Aspirin challenge/desensitisation before coronary stenting in subjects with history of hypersensitivity. A pragmatic approach.

BACKGROUND: Aspirin hypersensitivity may represent a major problem in patients with ischemic coronary disease who need a stenting procedure. In those patients, clinically unsettled reasonably quick desensitisation procedures are needed. In our study we attempted to select the most suitable procedure on the basis of characteristics and severity of ASA hypersensitivity. METHODS: Thirty patients with a history of mild reactions to anti-inflammatory doses of aspirin (> 325 mg) were considered at low risk and underwent a tolerance test in 5 steps. Thirty-one patients, with a history of severe reactions to anti-platelet doses of aspirin 0 mg) underwent a slow desensitisation in 12 steps, reaching a cumulative dose of 150 mg ASA in 220 minutes. RESULTS: In the first group, 29 patients tolerated the challenge. One developed urticaria, thus underwent challenge/desensitisation and achieved tolerance. In the second group, 3 patients did not tolerate the procedure and had to discontinue. CONCLUSION. Our approach to aspirin hypersensitivity in patients needing coronary stenting, based on a severity stratification, allowed to achieve an effective tolerance to aspirin in the majority of subject in a reasonable short time.

Coronary stenting for ST-elevation myocardial infarction vs. other indications in patients on oral anticoagulation: any difference in in-hospital management and outcome?

AIM: The aim of this paper was to compare the in-hospital management and outcome of patients on oral anticoagulation (OAC) undergoing coronary artery stenting (PCI-S) for ST-elevation myocardial infarction (STEMI) vs. other indications. METHODS: One hundred and sixteen patients on OAC at the time of PCI-S who were prospectively enrolled in a multi-center, observational registry, were evaluated. Patients were segregated according to whether PCI-S was performed for STEMI (group 1) or other indications, such as non ST-elevation acute coronary syndromes, stable angina, silent ischemia, etc. (group 2), and the pharmacological and procedural management, as well as the in-hospital outcome, were compared. RESULTS: No significant differences were observed in vascular access site, sheath size and type of stent implanted, nor was significantly different the use of glycoprotein IIb/IIIa inhibitors, and the use and dose of intravenous unfractionated heparin. Although not statistically different, the in-hospital occurrence of death (3.7% vs. 1.1%; OR 3.3; 95% confidence intervals [CI] 0.2-56.0), stent thrombosis (3.7% vs. 1.1%; OR 3.3; 95% CI 0.2-56.0) and major bleeding (7.4% vs. 2.2%; OR 3.4; 95% CI 0.4-25.9) was consistently about 3-fold higher in group 1. CONCLUSION: The in-hospital pharmacological and procedural management of OAC patients undergoing PCI-S for STEMI vs. other indications appears not different. Although not significantly different however, the in-hospital occurrence of major bleeding, as well as of death and stent thrombosis, appears substantially higher in patients treated for STEMI, warranting therefore further larger, prospective studies.

Results of coronary stenting for unstable versus stable angina pectoris.

Coronary artery stenting has been shown to improve the short- and long-term results of coronary angioplasty in mainly stable patients with 1-vessel disease, but it is uncertain whether its use in an unstable clinical setting may be safe and useful. To evaluate the stenting efficacy in patients with unstable angina, we retrospectively examined our experience with the Palmaz-Schatz balloon expandable stent in 231 consecutive patients. Patients were divided into 2 groups on the basis of symptoms at the time of stent implantation: group U (132 patients) had unstable angina, and group S (99 patients) had stable angina. After stent insertion, patients were treated with anticoagulant or combined antiplatelet therapy. Baseline characteristics of the 2 groups were comparable with the exception of age (higher in the unstable group) and angiographic characteristics of the target lesions (more unfavorable in unstable patients). In both groups, coronary stenting presented a high procedural success rate. Major in-hospital complications occurred in 9 unstable (6.8%) and in 2 stable (2%) patients (p = NS) and were mainly related to subacute stent thrombosis. In both groups, subacute stent thrombosis mostly occurred in patients treated with anticoagulant therapy (7 of 9 unstable patients, 2 of 2 stable patients). At 6-month follow-up, unstable and stable patients had a similar incidence of death (0%), Q-wave myocardial infarction (0%), and need of coronary artery bypass graft (3.2% vs 4%, p = NS), but coronary angioplasty repetition (4.8% vs 14%, p = 0.027) and target vessel revascularization (6.3% vs 17%, p = 0.019) rates were lower in the unstable group. In conclusion, stent insertion increases the short- and midterm coronary angioplasty effectiveness in unstable angina, making it possible to achieve outcomes quite comparable to stable angina. Compared with conventional anticoagulant regimen, combined antiplatelet therapy after placement of coronary stents seems to reduce the incidence of subacute thrombosis also in this clinical setting.

Coronary stenting for unstable angina: predictors of 30-day and long-term clinical outcome.

BACKGROUND: Unstable angina is usually caused by acute thrombosis superimposed on a fissured plaque. Coronary artery stenting has been shown to improve short- and long-term results of coronary angioplasty in mainly stable patients with one-vessel disease, but it is uncertain whether its use in an unstable clinical setting can be safe and useful. This study sought to evaluate the results of coronary stenting in unstable angina and to determine patient, lesion and procedure-related predictors of 30-day and long-term ischemic events. METHODS: We studied 266 consecutive patients (mean age 62 +/- 9 years) with unstable angina who underwent coronary artery stenting. The procedure was performed electively in 24%, in bailout situations in 11% and for a suboptimal result of conventional angioplasty in 65%. After stent implantation, patients were treated with anticoagulation (61) on combined antiplatelet therapy (200). Multivariate logistic regression analyses were performed to determine 30-day and long-term predictive factors of ischemic complications. RESULTS: Procedural success was obtained in 261 patients (98.1%). During the first 30 days after stenting, one patient died from cardiogenic shock (0.3%) and six (22%) suffered a non-fatal Q-wave myocardial infarction. Patients with combined antiplatelet therapy had a significantly lower stent thrombosis rate (1.5% versus 11.4%, P = 0.002) than those treated with anticoagulant regimen. At long-term follow-up (17.7 +/- 9.4 months) cardiac mortality myocardial infarction and target-vessel revascularization rates were 0.4%, 1.5% and 9.3%, respectively. In multivessel and diabetic patients, a worse long-term event-free survival was observed. Logistic multivariate analysis revealed bailout stenting, anticoagulant therapy, implantation of stents longer than 15 mm as predictors of 30-day ischemic events. In addition, multivessel coronary artery disease and stent application with balloon size of less than 3 mm were predictive of long-term ischemic events. CONCLUSIONS: This study demonstrates that, either electively or after failure of conventional angioplasty, coronary stenting represents an effective therapy for patients with unstable angina. In the same clinical setting, combined antiplatelet therapy is associated with a lower 30-day stent thrombosis rate than anticoagulant therapy. Bailout stenting, anticoagulant therapy, implantation of stents longer than 15 mm were shown to be predictors of 30-day ischemic events, whereas multivessel coronary artery disease and stent application with small balloon size were predictive of long-term ischemic events.

Percutaneous transluminal coronary angioplasty of the very proximal left anterior descending artery lesions: immediate results and follow-up.

In order to assess the results of percutaneous transluminal coronary angioplasty of the proximal (before the first septal branch) left anterior descending artery lesions, we analyzed the results in 206 consecutive patients, aged 56 +/- 12 years. The distance of the lesion from the origin of the left anterior descending artery was measured in the right oblique angiogram. The location of the lesions proved to be very proximal (less than 0.5 cm from the origin) in 22 patients, intermediate (0.5-1 cm from the origin) in 26 patients and distal (greater than 1 cm from the origin) in 158 patients. The initial angiographic success rate was similar among the 3 groups of patients: 95.8% in those with very proximal and intermediate lesions and 98.1% in those with distal lesions. Occlusive dissection of the left anterior descending artery without involvement of the mainstem occurred in 3.8% of the patients with intermediate lesions and in 1.9% of those with distal lesions. No complications occurred in any patient with very proximal lesions. The clinical follow-up was 25.2 +/- 12 months; angina recurred in 15.5% (31 out of 206 patients). Coronary angiography was performed in 103 patients. Restenosis occurred in 42.3% of the patients with very proximal and intermediate lesions (11 out of 26) and 31.2% of those with distal lesions (24 out of 77). In conclusion, in most patients with very proximal and intermediate lesions of left anterior descending artery, coronary angioplasty can be performed with low risk. The location of the lesion in the proximal portion of left anterior descending artery does not affect the overall success rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac disease after chest irradiation for Hodgkin's disease: incidence in 108 patients with long follow-up.

Occult or overt but delayed cardiac disease after thoracic radiotherapy for Hodgkin's disease may be common. Detailed cardiac evaluation was performed in 108 patients, mean age 46 +/- 6.2 years, with Hodgkin's disease at 175 +/- 43 months after irradiation. The study protocol included clinical examination, graded treadmill exercise test and echocardiography. Some patients with angina pectoris, previous myocardial infarction and an abnormal ECG were studied by thallium-201 scintigraphy, cardiac catheterization and coronary angiography. Cardiac disease was found in 12 patients (11%). Three patients had angina pectoris, one patient had myocardial infarction, two complained of dyspnea on effort and two had congestive heart failure. At catheterization, constrictive pericarditis was diagnosed in four patients; in two additional patients an occult constrictive pericarditis was found. One patient had both mitral and tricuspidal regurgitation and one had mitral regurgitation alone. Eight patients (7.4%) had severe coronary artery disease; four of these had associated constrictive pericarditis. Four patients had a pericardiectomy and another four had undergone coronary artery by-pass graft. Two patients died after operation from persistent pericardial constriction. It is concluded that the incidence of delayed cardiac disease after radiotherapy is relatively high; chronic pericardial disorders and coronary artery disease are the most frequent manifestations of this disease. Standard surgical treatment may be beneficial because of the relative youth of these patients.

Adjustment of pulmonary capillary wedge pressure for wave delay increases the accuracy of mitral valve area measurement.

Pulmonary capillary wedge pressure, currently accepted as an approximation of left atrial pressure, leads to underestimation of mitral valve area calculated with the Gorlin formula. Wave delay has been pointed out as a major source of the underestimation. The aim of this study was to increase the accuracy of pulmonary artery wedge pressure-based measurements through a correction for time delay. Electrocardiogram, pulmonary capillary wedge, left atrial and left ventricular pressures were recorded simultaneously at high paper speed in 18 patients with mitral stenosis who underwent transseptal left atrial catheterization prior to mitral valvulotomy. Heart rate and wedge pressure wave delay were closely correlated (r = 0.78, p < 0.001). Linear regression equation (y = 1.1x + 8) was then applied in order to adjust the pulmonary capillary wedge pressure for time delay in every complex. Relative to mitral area measured with left atrial pressure, areas calculated using wedge pressure with and without correction were, respectively, 5 +/- 6% and 16 +/- 7% (p < 0.001) lower. Both methods showed a close correlation (r > 0.95) with measurements obtained using left atrial pressure; plotting the standard deviation against the mean, the correction of capillary wedge pressure significantly (p < 0.001) increased the accuracy of area measurement. In conclusion, pulmonary wedge pressure, properly obtained and adjusted for time delay, allows a more reliable measurement of the mitral area.

Iomeprol and iopamidol in cardiac angiography: a randomised, double-blind, parallel-group comparison.

During cardiac angiography, hemodynamic alterations and surface electrocardiographic changes are common, predictable and dose-related adverse reactions to radiocontrast media. High osmolality, inadequate sodium content and local transient hypocalcemia are thought to be the main mechanisms responsible for these untoward cardiovascular effects. The purpose of this double-blind, parallel-group trial was to compare the hemodynamic and electrocardiographic responses to cardiac and selective coronary artery injection of iomeprol 400 (400 mgI/ml) and iopamidol 370 (370 mgI/ml). One-hundred consenting adult inpatients were randomised to receive iomeprol 400 (41 males, nine females; mean age, 56.6 years) or iopamidol 370 (46 males, four females; mean age, 57.6 years). Both agents produced minor and transient hemodynamic and electrophysiological effects. Following left ventriculography, iopamidol 370 produced a significantly greater increase in LVEDP than iomeprol 400 (mean increases after first and second left ventriculogram: 2.5 and 4.6 mmHg with iomeprol 400, 3.3 and 9.9 mmHg with iopamidol 370, P = 0.027). The QT-interval was more affected by iopamidol 370 than by iomeprol 400. However, post-contrast prolongation of the QT-interval was not significant with either agent, nor were there any significant T-wave, ST-segment or RR-interval changes associated with the injection of the test compounds. No serious adverse events occurred throughout the study. Mild pain was complained by only one patient, while most patients reported mild to moderate sensation of heat. Image quality of the vast majority of the procedures was rated as good or excellent in both patient groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous aortic valvuloplasty in the adult. When and why is now useful?]. / La valvuloplastica aortica percutanea nell'adulto. Quando e per chi è ancora utile?.

Percutaneous aortic valvuloplasty was introduced into clinical practice in 1986 and widely applied in elderly patients with symptomatic aortic stenosis. Nevertheless its results have been unsatisfactory over the mid to long term due to a high incidence of restenosis after 6-12 months. At the same time, patients over 70 years are more frequently undergoing surgical aortic valve replacement with low immediate postoperative mortality and good long term results. Although randomized trials are not available, aortic valve replacement seems to be a definitive therapeutic treatment when compared to the palliative result of aortic percutaneous valvuloplasty. However, since the complication rate of valvuloplasty carried out in cardiological centers with experienced personnel is low, this procedure is still indicated in selected patients. The very old (> 80 years) patients with associated systemic disease, and candidates for major surgery are referred for this procedure. Another indication for aortic valvuloplasty is severe aortic stenosis with cardiogenic shock; in this case, valve dilatation improves clinical status and acts as a "bridge" to surgery, enabling surgical intervention to be carried out at a later date. Nowadays, aortic percutaneous valvuloplasty is a possible alternative to surgical treatment in patients with an absolute surgical contraindication and in those who are in such poor clinical condition that they cannot be immediately referred to surgery. It is also useful for patients requiring urgent non-cardiac surgery (e.g., subjects with gastrointestinal bleeding). We discuss our results with this procedure which concord with those presented in the literature.

[Severe mitral insufficiency caused by the rupture of the chordae tendinae in acromegaly. Report of a case]. / Insufficienza mitralica severa da rottura di corda tendinea in acromegalia. Descrizione di un caso.

Cardiovascular disease is a common finding in patients with acromegaly. In such patients, heart failure frequently leads to death. Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. Because it is not clear whether acromegaly-related cardiomyopathy is a specific entity and since there are not many necropsy reports regarding mitral valve prolapse in acromegalic patients, we report the case of severe mitral regurgitation due to rupture of the chordae tendinae in a patient with mitral valve prolapse and acromegaly.

Severe subpulmonary obstruction caused by an aneurysmal tissue tag complicating an infundibular perimembranous ventricular septal defect.

A case of severe right ventricular obstruction caused by a huge aneurysmal tissue tag is described associated with a perimembranous ventricular septal defect with an infundibular extension. Angiograms and surgical inspection clearly showed that the ventricular septal defect extended into the outlet septum. The distinctive features of this case was the severity of the gradient related to the peculiar position of the aneurysmal tissue in the outlet portion of the ventricle. We presume that such an aneurysm, however small it is, developing in association with a ventricular septal defect with an infundibular extension may be a potential cause of severe obstruction and should therefore be carefully followed in the ensuing years.

Antithrombotic therapy after coronary stent placement.

Subacute stent thrombosis and hemorrhagic complications due to intensive anticoagulant therapy limit the clinical benefit of coronary stenting. Antithrombotic therapy after coronary stent placement has not been standardized yet. From January 1994 to December 1995 a total of 338 Palmaz-Schatz stents were implanted in 285 patients. Procedural success rate was 98.8%. In the initial period, after stent placement, patients were treated with acetylsalicylic acid (ASA) and warfarin (135 patients, Group A), while subsequently, according to the results of other studies, patients were treated with ASA plus ticlopidine (146 patients, Group B). Two hours after sheath removal, Group A patients were treated with intravenous heparin until therapeutic INR (2.5-3.5) was reached; warfarin was stopped 3 months later. In Group B patients 2 hours after sheath removal a treatment with subcutaneous heparin 25,000 IU/die plus ticlopidine 500 mg/die was started. Subcutaneous heparin was maintained until hospital discharge, ticlopidine was stopped after 1 month and ASA was maintained indefinitely. There were no significant differences in baseline characteristics between the two groups. Most patients had unstable angina and in the majority of cases the stent was implanted due to intimal dissection after balloon dilation. Eleven patients had subacute thrombosis of the stent (3.9%): 9 patients were in Group A (6%) and 2 patients were in Group B (1.3%; p = 0.04). Seven patients (6 in Group A, 1 in Group B) were treated with emergency coronary angioplasty and 3 (2 in Group A, 1 in Group B) with coronary bypass; nevertheless 7 patients (6 in Group A, 1 in Group B) had an acute myocardial infarction. Eight patients (6 in Group A, 2 in Group B) had major bleeding due to a large groin hematoma requiring blood transfusion or vascular surgery. In conclusion, after coronary stenting antithrombotic therapy with ASA plus ticlopidine, as compared with anticoagulant therapy, reduces the incidence of both cardiac events and hemorrhagic complications.

[Rupture of interventricular septum and ventricular aneurysm secondary to acute myocardial infarction in a case with normal coronary arteries (author's transl)]. / Aneurisma ventricolare e rottura del setto interventricolare post-infartuale in un caso con coronarie "normali".

A patient with ventricular septal defect and ventricular aneurysm after an acute myocardial infarction with normal coronary arteries is reported. Heart failure at 3 weeks after acute myocardial infarction was the indication for surgical treatment. The patient was successfully operated upon with resection of the aneurysm and closure of the ventricular septal defect. Coronary angiography performed before and after cardiac surgery demonstrated a normal coronary tree with transient systolic subocclusion of the left anterior descending coronary artery. The implication of a muscular bridge on the complications of myocardial infarction are discussed.

[Critical mitral stenosis in pregnancy: description of a case treated with percutaneous valvuloplasty]. / La stenosi mitralica critica in gravidanza: descrizione di un caso trattato con valvuloplastica percutanea.

We report the case of a 26-year-old woman who underwent mitral valvuloplasty during the 23rd week of gestation, following an episode of pulmonary edema. Dilation, performed without complications, increased mitral valve area from 0.9 to 1.8 cm2, cardiac output from 4.8 to 5.9 l/min, and decreased mean transvalvular gradient from 13.2 to 5 mmHg. The patient delivered spontaneously a full-term normal baby. Echocardiographic evaluation at 6 months confirmed the persistency of procedure's good outcome. According to some Authors and to our results it can be inferred that mitral valvuloplasty is a feasible and effective treatment for critical mitral stenosis during pregnancy.

[Multiple coronary fistulas to the left ventricle. An unusual cause of myocardial ischemia]. / Fistole coronariche multiple dirette al ventricolo sinistro. Una causa insolita di ischemia miocardica.

Diffuse communications between the left coronary artery and the left ventricular cavity were found in a 54-years-old man presenting with angina pectoris and reversible ischemia documented on stress Thallium scintigraphy. During atrial pacing the patient experienced chest pain which was accompanied by lactate production. Atenolol, but not nifedipine, did ameliorate the symptoms. The anatomical types and the embriogenesis of coronary microfistulas along with possible mechanisms of ischemia are discussed.

[Coronary angioplasty in the aged]. / L'angioplastica coronarica nell'anziano.

The safety and clinical efficacy of percutaneous transluminal coronary angioplasty (PTCA) in elderly patients has not been established. PTCA was attempted in 34 patients aged 65 or more (mean age 67.4). Patients were referred for angioplasty because of significant symptomatic ischemic heart disease with either stable, unstable angina or chest pain after myocardial infarction. Primary success was achieved in 29 patients (85.3%). Significant complications were encountered in three patients (8.8%): two emergency surgical procedures (5.8%), one transmural infarction (3%). In two patients (5.8%) the PTCA failed because the balloon dilating catheter didn't cross the tight stenosis. Follow-up data (mean 13.8 +/- 10.3 months) are available: 22 (73.4%) are asymptomatic. A clinically apparent recurrence occurred in 8 patients (26.6%). Coronary angiography was performed in 19 patients (63.3%) 6.3 +/- 2.4 months after PTCA. Angiographic restenosis occurred in 10 patients (52.6%). All patients with restenosis were ridilated with completely success. In conclusion, PTCA can be performed in elderly patients with a good success rate, an acceptable complication rate, a relatively low clinically apparent recurrence rate, and should be considered as a therapeutic modality for selected geriatric patients.

[Percutaneous embolization of a Blalock-Taussig shunt in an adult]. / Embolizzazione percutanea di uno shunt di Blalock-Taussig in un adulto.

The technique used in percutaneous embolization of a Blalock-Taussig shunt in a 35-year-old male is described. After selective catheterization of the left subclavian artery leading to the shunt, some spring coils were inserted which completely occluded the shunt. The choice of occluding material is discussed.

[Valvular lesions in the course of nonpenetrating thoracic trauma: their diagnosis by transesophageal echocardiography]. / Lesioni valvolari in corso di trauma toracico non penetrante: diagnosi mediante ecocardiografia transesofagea.

Two cases are reported with nonpenetrating chest trauma and involvement of mitral valve in one case and aortic valve cusps in the other, without aortic rupture. In both patients transesophageal echocardiography allowed us an accurate diagnosis, confirmed by surgical findings. In the patient with involvement of the aortic cusps, the regurgitation developed 3 months after the trauma. In conclusion, cardiac valve injuries are rare but not exceptional following nonpenetrating blunt chest trauma. Transesophageal echocardiography is the imaging technique of choice for these patients. The operator performing the study must be aware of the possible coexistence of different cardiac lesions secondary to blunt chest trauma. In the case of valvular regurgitation the accurate definition of the pathophysiological mechanism is mandatory in order to choose the appropriate surgical strategy. In the case of aortic incompetence of unknown origin, a nonpenetrating chest trauma must be searched out during the clinical interview.

Coronary stenting with the half (disarticulated) Palmaz-Schatz stent: immediate results and six-month follow-up.

Coronary stenting with the half disarticulated Palmaz-Schatz stent is particularly suitable for ostial stenoses, diaphragm stenoses, stenoses distal to tortuous segments or coronary bends and localized dissections after balloon angioplasty. Nevertheless very few data regarding the half stent exist and follow-up data are nonexistent. From January of 1994 to December of 1995 a total of 207 half stents were implanted in 175 patients. Most patients had stable or unstable angina and in the majority of cases the stent was implanted due to localized dissection or to suboptimal result. The procedural success rate was 98%. After stent implantation, 82 patients were treated with acetylsalicylic acid (ASA) and oral anticoagulant (group A), whereas 93 were treated with ASA and ticlopidine (group B). Seven patients had subacute thrombosis (5, group A; 2, group B), and six patients had major bleeding (5, group A; 1, group B). Overall, patients in group A had more cardiovascular complications than patients in group B (10, group A; 3, group B; p = 0.047). After 6-mo follow-up, 1 patient had died and 27 patients had symptoms of angina (16%). Thirteen patients underwent a second PTCA (7%) and four patients (2%) were referred for coronary artery bypass. In conclusion, coronary stenting with half Palmaz-Schatz stent appears to be a safe and effective procedure. In selected cases, the half Palmaz-Schatz stent is easier to handle than the complete stent, it is associated with a low rate of clinical restenosis, and it lowers procedural costs.