[Gamma-interferon-induced cardiomyopathy during treatment of renal cell carcinoma: a case report].

A 78-year-old woman with renal cell carcinoma and pulmonary metastasis presented with reversible cardiomyopathy induced by gamma(gamma)-interferon. She was treated with gamma-interferon twice a week since November 1996. She presented with severe acute congestive heart failure and gamma-interferon was immediately discontinued in December 1997. Left ventricular fractional shortening was 38% before admission, 12% on admission, and improved to 31% by 40 days after discontinuation of interferon together with administration of diuretics and angiotensin converting enzyme inhibitor. We restarted the same gamma-interferon regimen because it was effective against renal cell carcinoma after 47 days. She has remained well with no significant changes of cardiac function or renal cell carcinoma for almost one year.

Long-term clinical and echocardiographic outcome in patients with mitral stenosis treated with percutaneous transvenous mitral commissurotomy.

Long-term follow-up after percutaneous transvenous mitral commissurotomy (PTMC) is limited. Ninety-four middle-aged (51+/-9 years) mitral stenosis patients who underwent successful PTMC were followed up with annual echocardiography for 6.1+/-1.4 years. PTMC success was defined as either mitral valve area (MVA) >1.5 cm2 or a MVA of more than twice the pre-procedural value, together with no worsening of mitral regurgitation >grade 2+. Mitral valve replacement (MVR), worsening of congestive heart failure (CHF), and thromboembolism were sought for survival analysis. Restenosis was defined as loss of more than 50% of the initial procedural MVA gain. Functional limit of daily activities was assessed through a questionnaire. The study population was divided into group 1 (post-procedural MVA >2.0 cm2), group 2 (MVA > 1.5 cm2 and < or = 2.0 cm2) and group 3 (MVA < or = 1.5 cm2). The 6-year survival with freedom from MVR, CHF, thromboembolism, and combined events (MVR+CHF) was 92%, 95%, 91%, and 88%, respectively. No group 1 patient experienced MVR or CHF. Restenosis was predominant in group 3. Deterioration of daily activities during follow-up was not observed in group 1; however, it was significant in group 2 (p<0.05) and group 3 (p<0.001). These results demonstrated that patients who attained a large MVA (>2.0cm2) immediately after PTMC maintained their procedural benefit with less clinical complication and with less limitation of daily activity.

Mid-term follow-up of coronary artery aneurysm after directional coronary atherectomy.

Coronary artery aneurysm (CAA) occurs in 6-12% of lesions after directional coronary atherectomy (DCA). The prognosis and the optimal treatment for DCA-related CAAs have not been well known. Therefore, we reviewed the clinical course of 214 consecutive patients with DCA-related CAAs who underwent DCA in our hospital. Follow-up coronary angiography 6 months after DCA was completed in 193 patients (212 lesions) and 14 lesions with CAAs (14 patients) were detected. We evaluated these 14 lesions by repeat coronary angiography at an average of 32 months after DCA in comparison with the adjacent reference vessel. Twelve of the 14 patients have been uneventful but 2 suffered from de novo angina due to new stenotic lesion unrelated to the DCA procedures. We compared the preprocedural angiographic characteristics and periprocedural parameters between the 14 lesions with CAAs[CAA(+)group] and the 198 without CAAs [CAA(-)group], but found no significant differences. Histological examination of specimens retrieved during atherectomy demonstrated that subintimal resection was more frequent in the CAA(+)group(57%) than the CAA(-)group(31%). The diameter of the aneurysm divided by the reference diameter was significantly larger at 6 months immediately after DCA(1.71 +/- 0.21 vs 1.31 +/- 0.18, p < 0.05) but did not change subsequently (1.68 +/- 0.23). Our retrospective analysis revealed a good mid-term (an average of 32 months) prognosis for CAAs found by routine follow-up coronary angiography and also demonstrated that the depth of resection was significantly associated with aneurysm formation.

Effects of cilostazol on late lumen loss after Palmaz-Schatz stent implantation.

Cilostazol inhibits intimal hyperplasia after stent implantation into canine iliac arteries. To determine the antiproliferative effect of this agent, cilostazol or aspirin was randomly given for 6 mo to 36 patients treated with Palmaz-Schatz stent implantation. Initial success was obtained in 34 patients. Repeat angiography was performed in 33 patients, and the complete angiographic data were obtained in 22 lesions of the cilostazol group and in 21 lesions of the aspirin group. The reference diameter and minimal luminal diameter were similar in both groups before and immediately after stent implantation. At follow-up, minimal luminal diameters were significantly greater in the cilostazol group than in the aspirin group (P < 0.001). Late loss and loss index were significantly smaller in the cilostazol group than in the aspirin group (P < 0.001). These results suggest that cilostazol reduces angiographic late lumen loss and thereby may reduce the incidence of restenosis after Palmaz-Schatz stent implantation.

[Palmaz-Schatz stent implantation for aorto-ostial stenoses of native coronary arteries and saphenous vein grafts].

Conventional balloon angioplasty treatment of aorto-ostial stenoses in native coronary arteries and saphenous vein grafts is associated with a low primary success rate, a high complication rate and a high incidence of restenosis. The short-term outcome of Palmaz-Schatz stent implantation in aorto-ostial lesions was compared with that of balloon angioplasty. Thirteen patients underwent stent implantation for 13 de novo lesions (four in the left main coronary trunk, two in the right coronary artery, seven in the vein graft) between January 1994 and December 1995. Fourteen patients underwent balloon angioplasty for 14 de novo lesions (five in the left main coronary trunk, four in the right coronary artery, five in the vein graft between January 1986 and April 1992. Both groups had similar clinical characteristics. Initial success was obtained in all patients in the stent group, compared with 71% of the balloon angioplasty group. Insufficient dilation was the main cause for such failure in the balloon angioplasty group. Baseline reference diameters were similar (3.40 +/- 0.65 mm in the stent group vs 3.36 +/- 0.42 mm in the balloon angioplasty group) and there was no difference in baseline minimal luminal diameter (1.41 +/- 0.74 vs 1.08 +/- 0.56 mm). Minimal luminal diameter was significantly greater in the stent group than in the balloon angioplasty group at both post-procedure and follow-up examinations (post: 3.36 +/- 0.58 vs 2.69 +/- 0.45 mm, p < 0.01; follow-up: 2.33 +/- 0.96 vs 1.52 +/- 0.68 mm, p < 0.05). There was no subacute occlusion in either group. The overall angiographic restenosis rate (> 50% stenosis) was lower in the stent group (17%) than in the balloon angioplasty group: the restenosis rates of native lesions were 0% in the stent group and 40% in the balloon angioplasty group; those of saphenous vein graft lesions were 33% in the stent group and 50% in the balloon angioplasty group. Although the number of patients was limited, these results suggest that Palmaz-Schatz stent implantation may be a safe and effective strategy for treating aorto-ostial lesions in both native coronary arteries and saphenous vein grafts.

[Native aortic valve thrombus revealed by routine echocardiography: a case report].

A 75-year-old man presented with palpitations due to atrial flutter. Transthoracic echocardiography revealed a mobile aortic valve mass (17 mm in diameter) attached to the non-coronary cusp of the aortic valve. There was no evidence of hypercoagulative state. Computed tomography showed old cerebral infarction in the territory supplied by the right middle cerebral artery. The mass was surgically resected. The aortic valve was preserved because there were no organic changes in the valve. Histological examination demonstrated an organized thrombus. Only three cases of thrombus attached to the normal native aortic valve have been reported. Native aortic valve thrombus may be important in the differential diagnosis of aortic valve mass.

[Ten-year follow-up of percutaneous transluminal coronary angioplasty].

The long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA) was evaluated in 124 patients who underwent PTCA between October 1982 and June 1985. Seventy-six patients had their proximal coronary arteries completely revascularized by PTCA (including repeat PTCA) and follow-up angiography showed the vessels were patent 3 to 6 months after the last intervention (group A). The other 48 patients showed incomplete revascularization (group B). The 10-year event-free survival rates from cardiac death and non-fatal myocardial infarction were 89.7% in group A and 93.5% in group B, respectively. Survival rates free from cardiac death, myocardial infarction, coronary bypass surgery, and repeat angioplasty for new lesions were 82.5% and 62.7%, respectively (p < 0.001). Ninety-nine percent of patients in group A and 79.5% of patients in group B were asymptomatic at the follow-up. Coronary angiography was performed in a total of 22 patients (19 patients in group A, 3 in group B). In group A, myocardial infarction occurred in one patient 8 years after PTCA. The infarct-related lesion seemed to be the same as the previous PTCA lesion. Although the other 20 PTCA lesions were all patent without progression, nine significant and new lesions were found on the coronary angiograms. Successfully revascularized vessels remained patent for over 10 years, but new lesions sometimes occur in segments other than the previously treated segment.

Comparison of aortic valve replacement and percutaneous aortic balloon valvuloplasty for elderly patients with aortic stenosis.

The outcome of aortic balloon valvuloplasty (ABV) was compared with that of aortic valve replacement (AVR) in aortic stenosis (AS) patients more than 60 years old. The indications for ABV included low respiratory and renal function, cancer, the patient's refusal of surgery, and low daily activity. Twenty six patients underwent AVR and 13 underwent ABV. Initially, the AVR group was younger and more symptomatic than the ABV group. Two perioperative deaths occurred in the AVR group, while there were none in the ABV group. Twenty-four AVR patients and 12 ABV patients had a successful outcome, with remarkable pressure gradient reduction in both groups. In the follow-up, only 1 death and no cardiac events were detected in the AVR group (mean follow-up of 27 months), whereas 3 deaths, 6 heart failures, 2 repeated ABV, and 4 AVR were seen in the ABV group (mean follow-up of 10 months). The data showed that ABV was safer than AVR, but a higher rate of restenosis limited its efficacy. In the ABV group, a higher ratio of balloon size to aortic diameter correlated with longer event-free survival. We concluded that for elderly AS patients, ABV should be used only in those with high surgical risk as a palliative therapy or a bridge therapy to AVR, and AVR should be primarily recommended under rigid evaluation of the patient's physical status.

Effects of competitive blood flow on arterial graft patency and diameter. Medium-term postoperative follow-up.

To identify predictors of arterial graft patency, we followed up 30 internal thoracic arterial grafts and 23 right gastroepiploic arterial grafts in situ with patency documented during postoperative angiography. After 24 months of follow-up on average, repeat angiography detected that one internal thoracic artery and two gastroepiploic arteries were anatomically occluded and that the other three gastroepiploic arteries were nonfunctioning. The logistic regression model identified a relationship between graft patency and competitive flow, which was detected as stenosis in the recipient coronary arteries (coefficients, p < 0.05; model, Hosmer-Lemeshow chi2 statistic 3.59, p = 0.89). The linear regression model demonstrated that changes in graft luminal diameter correlated with competitive flow (p < 0.01), smoking history (p < 0.05), and type of arterial grafts (p < 0.001) (R2 = 0.40, adjusted R2 = 0.36). The findings suggest a temporal relationship between competitive flow and prognosis of arterial graft.

Intracoronary stenting of a coronary occlusion resulting from an aortic dissection.

Acute myocardial infarction secondary to aortic dissection may occur due to compression of the coronary arteries by a hematoma or extension of the dissection into the coronary arterial wall. We report a patient with this condition who was successfully treated by Palmaz-Schatz stenting, providing an alternative to thrombolysis or angioplasty.

[SH/TA-508 clinical phase II study: dose evaluation of SH/TA-508 in echocardiography].

A cooperative study was conducted at 18 institutions to evaluate the safety and usefulness of SH/TA-508, a contrast medium for ultrasound diagnosis, and to find its optimum dose. One hundred and one patients with confirmed or suspected ischemic heart disease were examined with two-dimensional echocardiography, and 95 patients with mild mitral insufficiency were studied with the color Doppler method. The contrast medium was administered at low-dose (1.5-1.6g galactose) and high-dose (3.0-3.2 g galactose) levels at concentrations of 200, 300 and 400 mg/ml. The contrast effect was evaluated into five grades by two-dimensional echocardiography: - (ineffective), + (weak), 2+ (moderate), 3+ (good), 4+ (excessive effect) and into four grades with the color Doppler method, - (ineffective), + (weak), 2+ (optimum), 3+ (excessive effect). The two-dimensional echocardiographic studies showed effects graded at 2+ and above in most patients (83-93%). These findings were significantly more common in patients who had received the 300 and 400 mg/ml concentrations than in those who received the 200 mg/ml concentration. Statistical analysis found no significant differences between the high-dose and low-dose groups. Color Doppler echocardiography found signal enhancement graded at 2+ and above in 80-93% of cases. There were no significant differences in enhancement effect attributable to concentration or total dose. However, since excessive signal intensity was seen quite frequently, the dose levels in the present study were considered to be a little too high. Side effects includes transient feelings of warmth or cold, and the incidence of side effects was higher at higher doses and concentrations. The results show that the optimum concentration for two-dimensional echocardiography is 300 mg/ml and for color Doppler 200 mg/ml. No particular safety problems were seen with SH/TA-508, and this contrast medium is useful in echocardiography of the left ventricle and in enhancing mitral regurgitation signals in color Doppler examinations. Therefore, a phase III multicenter trial should be performed.

Ischemic cardiomyopathy without significant coronary stenosis. A case report.

The authors present a rare case of myocardial infarction in a fifty-eight-year-old man without significant coronary artery stenosis apparent on the emergency coronary angiogram. However, a second angiogram two days later revealed a total occlusion of the left anterior descending artery. Intracoronary thrombolytic therapy was performed with a successful outcome. The patient was subsequently readmitted with an acute myocardial infarction, and the coronary angiogram again failed to demonstrate significant stenosis. Thereafter, the patient's left ventricular function deteriorated progressively, with the occurrence of another myocardial infarction and frequent bouts of symptoms related to congestive heart failure. He died of ischemic cardiomyopathy about seven years later. Findings including an autopsy report showed that myocardial ischemia was involved in the pathogenesis of what initially appeared to be primary dilated cardiomyopathy, based on emergency angiograms.

Luminal loss and site of restenosis after Palmaz-Schatz coronary stent implantation.

Restenosis has frequently been observed at the articulation of the Palmaz-Schatz stent. However, the precise mechanism for this remains poorly understood. We measured the luminal diameter in 5 segments within the stent in 67 lesions of 63 patients with successful stenting. Luminal diameter at all 5 sites was significantly reduced 6 months after stent implantation (3.2 +/- 0.5 vs 2.4 +/- 0.7 mm, p < 0.05). Angiographic restenosis rate was 18%. Restenosis involving the articulation was found in 75% of the lesions, and that involving the articulation or edges in 83%. The diameter at the articulation was significantly smaller both immediately (3.0 +/- 0.5 mm vs 3.3 +/- 0.5 mm, p < 0.05) and 6 months after (2.1 +/- 0.8 mm vs 2.5 +/- 0.7 mm, p < 0.05) stenting than the diameter of other stent segments. The loss index was significantly greater at the proximal and distal edges than at the bodies of the stent (0.98 vs 0.60, p < 0.05). The edges of the Palmaz-Schatz stent tend to dilate more than the body of the stent during normal inflation. Although this anchoring system protects against dislodgment or migration of the stent, it may cause more injury. The articulation has 2 anchoring edges within only a 1 mm diameter. Thus, restenosis at the articulation may be ascribed to residual stenosis, increased intimal proliferation due to more severe injury, and delayed late vessel remodeling from lack of mechanical support. These characteristics may be attributed to stent design, and design improvement of the articulation may lead to more favorable results after stent implantation.

Short-term outcome and long-term follow-up of percutaneous coronary intervention in patients aged 40 years or younger.

Forty five patients aged 40 years or younger were treated with coronary intervention in our institution between 1983 and 1994. This young Japanese population had a strong predisposition to risk factors but did not have extensive disease. These patients underwent 50 elective interventional procedures for angina pectoris or old myocardial infarction and 6 direct balloon angioplasty procedures for acute myocardial infarction. The initial successful result was obtained in 41 of the 45 patients (91%). The mean follow-up was 43 +/- 35 months. Angiographic follow-up was available in 31 of the 41 eligible patients (76%). Angiographic restenosis was seen in 9 of these 31 patients (29%), and in 12 of the 38 lesions (32%) with initial successful intervention. There were no deaths among the successfully treated patients. Event-free survival rate without death, myocardial infarction, or coronary artery bypass surgery was 94%; however, event-free survival rate without death, myocardial infarction, coronary artery bypass surgery, or repeat intervention was 66% at 43 months. Ninety three percent of the eligible patients were free from angina at follow-up. These short- and long-term results suggest that young Japanese patients can be treated safely and effectively with coronary interventions.

Elastic recoil following percutaneous transluminal coronary angioplasty and Palmaz-Schatz stent implantation.

The post-procedural elastic recoil in 133 lesions treated with the Palmaz-Schatz stent was compared to 133 matched lesions treated with balloon angioplasty to determine the role of prevention of elastic recoil in the creation of a larger initial luminal diameter. Elastic recoil was defined as the difference between the maximal diameter of the inflated balloon and the minimal luminal diameter of the dilated segment immediately after the procedure and was evaluated by quantitative coronary angiography. Overdilatation was defined as a dilatation induced by a balloon with a maximal diameter larger than the pre-procedure reference diameter. The percent diameter stenosis was reduced from 73% to 31% in the balloon angioplasty group and from 72% to -4% in the stent group (31% vs. -4%, p < 0.01). Elastic recoil was significantly larger in the balloon angioplasty group than in the stent group (0.94 +/- 0.29 mm vs. 0.09 +/- 0.09 mm, p < 0.01). Overdilatation and lesion morphology had no significant effects on elastic recoil in the stent group. In the balloon angioplasty group, overdilatation, noncalcified lesions and eccentric lesions were associated with increased elastic recoil. These results indicated that the larger post-procedural luminal diameter associated with the Palmaz-Schatz stent was primarily the result of prevention of elastic recoil, which was not influenced by the degree of overdilatation or lesion morphology.

A dual blood supply protects the right gastroepiploic arterial graft: report of two cases.

We report two cases whose right gastroepiploic arterial bypass grafts were protected by a dual blood supply due to the anatomical anastomosis between the celiac and the superior mesenteric artery systems. This unique characteristic of the graft adds an advantage for its use as a graft conduit.

Repeat embolization of the side branch of the internal mammary artery graft by gelatin sponge particles and micro coils.

The internal mammary artery (IMA) is increasingly used as a coronary bypass conduit because of better long-term patency and improved prognosis as compared with venous grafts. Previous investigators have suggested that the "steal" of blood flow of the IMA graft via the subclavian artery or a persistent large side branch of the graft may lead to its thinning. However, only a few reports have described the embolization of a large side branch using a transcatheter procedure. We present a case of repeated embolization of a large lateral costal side branch of the left internal mammary arterial graft applying gelatin sponge particles and micro coils, as well as angioplasty to the graft conduit, with resulting easing of chest pain.

Diffuse spasm of a free gastroepiploic artery graft during percutaneous balloon angioplasty.

Percutaneous transluminal balloon dilation of an 8-month-old free graft of the gastroepiploic artery was followed by diffuse and profound graft spasm. Because free arterial grafts are more prone to spasm, suitable precautions, such as administration of calcium channel antagonists, should be taken before attempting any interventions on these vessels.

Angiographic follow-up of patients after transluminal coronary extraction atherectomy.

The transluminal coronary extraction-endarterectomy catheter (TEC) consists of a torquing tube with a distal, conical rotating blade. We successfully treated 26 patients (27 lesions) using this catheter with adjunctive balloon angioplasty. Twenty-five patients (26 lesions) had serial angiography before, 1 day after, and 3 months after the procedure. All 17 patients without restenosis 3 months after the procedure had angiography at 6 months. Restenosis, defined as > 50% diameter stenosis, was noted in nine lesions at 3 months (early restenosis) and in five lesions at 6 months (late restenosis). Between vessels with and without early restenosis, the percentage of diameter stenosis seen 1 day after the procedure and the luminal diameter were significantly different (38% +/- 14% vs 22% +/- 12%, respectively, p < 0.01; 2.3 vs 2.9 mm, p < 0.01, respectively). However, between vessels with and without late restenosis, these variables were not significantly different. The overall restenosis rate was 54% (native vessels 50%; grafts 80%). This observational study suggests that very early diameter narrowing seen 1 day after the procedure has greater contribution to early restenosis than to late restenosis after successful TEC atherectomy with adjunctive balloon angioplasty.

[Outcome of coronary angioplasty and coronary artery bypass grafting in patients over 75 years old].

Mortality, morbidity, and 3-year survival rates were evaluated in patients aged over 75 years undergoing initial revascularization by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The groups of 74 patients undergoing PTCA and 27 undergoing CABG had similar clinical characteristics including age, sex, emergency operation, prior myocardial infarction, and ejection fraction. The PTCA group contained significantly more patients with single vessel disease (44% vs 8%, p < 0.01) while the CABG group had more three-vessel or left main trunk disease (30% vs 70%, p < 0.01). The patients in the PTCA group demonstrated more prior cerebral vascular events, renal insufficiency, and abdominal aortic aneurysms. Angiographic revascularization was achieved in 112 of 130 lesions (86%) and in 63 of the 74 (84%) patients in the PTCA group. Hospital mortality for the PTCA group was 5.4% (two cardiac deaths and two non-cardiac deaths), but 0% for the CABG group. Myocardial infarction occurred in 1.3% and 3.7%, respectively (p = NS). Three-year survival, excluding hospital deaths, was 90% for patients with PTCA and 96% for those with CABG (p = NS). All these deaths were of non-cardiac origin. Both PTCA and CABG are safe and effective for selected patients over the age of 75 years.