Excimer laser technology in percutaneous coronary interventions: Cardiovascular laser society's position paper.

Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.

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.

Image quality criteria in cardiology.

Image quality evaluation plays a key role in the process of optimisation in radiological procedures. Image quality criteria for cardiac cine-angiography were recently agreed as part of a European Research Project, and a scoring system based on these criteria has been developed to allow an 'objective' measurement of the quality of cardiac angiograms. Two studies aimed at the evaluation of the methodology have been completed, demonstrating that the method can be applied to cardiac images and translated into a scoring system that yields reproducible data. Based on the results of these studies, quality criteria have been further reviewed by DIMOND III panel and the updated version is presented in this paper.

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.

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.

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.

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.

[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.

[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.

[Intravascular echocardiography (ICUS) diagnosis of post-traumatic coronary dissection involving the common trunk. A case report and review of the literature]. / Diagnosi con ecocardiografia intravascolare (ICUS) di dissezione coronarica post-traumatica coinvolgente il tronco comune. Descrizione di un caso e revisione della letteratura.

A case is reported in which a 31-years-old man experienced coronary artery dissection with an acute anterior myocardial infarction following blunt chest trauma in a car accident. Due to ECG signs of acute myocardial infarction a coronary angiography was performed showing an abrupt occlusion of the mid part of the left anterior descending artery and a linear filling defect in the proximal portion of the vessel. Additional detailed intravascular ultrasound was performed, revealing a long intimal tear involving the left anterior descending artery and the left main. The patient underwent immediate coronary artery bypass surgery. Two vein grafts were made from aorta to the left anterior descending artery and the circumflex artery, respectively. Repeat angiography was performed early after the operation; dissection of the left main and the left anterior descending artery was still visible and the grafts to the left descending artery and the circumflex were patent.

Right bundle branch block, intermittent ST segment elevation and inducible ventricular tachycardia in an asymptomatic patient: an unusual presentation of the Brugada syndrome?

We describe the case of an asymptomatic 54-year-old female who underwent a routine electrocardiogram (ECG) in July 1997, which showed incomplete right bundle branch block and an important ST segment elevation with a coved fashion and the inversion of T waves in leads V1-V2. Her family and personal history was free of any cardiovascular pathology. She previously underwent a routine ECG in 1991 and 1995, showing an incomplete right bundle branch block with a moderate ST segment elevation in leads V1-V2. Exercise test, 24-hour Holter ECG, echocardiogram and QT dispersion analysis were all normal. The heart-rate variability in the frequency domain revealed low vagal tone. The signal-averaged ECG was positive due to the presence of three criteria. The patient underwent an electrophysiologic study. The baseline ECG resembled the ones performed in 1991 and 1995. Sinoatrial node and atrioventricular node were normal. The HV interval resulted of 62 ms. A syncopal polymorphic ventricular tachycardia (cycle length 220 ms) interrupted by electrical defibrillation (200 J) was induced with double extrastimulus during pacing at a cycle length of 600 ms from the apex of the right ventricle. At the end of the study, one minute after a bolus of ajmaline 1 mg/kg, an important ST segment elevation in lead V1 and a left axis deviation appeared. The patient began therapy with sotalol 80 mg t.i.d. and the electrophysiologic study was repeated three days later. A non-sustained polymorphic ventricular tachycardia (cycle length 200 ms) was induced with triple extrastimulus during pacing at a cycle length of 370 ms from the outflow tract of the right ventricle. On the basis of these results and as also suggested by recent reports, we decided to implant an Automatic Implantable Cardioverter Defibrillator.

Bail-out rotational atherectomy to ablate stent struts after treatment of a LAD bifurcation lesion with the Trousers technique.

We present a previously unreported complication of the "trousers" stent procedure used for treatment of a bifurcation lesion in the left anterior descending artery and the first diagonal branch. Closure of the main vessel occurred. A balloon, however, could not be advanced across the side-branch stent to open the struts toward the main branch. Therefore, a bailout rotational atherectomy was performed to ablate the stent that then allowed a further dilatation with a PTCA balloon. This procedure resolved a potentially lethal outcome for the patient who subsequently underwent uneventful coronary by-pass grafting.

Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: analysis in relation to radiation exposure parameters.

Few data are available on the quantitative assessment of complexity (C), especially in relation to a patient's exposure to radiation. The relationship between several clinical (CFs), anatomic (AFs), and technical factors (TFs) versus fluoroscopy time (FT) was evaluated in 402 random percutaneous transluminal coronary angioplasty (PTCA) procedures. CFs were age, sex, single or multivessel disease, ejection fraction, and previous coronary artery bypass graft. AFs were assessed based on the American Heart Association / American College of Cardiology classification. TFs were multivessel PTCA, use of the double wire or double balloon technique, stenting, ostial stenting, bifurcation stenting, and intravascular ultrasonography. No CFs significantly influenced FT, whereas all AFs and TFs (except multivessel PTCA) did significantly influence FT. A scoring system was developed, and two complexity indexes (CI) were conceived, based on which the procedures were divided into three groups: simple, medium, and complex. The mean FTs were 471+/-289, 805+/-532, and 1,190+/-641 (P <0.0001), respectively. Total cine frame recordings were 1,119+/-572, 1,265+/-644 (P = 0.0355), and 1,418+/-785 (P<0.0001 vs. simple; P = NS vs. medium). The dose/area product measurement was 65.8+/-41.4, 93 +/-58.5 (P<0.0001), and 116.7+/-72.8 (P<0.0001 vs. simple; P = 0.00159 vs. medium), respectively. In our series, CI was directly related to AF and TF, but not to CF. Comparison of PTCA procedures and definition of appropriate FT should consider CIs.

[Idiopathic atrial fibrillation: clinical-instrumental characterization and thromboembolic risk]. / Fibrillazione atriale idiopatica: caratterizzazione clinico-strumentale e rischio tromboembolico.

Ninety-two patients with diagnosis of lone atrial fibrillation (AF) were retrospectively identified by our in-hospital records. Among the 92 patients, 62 were males and 30 females. Mean age was 50 +/- 15 years (range 13-81). In 30% of the patients mild to moderate systemic hypertension was present. None had thyroid dysfunction. At the time of our first clinical observation, AF showed the following characteristics: recurrent AF in 58% of the cases (53 patients), chronic AF in 16% of the cases (15 patients) and first episode of AF in 26% of the cases (24 patients). Patient's symptoms were: palpitation in 73% of the cases, dyspnea in 24%, asthenia in 22%, chest pain in 19%, dizziness in 19% and syncope in 9% of the cases. In 9% of the subjects AF was asymptomatic. Recurrent AF presented with more than one episode per day in 12% of the cases, one per week in 16% of the cases, one-two episodes in 1 month in 8% of the cases and between two and six episodes in 1 year in 33% of the cases. Cross-sectional echocardiography, evidenced a higher prevalence of left atrial enlargement in patients with chronic AF (7/15 cases = 47%) either compared to subjects with recurrent AF (5/53 cases = 9%, p < 0.005) or compared to subjects with a first episode of AF (3/24 cases = 11%, p < 0.05). Echocardiographic signs of left ventricular dysfunction (left ventricular enlargement or hypokinesia) were found in 27% of the patients with chronic AF and in 8% of the other two groups (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Transvenous cardioverter-defibrillators: clinical experience at implantation and follow-up]. / Cardioverter-defibrillatori impiantati per via transvenosa: esperienza clinica all'impianto e durante il follow-up.

Thirty-seven patients with ventricular tachyarrhythmias refractory to antiarrhythmic drug treatment, guided by electrophysiological testing, were submitted to implantation of a cardioverter-defibrillator by the transvenous technique. Mean age was 55 +/- 14 years and the underlying heart disease was coronary heart disease in 24 patients, cardiomyopathy or other etiologies in 11 patients. In 2 patients ventricular arrhythmias were idiopathic. Left ventricular ejection fraction was < or equal to 40% in 65% of the patients. The following devices were implanted: CPI Ventak P in 2 patients, Ventak P2 in 9 patients, Ventak PRx in 9 patients, Ventak PRxII in 2 patients, Telectronics Guardian ATP III 4215 in 9 patients, Siemens Siecure in 5 patients, Medtronic Jewel PCD in 1 patient. At implantation defibrillation threshold was lower with biphasic shocks than with monophasic shocks (17.0 +/- 3.2 vs 20.9 +/- 3.8 J, p < 0.003) and the need for subcutaneous patches was lower when biphasic shocks were employed. Operative and perioperative mortality were 0% and no significant complications were observed. During the follow-up (16 +/- 11 months) 35% of the patients had appropriate shocks and 93% of the patients with antitachycardia pacing availability (n = 15) had effective antitachycardia pacing interventions. The following complications were observed: lead failure in 4 patients (3 insulation breaks and 1 elongation for stretching), late lead dislodgement in 2 patients, lead recall in 1 patient, all of which required reintervention. Inappropriate shocks occurred in 30% of the patients and were related to lead failure, supraventricular arrhythmias or alternating current interference. During the follow-up one patient died of sudden death and one was submitted to heart transplantation. In conclusion, implantation of a cardioverter-defibrillator by the transvenous technique is a procedure relatively free from complications. During the follow-up lead failure appears to be one of the most relevant complications. Antitachycardia pacing allows effective termination of ventricular tachycardias without cardioversion, with a better compliance.

Intraoperative transesophageal echo-Doppler evaluation of stentless aortic xenografts. Incidence and significance of moderate gradients.

BACKGROUND: The aim of this study was to assess the utility of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing aortic valve replacement with the CryoLife-O'Brien (CLOB) Stentless Porcine Aortic Bioprosthesis. METHODS: Between May 1994 and March 1995, 26 patients (15 men, mean age 68.4+/-10.78 years) had a CLOB valve in the aortic position. Transprosthetic gradients and valve regurgitation were detected by intraoperative TEE. Prosthetic regurgitation and transvalvular gradients were evaluated at six-month intervals using transthoracic echo-Doppler (TTE). RESULTS: The majority of implants resulted in low gradients (83.7%), with only four patients exhibiting a moderate gradient (15.3%). Color flow Doppler imaging showed central aortic regurgitation in only four of 25 patients (trivial, n=4; mild, n=1). There was one paravalvular leak (trivial, n=1). At follow-up examination (mean 37+/-12 months), 24 of 25 patients exhibited low mean gradients (7.25+/-2.81 mmHg). At follow-up one patient who had low velocities in the LVOT at perioperative evaluation exibited a moderate gradient (45 mmHg) with an effective orifice area of 0.8-0.9 cm(2). CONCLUSIONS: Intraoperative TEE was effective in assessing prosthetic stentless valve function.