Retrospective evaluation of occurrence of skin injuries in interventional cardiac procedures.

Interventional cardiology procedures can involve high doses to patients and, in particular, to patients' skin, the tissue at greatest risk of deterministic injuries. The evaluation of skin dose from interventional procedures is recommended, but difficult because of the amount of different X-ray fields and projections used in a procedure. For this reason, a retrospective follow-up study has been developed to identify skin injuries in patients submitted to one or more cardiac interventions in the Udine hospital between 1998 and 2002. Seventy-eight patients with a cumulative dose-area product >300 Gy cm2 were selected from 3332 patients, who underwent 5039 procedures. In this group the maximum skin dose was 6.7 Gy. The clinical follow-up, performed using the LENT-SOMA methodology, has not detected skin injuries and this result allows a frequency to be estimated for skin injuries in patients undergoing repeated cardiac procedures of <3 x 10(-4) in our centre.

A study to validate the method based on DIMOND quality criteria for cardiac angiographic images.

A method based on image quality criteria (QC) for cine-angiography was developed to measure the quality of cine-angiograms (CA). A series of 30 CA for left ventriculography (LV) and left and right coronary angiography (LCA, RCA) have been scored and 172 readings were obtained. Standard deviation of quality scores indicated the reproducibility of the method. Each part of CA was examined separately, giving scores for LV, LCA and RCA and a total score (TS), with clinical (C) and technical (T) criteria defined and examined separately. In 83% of the studies TS was >0.8 and with standard deviation from 0.02 to 0.21. In general, LV had a lower score and greater disagreement compared with RCA and LCA. Disagreement was greater in T, compared with C. In conclusion, these results indicate that QC, translated into a scoring system, yields reproducible data on the quality of cardiac images.

Signal-averaged electrocardiography and Doppler echocardiographic study in predicting acute rejection in heart transplantation.

BACKGROUND AND METHODS: In a prospective protocol for noninvasive diagnosis of acute cardiac rejection, 83 routine endomyocardial biopsies, followed each time by the analysis of signal-averaged electrocardiography and by a cardiac Doppler echocardiographic study, were performed in 18 heart transplant recipients. The follow-up time was 5 +/- 3.6 months. To detect noninvasively acute cardiac rejection, we compared biopsy findings with the presence of late potentials at signal-averaged electrocardiography and with two diastolic indexes, pressure half-time, and isovolumic relaxation time obtained from Doppler echocardiographic study. RESULTS: Thirteen acute rejection crises requiring modification of immunosuppression were diagnosed by means of endomyocardial biopsy. This clinically relevant acute cardiac rejection was associated with the presence of late potentials in 69% of cases and with the presence of pressure half-time < or = 55 msec and isovolumic relaxation time < or = 60 msec in 69% and 62% of cases, respectively. Sensitivity and specificity were as follows: for late potentials, 69% and 71%; for pressure half-time < or = 55 msec, 69% and 76%; for isovolumic relaxation time < or = 60 msec, 62% and 83%, respectively. The presence in a single patient of at least one abnormal parameter showed a sensitivity of 100% and a specificity of 60% in detecting important rejection. CONCLUSIONS: These data support the use of combined signal-averaged electrocardiography and Doppler echocardiographic study of the left ventricular diastolic function in the screening of acute cardiac rejection. Such results can suggest when endomyocardial biopsy should be performed, with the reliance that a normal noninvasive study highly excludes the presence of acute cardiac rejection requiring intensified immunosuppression.

The CryoLife O'Brien stentless porcine aortic bioprosthesis: 5-year follow-up.

BACKGROUND: Mortality, morbidity, complication rates, and echo hemodynamic results using the Cryolife O'Brien stentless aortic bioprosthesis over a 5-year period are reported. METHODS: The stentless valve was implanted in 97 conscecutive patients, 54 male and 43 female, mean age 70.9 +/- 6.5 years. All patients underwent preoperative, discharge (early study), 6-month (intermediate study), and late (18.3 +/- 10.4 months) echocardiography. RESULTS: The actuarial 5-year survival rate was 93.9% +/- 3%. Aortic regurgitation was absent in 95.5%, mild in 3.4%, and moderate in 1.1%. Peak and mean systolic gradients were significantly lower at discharge (p < 0.001) and at the 6-month follow-up (p < 0.001) but did not significantly fall further at the late study (p = NS). The effective orifice area index at discharge (p < 0.001) and at 6 months (p < 0.001) differed significantly from preoperative values, but variations at late study were not significant (p = NS). Left ventricular mass index decreased early postoperatively (p < 0.001) and at 6-month assessment (p < 0.001) with a further significant reduction at late echocardiography (p = 0.04). CONCLUSIONS: The 5-year results of this stentless valve showed a low rate of valve-related complications with excellent hemodynamic performance in all valve sizes.

Early and midterm results of model 300 CryoLife O'Brien stentless porcine aortic bioprosthesis.

BACKGROUND: The Cryolife O'Brien (CLOB) is a composite stentless bioprosthesis constructed from noncoronary leaflets of three porcine aortic valves. This study aimed to investigate early and midterm results after aortic valve replacement with CLOB xenograft. METHODS: Between 1993 and 2000, the CLOB was implanted in 125 patients (62 men; mean age 71.3+/-6.4 years). Mean prosthesis size was 23.6+/-2 mm. Mean follow-up time was 37.0+/-12.1 months. Patients underwent echocardiographic studies preoperatively, at discharge, at 6 and 12 months postoperatively, and yearly thereafter. RESULTS: Early (30-day) mortality rate was 2.4% (3 of 125 patients). Of the four late deaths, none was valve related. Actuarial 7-year survival was 93.6%+/-3%. Seven-year freedom from primary valve failure was 98.1%+/-1.8%. All patients showed an improvement of functional status (p < 0.001). ANOVA revealed a significant reduction over time in peak and mean systolic gradients (p < 0.001). Effective orifice area index increased (p < 0.001) and left ventricular mass index significantly reduced in all valve sizes (p < 0.001) during this time interval. CONCLUSIONS: Because the early and midterm results with CLOB xenograft have been satisfactory, we encourage its use as a valve substitute, particularly in patients with small aortic roots.

Early recovery of left ventricular function after stentless versus stented aortic valve replacement for pure aortic stenosis and severe cardiac dysfunction.

OBJECTIVE: The aim of this study was to evaluate early recovery of systolic function after stentless aortic valve replacement (AVR) versus stented AVR. METHODS: Fifty-four consecutive patients with pure aortic stenosis and impaired left ventricular function (LVEF < or = 35%) were studied retrospectively. Aortic regurgitation, concomitant valvular or coronary artery surgery, atrial fibrillation, and a previous AVR were exclusion criteria. Twenty-two patients (mean age, 70.0 +/- 6.5 years) received a stentless bioprosthesis and 32 (mean age, 58.9 +/- 6.2 years, P =.031 between groups) a mechanical or stented biologic valve. Patients underwent echocardiography preoperatively, at discharge, at 6 months, and at 1 year after surgery. RESULTS: At 6 months, analysis of variance demonstrated significant differences between groups in fractional shortening measured at the endocardium and midwall fractional shortening (<0.001), velocity of circumferential shortening (P <.001) ejection fraction (P =.02), left ventricular mass index (P <.001), systolic meridional wall stress, and circumferential wall stress (P <.001), One-year studies confirmed these findings. CONCLUSION: LV function showed, after a stentless AVR, an early recovery greater than in patients receiving a stented valve.

Left ventricular mass regression after aortic valve replacement with CryoLife-O'Brien stentless aortic bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: Left ventricular (LV) hypertrophy has been shown adversely to affect LV function and late outcome after aortic valve replacement (AVR). The study aim was to assess the time course of LV mass regression (LVMR) after AVR with a CryoLife-O'Brien stentless bioprosthesis, and to identify factors affecting late reduction of myocardial hypertrophy. METHODS: In total, 113 patients (60 males, 73 females; mean age 70.9+/-6.5 years) were studied by echocardiography preoperatively, at discharge, at six and 12 months postoperatively, and yearly thereafter. LV diameter and thickness were measured using M-mode echocardiography; LV mass was calculated using the Devereux formula and indexed by body surface area (BSA). RESULTS: LV end-systolic diameter, end-diastolic diameter, septal thickness and wall thickness decreased significantly after surgery (p <0.001). LV mass index (LVMI) was reduced by 16.6, 13.6, 10.1, 3.1, 3.3, 1.7, 2.6, and 1.8% at discharge and at 6 months and 1, 2, 3, 4, 5, and 6 years, respectively. Most LVMR occurred within the first year, with further (not significant) reductions at later examinations. Male sex (p = 0.002), arterial blood pressure > or =150 mmHg (p <0.001), LV ejection fraction (LVEF) < or =35% (p = 0.01), NYHA functional class > or = III (p = 0.01), atrial fibrillation (p <0.001), mean transvalvular gradient > or =40 mmHg (p = 0.001), and prevalent aortic incompetence (p <0.001) were factors influencing LVMR, independently of baseline effective orifice area and prosthesis size. CONCLUSION: AVR with the CryoLife-O'Brien stentless prosthesis resulted in significant LVMR. These findings encourage the use of this bioprosthesis in appropriate patients.

Quality criteria for cardiac images in diagnostic and interventional cardiology.

The quality of cardiac imaging plays a pivotal role in clinical decision-making and depends mainly on the technical performance of the imaging system and on angiographic technique. The Italian Society of Invasive Cardiology and The Italian Society of Physics in Medicine have set quality criteria giving precise guidelines regarding how an angiogram should appear provided that good equipment and correct angiographic technique are used. The criteria have been reviewed by the European Concerted Action DIMOND Cardiology group and are reported here to provide a reference standard for images for the most common procedures in daily practice.

"Side balloon stenting": a novel technique for bifurcation lesions.

We describe a new technique to treat stenoses of coronary bifurcations. The aim of this technique, called "side balloon stenting," is to treat the bifurcation lesions with the kissing balloon technique, implanting one or more stents without removing the guidewires which remain in place during the whole procedure, avoiding potential problems of access to the vessels jailed by stent struts. In addition, implanting the stent using the kissing balloon technique would prevent the "snow-plow" phenomenon (plaque shifting) in the side branch. The "side balloon stenting" technique was applied in 29 cases at various levels of coronary artery segments involving bifurcations (Table 1). The technical success rate of the side balloon stenting was 90% (25 procedures). The elective placement of one stent in the main vessel was done in 20/25 procedures (80%), and in only 5/25 (20%), it was also necessary to insert a second one in the side branch (due to suboptimal results), using the "culotte" technique in two and the T-technique in the other three. We were unable to advance the system to the right position in 4 patients (13%): in 2 due to twisting of the guidewires and in the other due to vessel tortuosity and insufficient backup of the system (guiding catheter and guidewires). In these four last cases, the delivery system was retrieved and a stent was successfully implanted in the right position in the main branch. Angiographic success (residual stenoses < 30% and TIMI 3 flow in both branches) was obtained in 100% of the cases. The post-intervention period was uneventful. These preliminary results show that the side balloon stenting technique is both feasible and safe in th treatment of coronary bifurcations with a satisfactory rate of procedural success and often (82%) positioning only one stent in the parent vessel, thus avoiding stenting the side branch. It will be necessary, however, to assess, based mainly on restenosis rate, whether these promising immediate results will persist in the long run.

[Identification of patients at risk of post-infarction heart rupture. Clinical and therapeutic characteristics of 121 consecutive cases and review of the literature]. / Identificazione del paziente a rischio di rottura di cuore postinfartuale. Caratteristiche clinico-strumentali di 121 casi consecutivi e revisione della letteratura.

In patients with acute myocardial infarction (AMI) since a decrease of deaths due to arrhythmia control and pump failure, rupture of the left ventricle free wall (RPL) has gained increasing importance as a cause of death. Of 4987 patients hospitalised for AMI from January 1969 to December 1993, RPL occurred in 121 patients (2.4%) and 17.6% of total deaths from AMI are the result of this complication. RPL was found more often in women > 75 years old, with a history of hypertension and sustaining a first coronary event. Cardiac rupture occurred after transmural myocardial necrosis, usually (60%) following an anterior AMI. RPL was an early phenomenon (in 40% it occurred within the first 24 hours and in more than 80% within 5 days from symptoms onset). Although RPL is widely considered catastrophic and unexpected, in the greater number of patients it is possible to recognise symptomatic markers (pain, emesis and agitation) indicative of impending rupture. A prompt diagnosis and the consideration that rupture is usually a stuttering process must point out an aggressive approach, which can allow a surgical treatment of RPL with a likely prognosis.

[Transesophageal and epicardial echocardiography in the evaluation of conservative surgery of the mitral valve. Complementary methods?]. / L'ecocardiografia transesofagea ed epicardica nella valutazione della chirurgia conservativa della valvola mitrale. Metodiche complementari?

BACKGROUND: Over the last two decades several new surgical methods for repairing a regurgitant mitral valve have been proposed. Unfortunately, early applications of such techniques were not always encouraging because the evaluation in the operating room led to false optimism due to a marked difference between static and functional anatomy of the repaired valve. By means of intraoperative echocardiography, be it transesophageal or epicardial, it is now possible to assess the functional result immediately after valvuloplasty and to decide about further surgery, right at the operating table. MATERIALS AND METHODS: Thirty-six patients (mean age 61.8 years) who underwent mitral valve repair were studied; all underwent preoperative transthoracic echocardiography in the week preceding surgery, and intraoperative transesophageal echo before cardiopulmonary bypass. The surgical results were evaluated by epicardial and/or transesophageal echocardiography in the operating room, and by transthoracic and/or transesophageal approach during follow-up. RESULTS: In 5 patients with intraoperative echocardiography done before valve repair, leaflets pathology and subvalvular apparatus were better evaluated. Besides, in 3 patients the more evident calcification of the leaflets led the surgeon to decide on direct replacement rather the reconstruction of the valve. The postoperative assessment has shown an unsatisfactory correction in 8 patients (24%). In 4 of these patients an important mitral regurgitation was reported and in 2 there was a moderate regurgitation. In the last 2, a iatrogenic stenosis had resulted. Of these 8 patients, 6 underwent valve replacement using an artificial valve. The other 2 patients (one with moderate stenosis and the other with moderate regurgitation) did not undergo a second operation because of the excessive operating time taken for valvuloplasty and the advanced age of the patients. During follow-up, from 6 to 54 months, a remarkable mitral regurgitation was present in 4 patients, one being severe and the other moderate. A persistence of ventricular dilatation was present only in these patients, while in the remainder the left ventricular diameters were normal. Finally, the mitral valve area after six months was between 1.5 an d4 cm2. CONCLUSIONS: Intraoperative echocardiography, both transesophageal and epicardial, can help the surgeon by giving him useful diagnostic information, if carried out before reconstructing the mitral valve with regurgitation. Its application is even more useful if applied straight after the surgical intervention. Unsatisfactory results may be evidenced at once and the operating team will decide right at the table for further repair or replacement, thus avoiding a second operation and the relevant risks.

Aortic pseudocoarctation. Description of two cases.

Aortic pseudocoarctation is a rare congenital anomaly characterized by elongation and kinking of the aortic arch. Regarded as a benign condition for a long time, several reports demonstrate that complications may occur so that a careful follow-up of patients affected by aortic pseudocoarctation is mandatory. In this context we describe two patients recently evaluated in our institution and review the literature to establish the most accurate diagnostic techniques (also considering newer noninvasive imaging modalities such as transesophageal echocardiography and nuclear magnetic resonance) and to evaluate the prognosis.

Clinical and hemodynamic evaluation of 21 mm and 23 mm Cryolife-O'Brien stentless bioprostheses implanted in the aortic position.

BACKGROUND: The aim of this study was to investigate early and mid-term results after aortic valve replacement with Cryolife-O'Brien stentless bioprosthesis, model 300. METHODS: Records of 59 patients who received a 21 or 23 mm (Group A) aortic Cryolife-O'Brien stentless valve were retrospectively reviewed and compared to 54 patients who received a valve > or = 25 mm (Group B). Group A patients were mainly female (p < 0.001), were older (p = 0.034), had dominant aortic stenosis (p = 0.011), and a smaller (p < 0.001) body surface area. Effective orifice area index was larger (p = 0.041) and left ventricular mass index higher (p = 0.024) in Group B. RESULTS: The actuarial survival at 5.5 years was 94.9 +/- 2.3% and 92.5 +/- 4.3% in Group A and B respectively (p = NS). The actuarial freedom from all events was 85.1 +/- 6.1% and 88.2 +/- 5.2% in Group A vs Group B respectively (p = NS). At late echocardiographic studies performed between 4 and 42 months (mean 27.3 +/- 6.1 months) postoperatively, peak and mean gradients decreased and effective orifice area index increased over the follow-up period (p = NS between groups). Left ventricular mass index decreased by 25% (p < 0.001) in Group A and by 20% (p < 0.001) in Group B from preoperatively and a further 13% (p = 0.034) and 8.5% (p = 0.004), respectively, from the early to the late study. No significant difference in left ventricular mass regression was noticed between groups (p = NS). CONCLUSIONS: The Cryolife-O'Brien porcine stentless bioprosthesis showed satisfactory mid-term results and may represent a good choice for patients with a small aortic annulus selected for a biological valve.

Coronary artery bypass grafting in patients with dialysis-dependent renal failure: ten-year results.

BACKGROUND: Coronary artery disease has been reported to be accelerated in patients with chronic renal failure on maintenance dialysis. Coronary artery bypass grafting (CABG) in patients on long-term dialysis is still a debated issue. METHODS: We retrospectively reviewed 19 patients (12 men, 7 women, mean age 64 +/- 11.2 years) with end-stage renal disease who underwent CABG between 1990 and 2000. Operative procedures were CABG alone in 15 (78.9%) patients and CABG associated with valve procedures in 4 (21.1%) patients. RESULTS: The early (30-day) mortality rate was 10.5% (2 of 19 patients). Non-fatal complications occurred in 6 patients (31.5%). Four delayed deaths occurred; the actuarial survivals at 1, 2, 5 and 10 years were 0.86 +/- 0.14, 0.78 +/- 0.10, 0.68 +/- 0.13 and 0.54 +/- 0.15 respectively. Among 13 survivors the mean Canadian Cardiovascular Society class was 1.3 +/- 0.3 (p < 0.001 vs preoperatively). ANOVA procedures showed age (p = 0.01), Canadian Cardiovascular Society class > or = III (p < 0.001), urgent/emergency operation (p < 0.001), left ventricular ejection fraction < 0.50 (p < 0.001), a prior myocardial infarction (p = 0.01), a preoperative mean creatinine level > or = 5 mg/dl (p = 0.02) and a duration of dialysis > or = 60 months (p = 0.03) to be strongly related to early and delayed mortality. CONCLUSIONS: CABG in patients with dialysis-dependent chronic renal failure is associated with acceptable results. Accurate patient selection, early referral to surgery, and adequate perioperative management are advisable.

Patient dose related to the complexity of interventional cardiology procedures.

In interventional cardiology (IC) the PTCA (percutaneous transluminal coronary angioplasty) procedure is the most frequent procedure with the highest dose to the patient. The procedure is usually performed by cardiologists having, in general, insufficient knowledge of radiation physics, radiation technology and radiation protection. The need for radiation protection is of paramount importance in this field of interventional radiology. Correlation between the complexity of PTCA procedure and irradiation parameters (fluoroscopy time, number of images and dose-area product--DAP) has been demonstrated. The presence of severe tortuosity and occlusion of > or = 3 months play a major role. Fluoroscopy time is better correlated with technical factors than DAP, which also includes the influence of patient size, collimation, operation modes, and X ray beam orientation. The number of acquired images is less correlated with the complexity of the PTCA procedure. A complexity index was conceived and procedures were divided into three groups, defined as: simple, medium and complex, which were significantly different in terms of patient dose.

A method based on DIMOND quality criteria to evaluate imaging in diagnostic and interventional cardiology.

Image quality criteria (IQC) for cine-angiography were recently settled. The aim of this study was to test whether these criteria allow a measurement of the quality of cine-angiograms. A questionnaire was derived from IQC where a binary response was required regarding the degree of visibility of anatomic or pathologic structures. Scores were given on a ranking scale. Two quality scores were defined (total score and minimum score) and standard deviation (SD) was assumed to be an indicator of the method's reproducibility. Data of the total score are presented for the first nine angiograms. Six experts obtained thirty-nine readings. The total scores ranged between 83 and 99% (SD 0.8-18.7%); 89% of the readings were within 4% of SD. This preliminary experience indicates that quality criteria can be translated into a scoring system that yields reproducible data in most instances. The analysis of the remaining angiograms will help in understanding how to improve these results.

[Kissing-stent technique for the treatment of spontaneous coronary artery dissection]. / Trattamento con tecnica "kissing-stent" di un'estesa dissezione spontanea dell'arteria discendente anteriore.

A 60-year-old woman referred to our hospital because of increasing dyspnea and angina. Her past history included an anterior myocardial infarction, associated with a large coronary dissection of the proximal left anterior descending coronary artery. The infarction resulted in a ventricular aneurysm which was treated with surgical excision without coronary revascularization. Coronary angiography showed a linear filling defect involving the left anterior descending coronary artery. Intracoronary ultrasound revealed a long intimal tear dividing the artery into two separated lumens. A kissing-stent technique was used to preserve the anatomical and functional integrity of the main vessel as well as of the diagonal branch. Two premounted stents were positioned covering the origin of both branches of the bifurcation. Simultaneous inflation of the two balloons created a metallic new-carina, 1 cm proximal to the bifurcation. Five months later the patient was readmitted with chest pain and repeat coronary angiography demonstrated a severe in-stent restenosis. Re-coronary angioplasty resulted in a good angiographic result. At 4 months from the last procedure there is no complaint of angina.

[Coronary angioplasty compared with aortocoronary bypass in patients with multivascular coronary disease]. / Angioplastica coronarica e bypass aortocoronarico a confronto nei pazienti con coronaropatia multivascolare.

Over the past two decades the use of angioplasty has rapidly expanded. As technology and experience have advanced, operators are increasingly faced with two-vessel and three-vessel disease. Coronary artery bypass graft surgery and coronary balloon angioplasty are two possible approaches for patients with multivessel coronary disease. Randomized trials comparing these two different procedures have found no difference in early as well as late mortality between assigned treatment groups. The Bypass Angioplasty Revascularization Investigation (BARI) showed a better long-term outcome with coronary artery bypass in the subgroup of patients with treated diabetes (35% died within 5 years after angioplasty compared with 19% who underwent surgery). Repeat revascularization was more common after angioplasty. Surgery offers more complete revascularization, but morbidity is higher; angioplasty is less invasive but patients are more likely to need another revascularization procedure mainly related to the occurrence of restenosis. Restenosis is often associated with the recurrence of symptoms requiring further revascularization. The use of stents and inhibitors of glycoprotein IIb/IIIa, minimally invasive surgical techniques and all-arterial grafting have the potential to change the scenery of coronary artery revascularization in the next few years.