Sidebranch occlusion in direct intracoronary stenting: predictors and results.

We assessed the angiographic predictors and results of major (> 1 mm) sidebranch occlusion (SBO) following direct intracoronary stenting (DS) in 86 patients. The occlusion of a sidebranch is a well-defined risk after balloon angioplasty and stenting. However, the impact of direct stenting without predilatation on the coronary flow of sidebranches emerging within the stented segment has not been studied solely. A total of 111 sidebranches were analyzed. Sidebranch type, take-off angle, ostial involvement and procedural characteristics were evaluated. Nine out of 111 (8%) stent-covered sidebranches were occluded. Sidebranches with > 50% stenosis that take off within or just beyond the diseased portion of the lesion (unfavorable morphology) were the most powerful morphologic predictor of SBO (odds ratio: 8.0; 95% confidence interval: 1.5--40.8; p = 0.007). Take-off angle of the sidebranch was not found to have any effect on SBO. Post-stent dilation using high-pressure inflation (15.0 +/- 2.1 atmospheres), inflation (odds ratio: 1.1; 95% CI: 1.0--1.2; p = 0.038), and 3 times inflation (odds ratio: 4.5; 95% CI: 1.1--18.3; p = 0.023) were the procedural predictor of SBO. Of those 40 unfavorable morphologies, seven (17.5%) were occluded compared to 2.8% (2/71) of the favorable morphologies. Nine out of 9 (100%) occluded after high-pressure inflation. Three patients complained of chest pain and 1 had non-Q wave myocardial infarction attributed to SBO. These findings indicate that the incidence of SBO and complications are less than expected and has a favorable outcome in direct intracoronary stenting.

[Left main coronary artery stent application: early and late period results]. / Sol ana koroner artere stent uygulamalari: erken-geç dönem sonuçlari.

OBJECTIVES: Percutaneous coronary intervention of left main coronary artery (LMCA) in the setting of acute myocardial infarction or in patients with cardiac and non-cardiac diseases that increase mortality rate after coronary artery bypass surgery has been proposed as "last resort option" and these patients can be managed safely with intracoronary stenting. In this study, we evaluated the short- and long-term follow-up outcomes of patients with left main coronary lesions underwent stent implantation in our clinic. METHOD: A total of 15 patients (12 M, 3 F; mean age 58 +/- 13 years) with left main coronary stenosis considered at high risk for surgical treatment or patients with acute myocardial infarction with LMCA stenosis were enrolled into the study and treated by stenting. Eight patients were treated for unstable angina (53%), 2 had stable angina (13%) and 5 had acute myocardial infarction (33%). Three patients had "protected" and 12 patients "unprotected" LMCA stenosis. An intraaortic balloon pump was used in 6 (40%) and pacemaker in 4 (26.6%) patients. RESULTS: In the study group the short and long-term mortality rate was 4 (26.6%). Among 13 survived cases, signs of left ventricular failure developed in 2 patients (15.3%). Restenosis rate on control coronary angiography was revealed in 28.8% of cases. CONCLUSION: Utilization of elective stenting in patients at high surgical risk with protected and unprotected LMCA lesions and percutaneous coronary intervention in patients with acute myocardial infarction and left main coronary artery lesions could be appraised as an alternative to surgical treatment approaches.

[Demographic and clinical features of coronary artery patients in the district of Antalya and comparison of them with Turkey's averages]. / Antalya bölgesindeki koroner arter hastalarinin demografik ve klinik özellikleri ve bu özelliklerinin Türkiye ortalamalari ile karsilastirilmasi.

OBJECTIVES: Many studies have proved high plasma cholesterol and triglyceride levels as determinant major risk factors for coronary artery disease. It is also well known that coronary artery disease incidence and related mortality and morbidity is low in communities applying Mediterranean diet. Turkey, having a high incidence of coronary artery disease, is unique because of the diversity of eating habits in different regions of the country. The inhabitants of Antalya region of interest in our study, are generally kept Mediterranean diet. We thought to determine the clinical and demographic features of the coronary artery disease patients living in the district of Antalya, and to find out if they correlate with Turkey's averages when compared. We also searched for the preventive effect of Mediterranean diet, if there was any. METHODS: 516 patients, who were admitted to the department of cardiology, were investigated in terms of age, sex, smoking habits, hypertension, hyperlipidemia, diabetes, family history, angina class, usage of aspirin and nitrates. RESULTS: The results revealed that clinical and demographical features of the coronary artery disease in the district of Antalya were similar with turkey's averages and that the benefits brought by the preventive effects of Mediterranean diet, might have been comprised by smoking.

Mechanical complications of intra-aortic balloon counterpulsation.

Intra-aortic balloon counterpulsation (IABP) related complications in a heterogeneous group of patients who received an IABP before or after thrombolytic therapy and mechanical revascularization or in the management of refractory unstable angina and myocardial infarction related mechanical complications were evaluated prospectively. Ninety-one patients were enrolled to the study. Mean IABP duration was 4.3+/-2.4 days. While the IABP was in place, three patients (3.3%) had femoral artery emboli, four patients (4.4%) had lower extremity ischemia that resolved after the removal of the balloon, eight patients (8.8%) had groin hematoma requiring blood transfusion (< or =2 units) and four patients (4.4%) had intra-aortic balloon rupture. The relation of several risk factors to groin hematoma requiring < or =2 units blood transfusion, emboli, lower extremity ischemia and to total complications was evaluated. A chi-squared analysis showed that nadroparine use was more often complicated with emboli (P = 0.00005) and ischemic events (emboli and/or lower extremity ischemia) (three patients; 30% of nadroparine group vs. four patients; 4.9% of heparin group, P = 0.005) and hypercholesterolemia (>200 mg/dl) was more often complicated with lower extremity ischemia (P = 0.017). Forward conditional logistic regression analysis did not show any relation between the risk factors identified and emboli, lower extremity ischemia, ischemic events and groin hematoma (P>0.05), but an inverse relation was found between IABP duration and total complications (P = 0.0198). In conclusion, IABP related complications were found to remain unchanged but were not life-threatening and were inversely related to IABP duration and this suggests shorter periods of IABP use whenever possible and one must be cautious to use low molecular weight heparin in patients with an IABP in place.

Concomitant use of intraaortic balloon counterpulsation and streptokinase in acute anterior myocardial infarction.

Using a prospective, nonrandomized design, the authors sought to determine whether concomitant use of intraaortic balloon counterpulsation (IABP) and streptokinase in acute anterior myocardial infarction (MI) would improve the in-hospital mortality rate and angiographic findings. The study included 45 patients with an acute anterior MI. All patients received intravenous streptokinase. Among these, 25 patients had concomitant IABP while the remaining 20 patients had streptokinase alone. All patients underwent cardiac catheterization. Patients treated with concomitant IABP had a significantly higher frequency of thrombolysis in myocardial infarction (TIMI) grade 3 flow (n: 11; 44% vs n: 1; 5%, p<0.05), and there was a trend toward a lower in-hospital mortality rate in the IABP group (n: 0; 0% vs n: 3; 15%, p=0.08). The angiographic presence of thrombus image and grade > or =2 coronary collateral circulation to the infarct-related coronary artery for the IABP and non-IABP groups did not differ significantly. The preliminary results of this study suggest that concomitant use of IABP and streptokinase in acute anterior MI increases the incidence of TIMI grade 3 flow and may have decreased the in-hospital mortality rate without unacceptable rates of vascular or hemorrhagic complications.

Late results of combined percutaneous balloon valvuloplasty of mitral and tricuspid valves.

Although combined mitral and tricuspid stenosis are rarely seen in patients with rheumatic heart disease, when both exist together, combined percutaneous balloon valvuloplasty can be an alternative to surgical treatment in suitable cases. We present the immediate and late follow up results of 12 patients with rheumatic tricuspid and mitral stenosis treated with combined percutaneous balloon valvuloplasty. Twelve patients (11 female, 91.7%; 1 male, 8.3%) with a mean age of 35.3 +/- 6.4 years were enrolled in the study. The patients were followed up for 38.8 +/- 12.6 months. The mitral valve area increased from 1.2 +/- 0.2 cm2 to 2.3 +/- 0.2 cm2 (P < 0.01) and on follow up the mitral valve area did not differ significantly (2.2 +/- 0.2 cm2; P > 0.05). The tricuspid valve area increased from 1.6 +/- 0.3 cm2 to 3.2 +/- 0.2 cm2 (P < 0.01) and on follow up the tricuspid valve area did not differ significantly (3.1 +/- 0.2 cm2; P > 0.05). Two patients (16.6%) had tricuspid restenosis and tricuspid re-valvuloplasty. One other patient (8.3%) was referred to surgery 14 months after the procedure secondary to severe tricuspid regurgitation. In conclusion, this study demonstrates a sustained benefit on late follow up after combined percutaneous balloon valvuloplasty of mitral and tricuspid valves and confirms the efficacy and safety of the procedure as an alternative to surgery in selected cases of combined mitral and tricuspid stenosis.

Comparative methods of repairing left ventricular aneurysms.

Between 1 March 1992 and 31 June 1996, we enrolled 72 patients with left ventricular aneurysms in a prospective, nonrandomized study to compare--by study of cardiac indices, single-plane ejection fractions, and nuclear ventriculograms--the effects of classical aneurysmectomy (group 1, n = 36) with those of endoaneurysmorrhaphy (group 2, n = 36). Preoperative and postoperative cardiac index measurements were, respectively, 1.96 +/- 0.6 and 3.51 +/- 0.53 for group 1, and 1.96 +/- 0.31 and 3.43 +/- 0.41 for group 2. In this regard, there was not any significant difference between the groups preoperatively or postoperatively. Preoperative and postoperative multiple-gated acquisition measurements, were, respectively, 34.3 +/- 7.76 and 43.1 +/- 11.1 for group 1, and 37 +/- 3.88 and 66.5 +/- 5.2 for group 2. Although there was not any significant preoperative difference between the groups (P = 0.34), group 2 had significant postoperative improvement in left ventricular ejection fractions (P < 0.001). Preoperative and postoperative single-plane contrast ventriculographic ejection fractions were, respectively, 43.4 +/- 8.7 and 48.6 +/- 11.2 for group 1, and 43.8 +/- 5.5 and 60.8 +/- 15.1 for group 2. Again, there was not any significant difference between the 2 groups in preoperative left ventricular ejection fractions (P = 0.87), but the postoperative left ventricular ejection fractions of group 2 were significantly better than those of group 1 (P = 0.022). We conclude that left ventricular functional improvement with endoaneurysmorrhaphy is superior to that with classical aneurysmectomy.

Comparative clinical and angiographic analysis of the initial efficacy and long-term follow-up of Wiktor stent implantation with conventional balloon angioplasty.

This study was retrospectively designed to examine if the Wiktor stent, a balloon-expandable tantalum coil stent, provides a more favorable procedural and long-term clinical and angiographic outcome than does conventional coronary balloon angioplasty (POBA). From April 1995 to April 1996, we implanted 56 Wiktor stents in 46 lesions (LAD: 23, RCA: 16, CX: 7) in 42 patients (average age 53 +/- 10 years). Coronary lesions from the stent group were matched with similar lesions of another 42 POBA patients whose characteristics were identical to the Wiktor group. Revascularization indications in the Wiktor and POBA groups, respectively, were recent myocardial infarction (RMI) (45%, 40%), unstable (31%, 39%) and stable (24%, 21%) angina pectoris. 7% of the stents and 17% of the POBA balloons were less than 3 mm in diameter (p > 0.05). Procedural success was significantly greater in the Wiktor group than in the POBA group (100% vs. 92%, p < 0.05). Neither major cardiac event (death, CABG, acute myocardial infarction) nor (sub)acute occlusion was encountered in the Wiktor group during the hospitalization period and 1 month follow-up. There was 1 urgent CABG and 4 subacute occlusions in the POBA group. Control angiography at 8 months was performed in patients of both groups, of whom some were symptomatic at long-term follow-up or completely event free for 8 months. Angiographic restenosis (> 50% diameter stenosis) occurred in 25% of the Wiktor patients and in 43% of those in the POBA group (p < 0.05). For an 18 month clinical follow-up, 91% of the patients in the Wiktor group were asymptomatic and without ischemia in radionuclide imaging (RI), whereas 79% of the POBA patients were angina-free and 74% were without ischemia in the RI study. In conclusion, Wiktor stent implantation, with no major cardiac event or subacute occlusion, provides a more favorable procedural and long-term clinical and angiographic outcome than does conventional POBA.

Thoracic aortocaval fistula due to gunshot wound.

This article presents a patient with an arteriovenous fistula between the brachiocephalic trunk and superior vena cava, a site not otherwise reported in the literature so far. The fistula was presumably the result of an accidental gunshot wound 8 years previously. Following the diagnosis, the fistula was repaired without any complication and the patient's symptoms disappeared.

Contribution of mitral valve reserve capacity to sustained symptomatic improvement after balloon valvulotomy in mitral stenosis: implications for restenosis.

OBJECTIVES: To explain the discrepancy between the symptomatic status of patients and the hemodynamically calculated mitral valve area during long-term follow-up after mitral balloon valvulotomy, mitral valve orifice variability after dobutamine infusion was investigated in two groups of patients. BACKGROUND: A significant increase in aortic valve area with increased aortic transvalvular flow has been reported in patients with calcific aortic stenosis after aortic balloon valvulotomy. A similar phenomenon with regard to the mitral valve has not been studied in detail. METHODS: Group 1 comprised 10 patients (mean age 33 +/- 9 years) with untreated mitral stenosis. Group 2 comprised 29 consecutive patients (mean age 32 +/- 7 years) who underwent successful percutaneous mitral balloon valvulotomy 13 +/- 2 months before the study. RESULTS: After dobutamine infusion, heart rate and cardiac index increased significantly in both groups. The mean pulmonary artery pressure, mitral valve gradient and pulmonary capillary pressure remained unchanged in Group 2 but increased significantly in Group 1. The mean mitral valve area was significantly larger in Group 2 after dobutamine infusion than at baseline (1.9 +/- 0.5 vs. 2.4 +/- 0.6 cm2, p < 0.0001) but was unchanged in Group 1 (1.2 +/- 0.2 vs. 1.3 +/- 0.3 cm2, p = NS). The mean mitral valve area in seven patients in Group 2 (24%) was < or = 1.5 cm2 before dobutamine infusion (1.3 +/- 0.4 cm2), which was defined as restenosis. In five of these seven patients who had minimal or no symptoms, the mitral valve area increased significantly after dobutamine infusion (1.3 +/- 0.1 vs. 1.9 +/- 0.1 cm2). In the other two patients who were symptomatic, the mitral valve area did not change after dobutamine infusion. These two patients were identified as having "true" restenosis, and redilation of the mitral valve was performed in both. CONCLUSIONS: In patients who underwent mitral balloon valvulotomy, increased mitral valve reserve capacity contributed to symptomatic improvement on long-term follow-up. Dobutamine infusion may be helpful in detecting clinically significant restenosis.