Acute and Chronic Erysipelothrix rhusiopathiae Infection in Lambs.

Polyarthritis caused by Erysipelothrix rhusiopathiae is a relatively common infection in lambs characterized by low mortality and high morbidity. E. rhusiopathiae is a ubiquitous Gram-positive bacterium that is both a commensal and a pathogen of vertebrates. The disease was studied during an outbreak in a Norwegian Spæl sheep flock. In the acute phase, 48 of 230 (20%) lambs developed clinical signs and 4 died (1.7%). One acute case was necropsied and E. rhusiopathiae was cultured from all major organs investigated and from joints. There was a fibrinous polyarthritis, increased presence of monocytes in vessels, and necrosis of Purkinje cells. Sixteen of the diseased animals (33%) developed a chronic polyarthritis. Eight of these lambs were necropsied; all had lesions in major limb joints, and 3 of 8 also had lesions in the atlanto-occipital joint. At this stage, E. rhusiopathiae was cultured only from the joints in 7 of 8 (87.5%) lambs, but by real-time polymerase chain reaction, we showed persistence of the bacterium in several organs. Pulsed-field gel electrophoresis typing of the bacterial isolates indicated that the same strain caused the acute and chronic disease. Five of 6 (83%) chronically affected animals had amyloidosis of the spleen, and 6 of 8 (75%) had amyloidosis of the liver. All chronically affected animals had a glomerulonephritis, and 6 of 8 (75%) had sparse degeneration in the brain. Ceruloplasmin and haptoglobin were significantly increased in the chronically diseased lambs. These results show that chronic ovine erysipelas is not restricted to joints but is a multisystemic disease.

Inflammatory response to therapeutic gold bead implantation in canine hip joint osteoarthritis.

Inflammatory changes associated with periarticular pure gold bead implants were studied in dogs involved in a clinical trial investigating motor dysfunction and chronic pain owing to hip joint dysplasia and osteoarthritis. Gold beads were percutaneously implanted via a needle into different locations surrounding the greater trochanter of the femur. Nine dogs with implants were necropsied. In all examined animals, characteristic histologic lesions were observed in the tissue surrounding the gold implants--namely, a fibrous capsule composed of concentric fibroblasts intermixed with a variable number of inflammatory cells and a paucicellular innermost layer of collagen with a few fibrocyte-like cells in empty lacunae. Lymphocytes dominated the inflammatory infiltrate, with rarely observed macrophages present in close proximity to the implant site. No giant cells were observed. Immunohistochemistry showed mixed populations of lymphocytes, both CD3 positive (T cells) and CD79a positive (B cells), which in some cases formed lymphoid follicles. Diffuse inflammatory changes were present to a minor extent in the perimysium and surrounding fascia. The inflammation observed in dogs is similar to that observed with gold implants in humans. It is possible that the clinically beneficial effect of gold beads for chronic osteoarthritis depends on sustained localized inflammation with localized release of soluble mediators. The encapsulation of the implant by a paucicellular and poorly vascularized fibrous capsule may help prevent an exaggerated inflammatory reaction by sequestering the gold bead from the surrounding tissue.

Continuously improving the practice of cardiology.

Guidelines for the management of patients with cardiovascular disease are designed to assist cardiologists and other physicians in their practice. Surveys are conducted to assess whether guidelines are followed in practice. The results of surveys on acute coronary syndromes, coronary revascularisation, secondary prevention, valvular heart disease and heart failure are presented. Comparing surveys conducted between 1995 and 2002, a gradual improvement in use of secondary preventive therapy is observed. Nevertheless, important deviations from established guidelines are noted, with a significant variation among different hospitals in the Netherlands and in other European countries. Measures for further improvement of clinical practice include more rapid treatment of patients with evolving myocardial infarction, more frequent use of clopidogrel and glycoprotein IIb/IIIa receptor blockers in patients with acute coronary syndromes, more frequent use of ß-blockers in patients with heart failure and more intense measures to encourage patients to stop smoking. Targets for the proportion of patients who might receive specific therapies are presented.

Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in The Netherlands.

OBJECTIVE: To determine how the decisions of Dutch cardiologists on surgical treatment for aortic stenosis were influenced by the patient's age, cardiac signs and symptoms, and comorbidity; and to identify groups of cardiologists whose responses to these clinical characteristics were similar. DESIGN: A questionnaire was produced asking cardiologists to indicate on a six point scale whether they would advise cardiac surgery for each of 32 case vignettes describing 10 clinical characteristics. SETTING: Nationwide postal survey among all 530 cardiologists in the Netherlands. RESULTS: 52% of the cardiologists responded. There was wide variability in the cardiologists' advice for the individual case vignettes. Six groups of cardiologists explained 60% of the variance. The age of the patient was most important for 41% of the cardiologists; among these, 50% had a high and 50% a low inclination to advise surgery. A further 24% were influenced equally by the patient's age and by the severity of the aortic stenosis and its effect on left ventricular function; among these, 62% had a high and 38% a low inclination to advise surgery. Finally, 23% of the cardiologists were mainly influenced by the left ventricular function and 12% by the aortic valve area. The presence of comorbidity always played a minor role. CONCLUSIONS: There were systematic differences among groups of cardiologists in their inclination to advise aortic valve replacement for elderly patients, as well as in the way their advice was influenced by the patients' characteristics. These results indicate the need for prospective studies to identify the best treatment for elderly patients according to their clinical profile.

Triage of patients for short term observation after elective coronary angioplasty.

OBJECTIVE: To evaluate triage of patients for short term observation after elective percutaneous transluminal coronary angioplasty (PTCA), as appropriate selection of patients for short term observation after angioplasty may facilitate early discharge. METHODS: 1015 consecutive patients scheduled for elective PTCA were prospectively included for short term observation. Patients with unstable angina Braunwald class III were excluded. There were no angiographic exclusion criteria. Patients were discharged from the interventional centre when considered stable during 4 hours of observation after PTCA. It was left to the operator's discretion whether to prolong the observation period. Procedural complications were defined as death, coronary bypass surgery, early repeat PTCA, and myocardial infarction. OUTCOME MEASURES: The need for prolonged observation (> 4 hours) and the occurrence of complications. Predictors for prolonged observation and the occurrence of complications after the 4 hours observation were assessed by univariate and multivariate analysis. RESULTS: Two patients died, including one of six patients who underwent emergency bypass surgery. In all, 922 patients (90.8%) were triaged to short term observation and had an uncomplicated three day follow up. Observation was prolonged in 87 patients (8.6%), and 40 patients had a complicated course. Independent predictors of procedural complications were acute closure (odds ratio (OR) 9.7; 95% confidence interval 4.4 to 21.4), side branch occlusion (OR 8.9; 3.4 to 23.7), no angiographic success (OR 5.1; 2.4 to 11.0), female sex (OR 3.1, 1.7 to 5.7), any unplanned stent (OR 2.8, 1.4 to 5.9), and ostial lesion (OR 2.2, 1.0 to 4.7). CONCLUSIONS: A 4 hour observation period is safe after elective coronary angioplasty. As procedural variables are the strongest predictors of postprocedural complications, the immediate procedural results allow effective triage of patients for short term or prolonged observation in order to anticipate complications.

Hyperemic coronary flow after optimized intravascular ultrasound-guided balloon angioplasty and stent implantation.

OBJECTIVES: This study evaluated the acute physiological gain of adjunctive intravascular ultrasound (IVUS) guided balloon angioplasty and stent implantation. BACKGROUND: Recent studies indicate safe coronary luminal enlargement and "stent-like" long-term outcomes using upsized balloons guided by IVUS. METHODS: After angiographically guided balloon angioplasty in 20 patients with 1-vessel disease and normal left ventricular function, IVUS was performed to determine the size of the adjunctive balloon using the mean of the maximal luminal diameter and the maximal diameter of the external elastic membrane measured in the adjacent proximal and distal reference segments. Serial adenosine-induced hyperemic blood flow velocity measurements were performed using a 0.014" Doppler guide wire to determine the physiological lumen obstruction after standard balloon angioplasty, followed by IVUS-guided balloon angioplasty and stent implantation. RESULTS: Upsized balloon angioplasty (increase balloon size: 0.98 +/- 0.26 mm; balloon:artery ratio 1.35 +/- 0.21) resulted in an additional increase of arterial dimensions: minimal lumen diameter (MLD) 2.18 +/- 0.38 mm to 2.73 +/- 0.51 mm; percent diameter stenosis (%DS) 34 +/- 13% to 19 +/- 22%; IVUS assessed minimal lumen area (MLA) 7.53 +/- 1.55 mm2 to 10.24 +/- 2.22 mm2 (all p < 0.0001). Major dissections (> or = type C) did not occur. Hyperemic blood flow velocity increased from 49.8 +/- 20.1 cm/s to 59.1 +/- 22.9 cm/s (p < 0.05) after IVUS-guided balloon angioplasty. Adjunctive stent implantation resulted in a further increase of MLD to 3.84 +/- 0.51 mm, %DS to -9 +/- 21% and MLA to 13.39 +/- 1.80 mm2 (all p < 0.0001), while hyperemic blood flow velocity remained unchanged (61.2 +/- 24.7 cm/s, p = 0.7). CONCLUSIONS: Upsized IVUS-guided balloon angioplasty increases arterial coronary dimensions and the distal hyperemic blood flow velocity. Adjunctive stent implantation does not yield a further gain in the hyperemic blood flow velocity, indicating the absence of a functional residual lumen obstruction after IVUS-guided balloon angioplasty. This may explain a similar clinical outcome reported after those coronary interventions.

Worse clinical outcome but similar graft patency in women versus men one year after coronary artery bypass graft surgery owing to an excess of exposed risk factors in women. CABADAS. Research Group of the Interuniversity Cardiology Institute of The Netherlands. Coronary Artery Bypass graft occlusion by Aspirin, Dipyridamole and Acenocoumarol/phenoprocoumon Study.

OBJECTIVES: This retrospective study sought to assess differences in graft patency and clinical outcome between women and men after coronary artery bypass graft surgery (CABG). BACKGROUND: A less favorable clinical outcome has been reported in women as compared with men. Its relation to graft patency has not been studied. METHODS: We analyzed one-year follow-up data of 912 patients (120 women) who entered a randomized clinical drug trial. All patients received vein grafts; in 494 patients (56 women) internal mammary artery (IMA) grafts were also used. Graft patency was assessed by coronary angiography at one year. Primary clinical end points were myocardial infarction, revascularization procedures and death; secondary clinical end points included recurrent angina, heart failure and arrhythmias. RESULTS: Occlusion rates of vein grafts were 16.7% in women and 12.4% in men (odds ratio [OR] 1.62, 95% confidence interval [CI] 0.88 to 3.00, p = 0.12); occlusion rates of IMA grafts were 3.4% and 5.7% in women and men, respectively (OR 0.56, 95% CI 0.08 to 3.96, p = 0.56). Primary clinical end points were observed in 16.7% of women and 9.2% of men (OR 1.97, 95% CI 1.10 to 3.34, p = 0.022), and any clinical end point in 41.7% of women and 25.8% of men (OR 2.06, 95% CI 1.39 to 3.04, p = 0.0004). Myocardial infarction (15% vs. 7.6%, OR 2.15, 95% CI 1.24 to 3.75, p = 0.013) and recurrent angina (26.7% vs. 15.4%, OR 2.00, 95% CI 1.28 to 3.11, p = 0.004) occurred most frequently. Multivariate regression analysis did not identify gender as an independent risk factor for graft occlusion or the clinical end points. Graft occlusion was an independent predictor of the composite primary clinical end point (OR 2.75, 95% CI 1.59 to 4.75, p = 0.0003) and each of the secondary clinical end points. The observed differences were due to an imbalance of risk factors at baseline and to surgical and graft characteristics. CONCLUSIONS: One-year occlusion rates of vein and IMA grafts were comparable in women and men. Clinical outcome was related to graft patency and was less favorable in women owing to their uneven distribution of risk factors among both groups.

To operate or not on elderly patients with aortic stenosis: the decision and its consequences.

OBJECTIVE: To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients. DESIGN: Cohort analysis based on a prospective inclusive registry. SETTING: 205 consecutive patients (>/= 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. RESULTS: The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment. CONCLUSIONS: In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Spinal cord stimulation in chronic intractable angina pectoris: a randomized, controlled efficacy study.

BACKGROUND: Spinal cord stimulation is known to be a successful treatment for chronic intractable angina pectoris. Its effect may be anti-ischemic. It is uncertain if the clinical effect is partly caused by a placebo effect of surgery for implantation of a stimulator. In this study, clinical efficacy is investigated, together with a possible placebo effect. METHODS AND RESULTS: Efficacy of spinal cord stimulation as a treatment for chronic intractable angina pectoris was studied for 6 weeks in 13 treated patients and 12 control patients with chronic angina. Assessments were exercise capacity and ischemia, daily frequency of anginal attacks and nitrate tablet consumption, and quality of life (perceived quality of life and pain). Compared with control, exercise duration (P =.03) and time to angina (P =.01) increased; anginal attacks and sublingual nitrate consumption (P =.01) and ischemic episodes on 48-hour electrocardiogram (P =.04) decreased. ST-segment depression on the exercise electrocardiogram decreased at comparable workload (P =.01). Anginal attacks and consumption of sublingual nitrates decreased (P =.01), perceived quality of life increased (P =.03), and pain decreased (P =.01). CONCLUSIONS: Spinal cord stimulation is effective in chronic intractable angina pectoris, and its effect is exerted through anti-ischemic action. Efficacy is unlikely to be explained as a placebo effect from surgery.

Immediate and long-term effect of balloon angioplasty or stent implantation on the absolute and relative coronary blood flow velocity reserve.

BACKGROUND: There is controversy regarding the immediate and long-term effects of PTCA on the coronary flow reserve. METHODS AND RESULTS: A total of 54 patients with 1-vessel disease and normal left ventricular function were studied after balloon angioplasty (n=34) or stent implantation (n=20). Distal coronary blood flow velocity reserve (CFR) was defined as the ratio of adenosine-induced hyperemic versus baseline blood flow velocity with a 0.014-in Doppler guidewire. The relative CFR was defined as the ratio of the distal CFR and the reference CFR measured in the normal adjacent coronary artery. Hemodynamic and angiographic measurements were performed before and directly after balloon angioplasty or stent implantation and at 6-month follow-up. CFR after PTCA

Training effects on peak VO2, specific of the mode of movement, in rehabilitation of patients with coronary artery disease.

Training effects on peak oxygen consumption (VO2), specific to the mode of movement, are well-known in exercise training of young, healthy adults. However, these specific training effects were never studied in patients with coronary artery disease, but may be important in the evaluation of training effects of cardiac rehabilitation programs. Exercise training programs dominated by, for example, cycling might improve peak VO2, measured during cycling, more than during treadmill testing. Therefore, the effects of an exercise training program dominated by cycling and of a program with both cycling and walking/jogging during a 6-weeks cardiac rehabilitation program were evaluated on both cycle ergometer and treadmill. Male patients (aged between 35 and 70 years) with coronary artery disease (history of myocardial infarction and/or angina pectoris and/or coronary artery bypass surgery) were randomly assigned to either a program dominated by cycling (Group I: n=18,mean age 53+/-6.7) or a program with both cycling and jogging (Group II: n=20, mean age 48+/-9.1). Before and after the program peak VO2 was measured on both cycle ergometer and treadmill. At baseline peak VO2 on treadmill was significantly greater than on cycle ergometer in both groups. Peak VO2 (both cycle and treadmill) increased highly significantly during both programs; in group I the increase of peak VO2 on cycle ergometer was greater than on treadmill (respectively, 28.1% versus 18.8%; p<0.05), in contrast to group II (respectively, 22.8% and 16.6%; n.s.). As a result, the difference between peak VO2 on treadmill and cycle ergometer decreased significantly more during the program in group I (p<0.05). These results suggest specific training effects in patients with coronary artery disease and should be considered outcome assessment and exercise prescription of cardiac rehabilitation programs.

Clinical events following excimer laser angioplasty or balloon angioplasty for complex coronary lesions: subanalysis of a randomised trial.

OBJECTIVES: To compare clinical outcome in patients with complex coronary lesions treated with either excimer laser coronary angioplasty (ELCA) or balloon angioplasty. PATIENTS AND DESIGN: 308 patients with stable angina and a coronary lesion of more than 10 mm in length were randomised to ELCA (151 patients, 158 lesions) or balloon angioplasty (157 patients, 167 lesions). The primary clinical end points were death, myocardial infarction, coronary bypass surgery, or repeated coronary angioplasty of the randomised segment during six months of follow up. Subanalysis was performed to identify a subgroup of patients with a beneficial clinical outcome following ELCA or balloon angioplasty. SETTING: Two university hospitals and one general hospital. RESULTS: There were no deaths. Myocardial infarction, coronary bypass surgery, and repeated angioplasty occurred in 4.6, 10.6, and 21.2%, respectively, of patients treated with ELCA compared with 5.7, 10.8, and 18.5%, respectively, of those treated with balloon angioplasty. ELCA did not yield a favourable clinical outcome in subgroups of patients with long (more than 20 mm) coronary lesions, calcified lesions, small diseased vessels (< or = 2.5 mm reference diameter), or total coronary occlusions. There was a worse clinical outcome in patients with tandem lesions treated with ELCA compared with balloon angioplasty (9/18 v 3/26 lesions; p = 0.01); while a trend towards an unfavourable clinical outcome was found in patients with vessels with a reference diameter of more than 2.5 mm (23/66 v 13/63 lesions, p = 0.07) and left circumflex coronary lesions (12/41 v 6/42 lesions, p = 0.08). CONCLUSIONS: The findings indicate a worse clinical outcome in patients with lesions of more than 10 mm treated with ELCA compared with balloon angioplasty who have tandem coronary lesions and in those with vessels with a reference diameter of more than 2.5 mm and left circumflex coronary lesions.

Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation.

OBJECTIVES: We sought to establish the diagnostic accuracy of transesophageal echocardiography (TEE) during cardiopulmonary resuscitation. BACKGROUND: Because of its bedside diagnostic capabilities, excellent cardiac images and lack of interference with resuscitation efforts, TEE is ideally suited to determine the cause of a circulatory arrest that is not due to severe arrhythmia. However, the diagnostic accuracy of TEE during resuscitation is unknown. METHODS: TEE was performed in patients with prolonged circulatory arrest. The TEE diagnoses were compared with diagnoses from autopsy, surgery and clinical follow-up. RESULTS: Of the 48 study patients (29 male, 19 female, mean age +/- SD 61 +/- 20 years), 28 had an in-hospital cardiac arrest and 20 an out-of-hospital onset of arrest. Forty-four patients eventually died; four survived to discharge. The diagnoses made with TEE were cardiac tamponade (n = 6), myocardial infarction (n = 21), pulmonary embolism (n = 6), ruptured aorta (n = 1), aortic dissection (n = 4), papillary muscle rupture (n = 1), other diagnosis (n = 2) and absence of structural cardiac abnormalities (n = 7). A definite diagnosis from a reference standard was available in 31 patients. The TEE diagnosis was confirmed in 27 of the 31-by postmortem examination (n = 19), operation (n = 2), angiography (n = 2) or clinical course (n = 4). In the other four patients the TEE diagnosis proved incorrect by postmortem examination. The sensitivity, specificity and positive predictive value of TEE were 93%, 50% and 87%, respectively. In 15 patients (31%), major therapeutic decisions were based on TEE findings. CONCLUSIONS: TEE can reliably establish the cause of a circulatory arrest during cardiopulmonary resuscitation.

Safety of low dose heparin in elective coronary angioplasty.

OBJECTIVES: To evaluate the safety of a low dose of heparin in consecutive stable patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA). DESIGN: Open prospective study in a single centre. PATIENTS: 1375 consecutive patients had elective PTCA (1952 lesions: type A 11%, B1 34%, B2 36%, and C 19%). There were no angiographic exclusion criteria. INTERVENTIONS: A bolus of 5000 IU heparin was used as the standard anticoagulation regimen during PTCA. The sheaths were removed immediately after successful completion of the procedure. Prolongation of heparin treatment was left to the operator's discretion. MAIN OUTCOME MEASURES: Procedural success was defined as < 50% residual stenosis without death from any cause, acute myocardial infarction, urgent coronary bypass surgery, or repeat angioplasty within 48 hours for acute recurrent ischaemia; the need for prolonged heparinisation; and the occurrence of puncture site complications. RESULTS: Procedural success without clinical events was achieved in 90% of patients. Mortality was 0.3%; coronary bypass surgery was performed in 1.7% of the procedures. The rate of myocardial infarction was 3.3%; repeat angioplasty within 48 hours was carried out in 0.7% of patients. A total of 89.1% of the patients were treated according to the protocol. Prolonged treatment with heparin was considered necessary in 123 patients (8.9%). Repeat angioplasty for abrupt closure was performed in two patients shortly after sheath removal and in two during prolonged heparinisation. Puncture site complications occurred in 2.1% of patients (low dose heparin 1.9% and prolonged heparinisation 4.9%). CONCLUSION: Elective PTCA can be safely performed using a low dose of heparin, with a negligible risk for subacute closure. Low dose heparin may reduce the incidence of puncture site complications, shorten hospitalisation, and enable out-patient angioplasty.

Long-term cigarette smoking is associated with increased myocardial perfusion heterogeneity assessed by positron emission tomography.

The pathophysiology of smoking-related coronary events in patients with normal coronary arteries is incompletely understood. This study was conducted to explore, in subjects without symptoms of cardiovascular disease, the long-term effects of smoking on regional coronary artery vasoactivity, especially during sympathetic stimulation. In ten smoking and ten non-smoking sex- and age-matched healthy volunteers, segmental myocardial perfusion was studied using dynamic parametric nitrogen-13 ammonia positron emission tomography at rest and during sympathetic stimulation evoked by the cold pressor stimulation. Smokers demonstrated a higher myocardial perfusion at rest (116+/-17 ml/min/100 g vs 96+/-20 ml/min/100 g, P <0.01) and an impaired myocardial perfusion increase during cold pressor stimulation (1.02+/-0.15 vs 1.18+/-0.17, P <0.05). The heterogeneity of perfusion, expressed as coefficient of variation, was significantly different between the smoking and the non-smoking group. The coefficient of variation of segmental myocardial perfusion was higher in smokers at rest (17.5%+/-4.2% vs 13.5%+/-1. 9%, P <0.05) and during cold pressor stimulation (17.0%+/-3.2% vs 13. 9%+/-1.8%, P <0.05). We conclude that the long-term effects of smoking in healthy volunteers are associated with (1) increased myocardial perfusion at rest, (2) impaired myocardial perfusion response to cold pressor stimulation, and (3) increased myocardial perfusion heterogeneity both at rest and during cold pressor stimulation. These results may suggest that in healthy subjects the long-term effect of smoking is related to abnormal coronary artery vasoactivity, presumably induced by an interplay of regional endothelial dysfunction and autonomic dysregulation.

Excimer laser angioplasty versus balloon angioplasty in functional and total coronary occlusions.

Registries of excimer laser coronary angioplasty have reported good results in the treatment of complex coronary artery disease, including total or subtotal coronary occlusions. One hundred three patients (103 lesions) with a functional or total coronary occlusion were included in a randomized trial (Amsterdam-Rotterdam [AMRO] trial, total of 308 patients), 49 patients were allocated to laser angioplasty and 54 patients to balloon angioplasty. The primary clinical end points were death, myocardial infarction, coronary bypass surgery, or repeated coronary angioplasty of the randomized segment during a 6-month follow-up period. The primary angiographic end point was the minimal lumen diameter at follow-up in relation to the baseline value (net gain), as determined by an automated contour-detection algorithm. Laser angioplasty was followed by balloon angioplasty in all procedures. The angiographic success rate was 65% in patients treated with excimer laser-assisted balloon angioplasty compared with 61% in patients treated with balloon angioplasty alone. No deaths occurred. There were no significant differences between the laser angioplasty group and the balloon angioplasty group in the incidence of myocardial infarctions (1 patient vs 3, respectively, p = 0.36), coronary bypass surgery (4 patients vs 2, respectively, p = 0.34), repeat angioplasty (10 patients vs 8, respectively, p = 0.46) or primary clinical end point (15 patients vs 12, respectively, p = 0.34). The net gain in minimal lumen diameter and restenosis rate (>50% diameter stenosis at follow-up) were 0.81 +/- 0.74 mm and 66.7%, respectively, in patients treated with laser angioplasty compared with 1.04 +/- 0.68 mm and 48.5%, respectively, in patients treated with balloon angioplasty (p = 0.59 and p = 0.15, respectively). Excimer laser-assisted balloon angioplasty demonstrated no benefit over balloon angioplasty with respect to initial and long-term clinical and angiographic outcome in the treatment of patients with functional or total coronary occlusions of >10 mm in length.

Value of systolic pulmonary venous flow reversal and color Doppler jet measurements assessed with transesophageal echocardiography in recognizing severe pure mitral regurgitation.

We evaluated the value of color and pulsed Doppler transesophageal echocardiographic parameters and of V waves in estimating the severity of mitral regurgitation (MR) in 62 consecutive patients (38 men and 24 women, aged 39 to 80 years) with angiographically proven chronic pure MR (15 grade I/II, 47 grade III/IV). Twenty patients were examined before cardiac surgery under general anesthesia. Sensitivity, specificity, and positive and negative predictive values of systolic pulmonary venous flow reversal for the presence of grade III/IV MR were 87%, 93%, 98%, and 64%, respectively, these were for jet areas > or = 8.0 cm2--66%, 100%, 100%, and 48%, for jet lengths > or = 50 mm--70%, 87%, 94%, and 48%, for enlarged V waves--86%, 38%, 83%, and 43%, and for either flow reversal or a jet area > or = 8.0 cm2--96%, 93%, 98%, and 88%. We conclude that a combination of measurements improved the negative predictive value considerably, which is of importance in a population with a high pretest probability of severe MR. Enlarged V waves are not reliable in predicting severe MR. The optimal cutoff value for jet area and jet length was lower in anesthesized patients than in conscious patients; in anesthesized patients, sensitivity, specificity, and positive and negative predictive values of jet area > or = 5.0 CM2 for grade III/IV MR were 67%, 100%, 100%, and 50%, respectively; these were 87%, 100%, 100%, and 71% for flow reversal. Because the results of mitral repair are often evaluated with transesophageal echocardiography during surgery, our findings have clinical implications for evaluation of severe MR in anesthesized patients: pulmonary venous flow direction is the first-choice measure; jet area can be used when a low cutoff point is chosen.

Angina pectoris refractory for conventional therapy--is neurostimulation a possible alternative treatment?

The treatment of angina pectoris as a symptom of coronary artery disease usually is focused on restoring the balance between oxygen demand and supply of the myocardium by administration of drugs interfering in heart rate, cardiac pre- and afterload, and coronary vascular tone. For nonresponders to drug therapy or for those with jeopardized myocardium, revascularization procedures such as coronary bypass surgery and percutaneous transluminal coronary angioplasty are at hand. However, the atherosclerotic process is not stopped by these therapies and, at longer terms, angina may recur. It is not always possible to revascularize all the patients who do not positively react to medical treatment. Those with angina, not responding to adequate medication and who are not suitable anymore for revascularization, are considered to suffer from refractory angina pectoris. This group of patients has a poor quality of life, for their exercise tolerance is severely afflicted. For these patients, neurostimulation has been described repeatedly as an effective and safe therapy. The mechanism of action of neurostimulation is not completely known, but recent studies suggest an anti-ischemic effect, exerted through changes in myocardial blood flow. As soon as its safety is sufficiently established, it may become a useful alternative in the treatment of refractory angina pectoris.