months, and intravenous heparin at 1000 U/h for 24 hours commencing with the beginning of catheterization before PTCA. Recatheterization was performed routinely at 6 months after PTCA, or earlier when clinically indicated. Angiographic evaluations were made by both visual and quantitative assessment. No significant side effects of PGE ( 1 ) treatment were observed. Only 17% of patients treated by PGE ( 1 ) experienced angina pectoris during 6-month follow-up period, as compared with 42% of patients who received conventional treatment (p = 0.13). Re-PTCA was more frequent in patients receiving conventional therapy than in those receiving PGE ( 1 ) (42% versus 11%; p = 0.06). The use of PGE ( 1 ) during PTCA was associated with 17% restenosis (both by computer and by visual evaluation) 6 months post-PTCA as compared with 33% and 50% restenosis (by computer and by visual evaluations, respectively) in the conventional group (p < 0.05). In conclusion, PGE ( 1 ) appears to decrease coronary restenosis 6 months after PTCA.

Fate of nonobstructive aneurysmatic coronary artery disease: angiographic and clinical follow-up report.

The incidence of coronary aneurysmatic dilatation without coronary stenosis is rare, and the clinical course of such an entity is unknown. We present five adult patients, four men and one woman, with such an anatomic finding. The age range was 44 to 60 years. In four patients the aneurysmatic dilatations involved multiple coronary sites. The clinical course in all five patients was suggestive of coronary insufficiency. Despite no obstructive disease, two of the patients developed transient ischemic ECG changes accompanied by chest pain, and another two patients demonstrated ischemic exercise nuclear ventriculography response. In time, all five patients developed acute myocardial infarction and recatheterization revealed complete occlusion of a previously nonstenosed aneurysmatic vessel. More information is needed in order to guide therapy. However, prevention of thrombus formation and close follow-up is highly recommended.

Rescue coronary angiography after failed thrombolysis: a real-life experience.

Failed thrombolysis in acute myocardial infarction (AMI) patients is associated with a high risk of morbidity and mortality. Rescue or salvage percutaneous transluminal coronary angioplasty (PTCA) in this group of patients is still controversial. We report our experience with early emergency angiography and rescue PTCA in 27 patients who were hemodynamically unstable or had a large area of myocardium at risk after failed thrombolysis. Rescue PTCA was successful in 95% of attempted PTCA. Three patients were referred to emergency CABG. Early 'rescue angiography' with or without rescue PTCA after failed thrombolysis in a selected patient population, is an important tool for early risk stratification and decision-making during the hyperacute phase of AMI, while it may also serve in restoring coronary artery patency of the infarct-related artery with a high success rate.

Balloon aortic valvuloplasty in the elderly: useful when there is no alternative.

Of 63 elderly patients with calcific aortic stenosis in whom balloon aortic valvuloplasty was performed, 26 treated with the new technique of Cribier and Letac are the subject of this report. Patients were referred for the procedure because they were at high surgical risk, or were not candidates for surgery. Seven matched patients who fit the criteria for balloon valvuloplasty but refused the valvuloplasty procedure served as controls. Aortic gradient decreased from 78 +/- 27 mm Hg to 35 +/- 20 mm Hg and aortic valve area increased from 0.47 +/- 0.16 cm2 to 0.83 +/- 0.38 cm2 (P < 0.0001). Symptomatic improvement was immediately obtained in each patient. Complications were rare, with only one patient needing vascular repair for femoral artery occlusion. Three patients died during the initial hospitalization (none during the procedure). Valvuloplasty patients were followed for a mean period of 9.6 +/- 9.4 months. Three months survival was 87%, 6 months survival was 76%, and 12 months survival was 61%. Four of seven patients in the control group (57%) died within 3 months after initial referral. Balloon aortic valvuloplasty is a useful treatment in elderly patients who are poor surgical candidates. It may have a positive influence on short-term survival.