Primary transcatheter patent foramen ovale closure is effective in improving migraine in patients with high-risk anatomic and functional characteristics for paradoxical embolism.

OBJECTIVES: In the present study, we sought to assess the effectiveness of migraine treatment by means of primary patent foramen ovale (PFO) transcatheter closure in patients with anatomical and functional characteristics predisposing to paradoxical embolism without previous cerebral ischemia. BACKGROUND: The exact role for transcatheter closure of PFO in migraine therapy has yet to be elucidated. METHODS: We enrolled 86 patients (68 female, mean age 40.0 +/- 3.7 years) referred to our center over a 48-month period for a prospective study to evaluate severe, disabling, medication-refractory migraine and documented PFO. The Migraine Disability Assessment Score (MIDAS) was used to assess the incidence and severity of migraine. Criteria for intervention included all of the following: basal shunt and shower/curtain shunt pattern on transcranial Doppler and echocardiography, presence of interatrial septal aneurysm and Eustachian valve, 3 to 4 class MIDAS score, coagulation abnormalities, and medication-refractory migraine with or without aura. RESULTS: On the basis of our inclusion criteria, we enrolled 40 patients (34 females, mean age 35.0 +/- 6.7 years, mean MIDAS 35.8 +/- 4.7) for transcatheter PFO closure; the remainder continued on previous medical therapy. Percutaneous closure was successful in all cases, with no peri-procedural or in-hospital complications. After a mean follow-up of 29.2 +/- 14.8 months (range 6 to 48 months), PFO closure was complete in 95%; all patients (100%) reported improved migraine symptomatology (mean MIDAS score 8.3 +/- 7.8, p < 0.03). Specifically, auras were eliminated in 100% of patients after closure. CONCLUSIONS: Primary transcatheter PFO closure resulted in a very significant reduction in migraine in patients satisfying our criteria.

Left atrial dysfunction in patients with patent foramen ovale and atrial septal aneurysm: an alternative concurrent mechanism for arterial embolism?

OBJECTIVES: We postulate that, in patients with large patent foramen ovales (PFO) and atrial septal aneurysms (ASA), left atrial (LA) dysfunction simulating "atrial fibrillation (AF)-like" pathophysiology might represent an alternate mechanism in the promotion of arterial embolism. BACKGROUND: Despite prior reports concerning paradoxical embolism through a PFO, the magnitude of this phenomenon as a risk factor for stroke remains undefined, because deep venous thrombosis is infrequently detected in such patients. METHODS: To test our hypothesis, we prospectively enrolled 98 consecutive patients with previous stroke (mean age 37 +/- 12.5 years, 58 women) referred to our center for catheter-based PFO closure. Baseline values of LA passive and active emptying, LA conduit function, LA ejection fraction, and spontaneous echocontrast (SEC) in the LA and LA appendage were compared with those of 50 AF patients as well as a sex/age/cardiac risk-matched population of 70 healthy control subjects. RESULTS: Pre-closure PFO subjects demonstrated significantly greater reservoir function as well as passive and active emptying, with significantly reduced conduit function and LA ejection fraction, when compared with AF and control patients. Furthermore, in PFO patients, 66.3% (65 of 98) had moderate-to-severe ASA and basal shunt; SEC was observed in 52% of PFO plus ASA patients before closure. Multivariate stepwise logistic regression revealed moderate-to-severe ASA (odds ratio: 9.4, 95% confidence interval: 7.0 to 23.2, p < 0.001) as the most powerful predictor of LA dysfunction. After closure, all LA parameters normalized to the levels of control subjects: no SEC, device-related thrombosis, or aortic erosion were observed on follow-up echocardiography. CONCLUSIONS: This study suggests that moderate-to-severe ASA might be associated with LA dysfunction in patients with PFO. The resultant similarities to the pathophysiology of AF might represent an additional contributing mechanism for arterial embolism in such patients.

Peripheral vascular disease endovascular management in patients scheduled for cardiac surgery: a clinical-angiographic approach.

BACKGROUND: Endovascular management of peripheral vascular disease before cardiac surgery is still debated. We sought to present our preliminary experience of endovascular stent placement in patients scheduled for urgent cardiac surgery. METHODS: Between November 2003 and August 2005, 20 patients scheduled for urgent coronary surgery (13 males, mean age 72.5+/-5.3 years) underwent endovascular repair of PVD on the basis of clinical and angiographic indications. Aspirin (100 mg/day) plus low molecular weight heparin (nadroparin calcium) 100 IU/kg/12 h for urgent coronary surgical revascularization was administered after the procedure. RESULTS: Endovascular stenting has been performed in four clinical settings: renal artery stenting prior to coronary surgery (nine patients) to decrease the impact of extracorporeal circulation on an impaired renal function, iliac artery artery angioplasty and stenting (eight patients) in order to facilitate aortic balloon pump insertion after surgery, subclavian artery angioplasty and stenting propedeutical to arterial conduits bypass surgery (one patient), carotid artery stenting before coronary surgery (two patients). All patients underwent successful endovascular repair followed by cardiac surgery. At a mean follow-up of 12+/-4.6 months all patients are alive and without evident thrombosis or restenosis of the implanted vascular stents. CONCLUSIONS: Endovascular treatment of PVD in patients scheduled for urgent coronary surgery may be effective, relatively safe and lasting in spite of low dose antiplatelet regimen.

Assessing the appropriateness and increasing the yield of renal angiography in patients undergoing coronary angiography: a scoring system.

The real appropriateness and yield of a coincident renal angiography in patients undergoing coronary angiography is still a matter of debate. We have attempted to defined a scoring system to assess the need for renal angiography in patients undergoing diagnostic coronary angiography. We retrospectively reviewed our invasive cardiology database searching for patients underwent coincident screening abdominal aorta angiography to detect occult renal artery stenosis were analyzed and entry in a development set. Univariate and multivariate logistic regression analyses were employed to determine independent predictors of extra-cardiac atherosclerotic involvement. Based on the odds ratio, identified variables were assigned to a weighted integer; the sum of integers was a total score. Thus, the scoring model was tested on a validation set based on a prospective series of consecutive patients enrolled on the basis of an identified cut-off score. In the development set (635 patients, mean age 68+/-11.2 years) an angiographically significant RAS was observed in 20% of cases (128 patients). The rate of significant angiographic findings increased proportionally with increasing risk score (Pearson coefficient 0.98). A score of >or=5 was identified to be the cut-off beyond which renal angiography seems to have a sufficiently good efficacy in detecting clinically significant renal artery diseases (>30% of patients). In the validation set the patients were enrolled on the basis of the identified cut-off score (317 patients, mean age 69+/-14.1 years): angiographic occult RAS was diagnosed in 156/317 (49.2%) patients of the validation set versus 128/635 (20%) patients of the development set, p<0.01. This scoring system, once applied in standard medium-high volume cath labs, may be effective in increasing the yield of renal artery angiography in patients undergoing coronary angiography.

Vascular profile of patients with multivessel coronary artery disease.

PURPOSE: Early and accurate diagnosis of peripheral atherosclerosis is of paramount importance for global management of patients with known coronary artery disease (CAD). We sought to retrospectively evaluate the clinical relevance of significant subclavian artery stenosis (SAS) and abdominal vessel stenosis or aneurysm (AVA) in patients undergoing coronary angiography. SUBJECTS AND METHODS: Medical records of consecutive patients underwent coronary angiography at two public institutions over a 12-month period were evaluated. Angiographic results of patients underwent coincident diagnostic abdominal aorta angiography to evaluate abdominal vessels or subclavian angiography on the basis of clinical and angiographic criteria were analyzed. RESULTS: During the study period, 724 consecutive patients (535 males, mean age 68.1+/-11 years) were enrolled (Table 2): a significant atherosclerotic disease of at least one arterial segments were observed in 198 patients (27.3%). Angiographically significant SAS was observed in 18/220 patients (8.1%) undergoing concomitant subclavian artery angiography and candidates to coronary surgery using the internal mammary artery. Ten patients with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting and bypass surgery using LIMA. AVA were reported in 180 (35.7%) of 504 consecutive patients: renal artery stenosis was found in 13.1% of cases (66 patients), aortoiliac artery disease in 13.7 % (69 patients), and aortic aneurismal disease in 8.9% (45 patients). Logistic regression analyses revealed > or =3-vessel CAD (odds ratio [OR] 9.917, p=0.002), age>60 years old (OR 3.817, p=0.036), > or =3 risk factors (OR 2.8, p=0.048) as independent predictors of SAS and AVA. CONCLUSION: Patients with multivessel CAD are frequently aged, have an high risk profile and multiple vascular atherosclerotic distributions, suggesting the usefulness of a more global and comprehensive cardiovascular approach.

Malpractice in invasive cardiology: is angiography of abdominal aorta or subclavian artery appropriate in patients undergoing coronary angiography? A meta analysis.

BACKGROUND: Identification of peripheral vascular disease by angiography in patients undergoing coronary angiography may be considered as malpractice but sometimes seems to be justified under clear entry criteria. The present mata-analysis is aimed to analyze the appropriateness and results of screening angiography of subclavian or abdominal aorta performed at the time of coronary angiography. METHODS: A search of published literature for peripheral angiography in patients undergoing coronary angiography over the last 10 years was performed using the MEDLINE database. No language restriction was employed. Only studies enrolling more than 100 patients for abdominal aortography and 50 patients for subclavian/internal mammary artery angiography were considered. Reference lists from identified studies were also reviewed to identify other potentially relevant references. RESULTS: Twenty-nine studies were retrieved: 8 articles about subclavian artery (SA) and internal mammary (IMA) angiography and 21 about renal (RA) and aortoiliac (AOI) angiography. The total number of patients enrolled was 27,936. Nine studies out of 29 were prospective. Defined entry criteria were reported in 24 out of 29 studies. Significant SA and IMA stenosis were reported in 5.5 and 9% of patients, respectively. RA stenosis >50% was present in 12.7% of patients with CAD. Finally, undetected AOI disease was reported in 35.5% of patients undergoing coronary angiography. Mean complication rate was 0.8 +/- 0.6%. Predictors of SA and IMA stenosis were unclear. Age, multi-risk profile, multi-vessel CAD, history of PVD or carotid disease, severe hypertension, unexplained renal dysfunction or decreased creatinine clearance have been reported most frequently as predictors of RA and AOI disease in patients undergoing coronary angiography. CONCLUSIONS: Consistent evidence of appropriateness of renal angiography in selected patients undergoing coronary angiography have been produced in literature. IMA and AOI angiography seem to be not justified unless they are part of SA in patients scheduled for arterial conduit with brachial differential pressure, thoracic irradiation or surgery, or of abdominal angiography to detect RA stenosis in laboratories with radiological digital peripheral equipment.

Evidence against the widespread use of angiography of noncoronary arteries during coronary artery angiography and cardiac catheterization.

PURPOSE: Although the most widely used screening techniques for extracardiac atherosclerotic distributions are noninvasive, in patients undergoing coronary arteriography, the question as to whether angiography of extracardiac arteries at the time of cardiac catheterization is really effective or if it should be considered malpractice is still open. We sought to determine the safety and real usefulness of angiography of extracardiac arteries performed by trained invasive cardiologists during cardiac catheterization. METHODS: Medical records of all patients undergoing combined coronary and noncoronary angiography between May 1998 and December 2002 were retrospectively reviewed. Moderate to severe arterial stenosis (>50% stenosis), vessel occlusion, aneurysmal, or severe ectasia were noted as significant angiographic findings. RESULTS: Two hundred and seventy patients (165 males, mean age = 67.7+/-9.2 years, mean serum creatinine = 1.1+/-0.8 mg/dl) underwent combined cardiac catheterization and angiography of extracardiac arteries following specific indications. Significant findings were reported in 66 (24.4%) patients. Logistic regression analyses revealed three-vessel coronary artery disease [CAD; odds ratio (OR)=9.917; 95% confidence interval (CI) = 2.2 to 43.8; P = .002) and hypercholesterolemia (OR = 2.851; 95% CI=1.03 to 7.9; P = .044) to be independent predictors of extracardiac atherosclerotic involvement. Complications rate was negligible. The detection of significant angiographic findings led to endovascular treatment in 37.8% and surgical vascular repair in 33.3% of cases. CONCLUSIONS: Angiography of extracardiac arteries at the time of coronary angiography appears justified only in patients with specific indications, multivessel CAD, and hypercholesterolemia.

Ultrasound assessment of internal carotid disease candidates to endovascular carotid stenting and cardiac surgery is inaccurate in patients with severe aortic valve stenosis.

PURPOSE: The association of internal carotid artery disease (ICAD) with aortic valve stenosis (AVS) constitutes a very high-risk clinical occurrence in which combined surgery may increase the operative risks and carotid stenting before or after cardiac surgery may be a valuable option. Unfortunately, in patients with AVS, the evaluation of carotid arteries by Doppler ultrasound (DUS) may be inaccurate. The present retrospective study is aimed to evaluate the pitfalls of DUS and the role of carotid angiography before carotid stenting in evaluating ICAD in patients with AVS. METHODS: We analyzed the clinical, hemodynamic, and angiographic findings of 200 patients with moderate to severe AVS (5.5% of 3600 patients underwent cardiac catheterization; mean age, 68.5+/-10.6 years) investigated in our institution over the past 2 years. Patients with moderate to severe AVS, candidates to open cardiac surgery, underwent carotid ultrasonography to assess ICAD and complete left and right catheterization with coronary artery angiography, and in case of doubtful carotid artery sonography, the patients underwent also carotid artery angiography at the time of complete cardiac catheterization before confirming the indication to carotid stenting or combined surgery. RESULTS: Seventy patients with moderate to severe AVS and doubtful carotid ultrasonography underwent coincident carotid angiography. Reasons for suboptimal Doppler ultrasonographic examination are related to the anatomical or to the difficult evaluation of Doppler flow due to hemodynamic influences of AVS. On carotid angiography, 20 patients (28.5%, male/female, 8/12; mean age, 72.1+/-5.1 years) were diagnosed to have critical stenosis of one (16 patients) or both (4 patients) internal carotid arteries; in five patients, a significant ICAD was not diagnosed by DUS, whereas in seven patients, the stenosis was underestimated by DUS (mean luminal narrowing, 58+/-12.7% vs. 76.7+/-19.3%, P<.03), and in the other eight patients, DUS overestimated ICAD (77+/-12% vs. 62+/- 13.4%, P<.02). Out of this group, six patients underwent successful carotid stenting, six combined surgical treatments, and eight underwent simple cardiac surgery. CONCLUSIONS: Doppler ultrasound may be inconclusive in evaluating ICAD in patients with moderate to severe AVS candidates to cardiac surgery and endovascular carotid stenting. Carotid angiography may be proposed at the time of cardiac catheterization in patients with inconclusive DUS examination.

Congenital heart diseases in aged patients: clinical features, diagnosis, and therapeutic indications based on the analysis of a twenty five-year Medline search.

OBJECTIVES: The increasing aging of the population make congenital heart disease more likely to be found in aged patients. No systematic data exist on epidemiology, diagnosis, and therapy in this complex class of patients. The purpose of this study was to provide specific clinical, diagnostic, and therapeutic information concerning patients over 65 with congenital heart disease (CHDs) and to identify the most frequent CHDs in such class of patients. METHODS: A Medline search was performed to include articles related to congenital heart disease in patients over 65 in worldwide literature from January 1977 to January 2004. Follow-up studies of old, operated CHDs were excluded. The selected papers were divided and numbered on the basis of key words in the title and contents into general, diagnostic, and therapeutic topics. RESULTS: One thousand ninety-five articles met the search criteria. Atrial septal abnormalities, coronary artery anomalies, bicuspid aorta and congenital aortic valve stenosis, and patent ductus arteriosus resulted in the most cited CHDs in the elderly. Clinical manifestations included syncope, supraventricular/ventricular arrhythmias, symptoms of chronic pulmonary hypertension, and congestive heart failure. Echocardiography for the most frequent CHDs and computed tomography and magnetic resonance for complex cases were the main diagnostic tools (277, 104, and 110 citations, respectively). Catheterization plays a marginal role (68 articles). Age is not considered a contraindication to interventions; surgical and endovascular therapy appeared to be similarly useful in managing the most frequent CHDs (88 and 63 citations, respectively), whereas medical treatments were selected for most complex CHDs (71 citations). CONCLUSIONS: Patients with CHDs, especially those with low mortality in childhood, are more frequently reaching old age. New imaging techniques and endovascular treatments seem useful in the challenging management of CHDs in aged patients.

Screening angiography of supraaortic vessels performed by invasive cardiologists at the time of cardiac catheterization: indications and results.

An aging population makes multiple vascular distributions more likely in patients arriving at the cath lab for coronary artery angiography or complete cardiac catheterization. Whether or not screening angiography of supraaortic vessels can be performed at the time of cardiac catheterization by the invasive cardiologist is still debatable. We sought to determine safety and utility of performing angiography of supraaortic vessels during cardiac catheterization. Medical records of all patients undergoing combined coronary and noncoronary angiography between May 1998 and December 2002 was retrospectively reviewed. One hundred and forty patients (80 males, mean age 67.8 +/- 5.4 years) underwent combined cardiac catheterization and angiography of supraaortic vessels. Carotid artery angiography was performed at the same time of cardiac catheterization in 62 patients and subclavian artery angiography in the other 78 patients. Significant findings were reported in 32 (22.8%) patients. Complications included 1 transient ischemic attack and 2 carotid spasm resolved with nitrates infusion. In most cases the same standard catheters used during coronary angiography were used also for noncoronary angiography (119 patients, 85%). The incidence of significant angiographic findings and the relatively frequent association of CAD with supraaortic vessel atherosclerosis supports combined cardiac catheterization and angiography of supraaortic arteries but only in patients with multivessel coronary artery disease.

Concomitant peripheral vascular and coronary artery disease: a new dimension for the global endovascular specialist?

BACKGROUND: Early and accurate diagnosis of peripheral atherosclerosis is of paramount importance for global ma agement of patients with known coronary artery disease (CAD). HYPOTHESIS: We sought to evaluate retrospectively the prevalence and clinical relevance of significant abdominal vessel stenosis or aneurysm (AVA) in patients undergoing coronary angiography. METHODS: Medical records of consecutive patients who underwent coronary angiography at two public institutions over a 12-month period were evaluated. Angiographic results of patients who underwent diagnostic abdominal aorta angiography, based on clinical criteria, to evaluate abdominal vessels the same time as coronary angiography were analyzed. RESULTS: During the study period, AVA was reported in 180 (35.7%) of 504 consecutive patients (335 men, mean age 68 +/- 13.8 years): renal artery stenosis was found in 13.1% of cases (66 patients), aortoiliac artery disease in 13.7% (69 patients and aortic aneurysmal disease in 8.9% (45 patients). Logistic regression analyses revealed > or = 3-vessel CAD (odds ratio [OR] 9.917, p = 0.002), age >65 years (OR 3.817, p = 0.036), > or =3 risk factors (OR 2.8, p = 0.048) as independent predictors of AVA. CONCLUSION: Multiple vascular atherosclerotic distributions are frequent in elderly patients who have multivessel CAD and a high-risk profile, suggesting the usefulness of a more global and comprehensive cardiovascular approach.

Simultaneous preoperative brachiocephalic angiography and coronary angiography to prevent coronary-subclavian steal syndrome in coronary surgery candidates.

BACKGROUND: Whether or not preoperative brachiocephalic angiography with left internal mammary artery (LIMA) visualization should be performed at the time of coronary angiography in patients in whom bypass grafting using LIMA is envisaged is still debated. We sought to assess the role of the routine brachiocephalic angiography artery in preventing the coronary-subclavian steal syndrome in patients who are candidates for bypass grafting using LIMA. METHODS: Medical records of 110 patients (mean age 69.3 +/- 8.4 years) who underwent concomitant coronary angiography and brachiocephalic arteriography between May 1998 and December 2002 were reviewed. Stenosis >50%, vessel occlusion, and aneurysm were noted as significant findings. RESULTS: Significant findings were observed in 23/110 patients (20.9%). Five patients with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting and bypass surgery using LIMA. During a mean follow-up of 24.7 +/- 10.7 months, only one patient developed a new subclavian artery disease after bypass grafting using LIMA, and underwent subclavian artery angioplasty. Logistic regression analysis revealed 3-vessel CAD (odds ratio (OR) 9.917 ; 95% confidence interval (CI) 2.2 to 43.8; P = .002), hypercholesterolemy (OR 2.74; CI 95% 1.05 to 7.7; P = .044), and age >65 (OR 3.55; CI 95% 2.2 to 9.2, P = .038) to be predictors of brachiocephalic disease. CONCLUSION: This study suggests that routine angiography of the brachiocephalic arteries at the time of coronary angiography is effective in preventing coronary-subclavian steal syndrome in select patients who are candidates for bypass grafting using LIMA.

Angiographic characteristics of renal arterial disease over the spectrum of coronary artery disease.

BACKGROUND/AIM: The angiographic characteristics of renal artery stenoses (RAS) in patients with coronary artery disease (CAD) have not been yet fully investigated. We sought to evaluate the angiographic characteristics of RAS in patients with CAD. METHODS: The medical records of consecutive patients who underwent coronary angiography in a single public institution over a 12-month period were evaluated. The patients who underwent coincident diagnostic renal angiography to evaluate renal vessels on the basis of clinical criteria and who had at least one-vessel CAD were analyzed. Moderate (50-70%) to severe (70-100%) arterial stenoses were noted as significant angiographic findings. The types of stenosis (ostial, true renal, mixed) and presence and location of calcium were recorded. RESULTS: Angiographically significant RAS were reported in 40 (19.5%) of 205 consecutive patients (mean age 67.1 +/- 12.8 years, mean serum creatinine concentration 2.1 +/- 0.5 mg/dl, mean glomerular filtration rate 52 +/- 13 ml/min) for a total of 55 lesions. The RAS severity was moderate in 30.9% (17/55), severe in 69.1% (38/55), ostial in 27.2% (15/55), true renal in 10.9% (6/55), and mixed in 61.8% (34/55) of the patients. The mean lesion length was 16 +/- 1.8 mm. Patients with > or = 3-vessel CAD had a statistically significantly higher prevalence of mixed calcified RAS (18/24, 75%). Logistic regression analyses revealed > or = 3-vessel CAD (odds ratio 9.917, p = 0.002), age > 65 years (odds ratio 3.817, p = 0.036), and > or = 3 risk factors (odds ratio 2.8, p = 0.048) as independent predictors of RAS. CONCLUSION: RAS in multivessel CAD patients seems to have a peculiar angiographic pattern, such as a higher prevalence of mixed calcified lesions and poststenotic enlargement, that should be taken in account when dealing with RAS.

Congenital coronary artery anomalies in the adult: a new practical viewpoint.

There is a certain confusion as to the universal classification of coronary artery anomalies (CAAs), since the existing classifications are often fragmented and difficult to apply as they combine many anatomical, angiographic, and clinical elements. A practical global classification of CAAs for diagnostic and clinical purposes has not been proposed previously. The authors propose to describe CAAs on the basis of seven angiographic patterns (1: hypoplasia/atresia, 2: hyperdominance, 3: fistula, 4: originating from other arteries, 5: originating from the wrong sinus, 6: splitting, and 7: tunneling) and four clinical significance classes (benign--class A, relevant--class B, severe--class C, and critical--class D). This global classification can be applicable to almost all significantCAAs, and in the authors' view it might help both angiographers and clinical cardiologists to familiarize themselves rapidly with a comprehensive description of most CAAs by simplifying the transmission of the angiographic data.

Validation of a clinical-significance-based classification of coronary artery anomalies.

The clinical significance and subsequent management of the various types of coronary artery anomalies (CAAs) are different, as is the relationship to sudden death, coronary artery disease, and myocardial ischemia. A practical global classification based on clinical significance has not yet been proposed. This retrospective study was aimed at evaluating the current clinical significance of CAAs and the effectiveness of a clinical-significance-based classification. In a single-center retrospective study at a public hospital, a review of the last 5,100 coronary angiographies was performed in order to select patients with CAAs. The CAAs were classified into 4 categories on the basis of a literature review according to angiographic appearance and clinical significance: benign (class I); relevant-associated with fixed myocardial ischemia (class II); severe-related to sudden death (class III); and critical-associated with superimposed coronary artery disease (CAD) (class IV). Clinical and instrumental records of the selected patients were reviewed as well as the occurrence of cardiovascular events from the date of diagnosis to July 2002. Sixty-two patients (1.2%, women/men 20/42, mean age 65.3 +/-10.6 years) had CAA on coronary angiography. From the above-described classification, 40 patients were categorized in class I (64.5%), 9 in class II (14.5%), 7 in class III (11.3%), and 6 in class IV (9.7%). During the follow-up (mean duration 60.4 +/-12.3 months) most cardiovascular events and death occurred in class III and IV patients (71.3% and 100% respectively). A high correlation was found between significance level and percentage of patients with cardiovascular events (r = 0.99). Actuarial survival at 5 years was 82.9%. CAAs can be practically classified on the basis of clinical presentation and significance. This clinical classification may be useful in managing patients with CAA and personalizing their follow-up and therapeutic options according to their class and case histories.

New perspectives in the treatment of damaged myocardium using autologous skeletal myoblasts.

Autologous skeletal myoblast transplantation may be used to ameliorate the healing process following myocardium infarct and, hopefully, cardiomyopathies. Despite successful animal experimentation, several issues need to be addressed in clinical settings, i.e., the impact of the delivery route, the extent of short- and long-term survival, and differentiation of the injected skeletal myoblasts. The authors offer some new hypotheses resulting from basic research, i.e., where and when to inject the myogenic cells, whatever their source, how to decrease new myofiber atrophy and improve their regeneration. Although these new hypotheses still need to be tested in humans, they may be decisive for future experimental studies and will lead to making endovascular cell implantation a more effective way to treat ischemic heart disease and failure.