Percutaneous transluminal coronary angioplasty for acute myocardial infarction.

Studies have suggested that intracoronary and intravenous thrombolysis and emergency PTCA result in decreased infarct size, improved left ventricular function, and decreased in-hospital mortality. Significant problems remain with all three treatment modalities. Thrombolysis is associated with significant bleeding, especially if acute catheterization also is performed. The intracoronary method of thrombolysis requires cardiac catheterization facilities and entails a significant delay in reperfusion. Lower rates of reperfusion initially were found with intravenous than intracoronary streptokinase, but the intravenous administration of t-PA has been associated with a reperfusion rate (75 per cent) similar to that of intracoronary streptokinase. Significant bleeding complications occur with t-PA just as with streptokinase. Furthermore, there are patients in whom thrombolysis is contraindicated because of the high risk of life-threatening hemorrhagic complications. Once thrombolysis is achieved, an underlying significant coronary artery lesion usually is present so that a significant risk of recurrent ischemia and/or reinfarction still exists. In controlled studies, the addition of cardiac catheterization and angioplasty after thrombolytic therapy is associated with a further increase in significant bleeding episodes. Also, in low-risk subgroups of patients randomized to emergency angioplasty versus elective angioplasty or noninvasive treatment after thrombolytic therapy, the complications of angioplasty may outweigh the benefits of further reduction in lesion severity. Potential problems of emergency angioplasty following thrombolytic therapy include: (1) hemorrhage into ischemic myocardium, which may have a deleterious effect on ultimate muscle recovery; (2) hemorrhage at the angioplasty site caused by thrombolytic therapy, with a resultant increased chance of occlusion of the vessel post-angioplasty, and (3) production of reperfusion arrhythmias and hypotension, predisposing to vessel reclosure and infarct extension. With primary angioplasty therapy, the reperfusion success rate is 85 to 90 per cent. This is higher than the approximately 75 per cent success rate with thrombolytic therapy alone. If angioplasty can be performed expeditiously, within 6 hours of the onset of ischemia, potential advantages of this technique include: (1) rapid reperfusion, possibly comparable to thrombolytic therapy alone; (2) higher success rate for reperfusion than thrombolytic therapy; (3) alleviation of underlying stenosis usually present after thrombolytic therapy alone; (4) avoidance of systemic thrombolysis, with a concomitant decrease in hemorrhagic risk; (5) possible avoidance of hemorrhagic infarction, which may have a deleterious effect on ultimate muscle recovery; and (6) applicability to patients in cardiogenic shock, who presently respond poorly to thrombolytic therapy alone. No large controlled randomized study exists comparing primary angioplasty with thr

Percutaneous laser-assisted thermal coronary angioplasty in native coronary arteries and saphenous vein grafts: initial results and angiographic follow-up.

Percutaneous laser-assisted thermal coronary angioplasty was attempted in 29 vessels (27 patients): 10 left anterior descending, 2 left circumflex and 17 mid-shaft (non-anastomotic) saphenous vein grafts. Argon or YAG laser thermal energy was applied via a 1.3, 1.6 or 1.9 mm metal capped probe followed by conventional balloon angioplasty in 27 vessels and sole thermal laser therapy in two vessels. The laser probe successfully crossed 83% (24/29) of vessels and subsequent balloon dilatation increased the success rate to 93% (25/27). Perforation occurred in a vein graft resulting in one in-hospital death post repeat emergency coronary artery bypass graft surgery. Angiographic follow-up was obtained in 85% (24/28) of vessels. Angiographic restenosis ( greater than 50% reduction in lumen diameter) occurred in 27% (3/11) of native coronary arteries and 62% (8/13) of saphenous vein grafts. Therefore, despite high initial success rates, the application of laser thermal energy with small laser probes relative to vessel size, followed by conventional balloon angioplasty, does not appear to alter restenosis. Further evaluation of coronary laser systems should be continued only with catheters that are capable of creating channels closer to the size of the vessel treated.

A model for hydration of peptides and its application to the conformational analysis of terminally blocked amino acids and dipeptides.

A theoretical model for peptide structure, which takes into account the effects of hydration in conformational energy calculations, is described. The free energy of hydration is composed of a term for "specific hydration," representing solute-water hydrogen bonding, and a term for "non-specific hydration," describing the interaction of the solute with water molecules in a first-neighbor shell. Minimum-energy conformations were computed for the hydrated N-acetyl-N'-methylamides of the 20 naturally occurring amino acids, and the results were compared with those computed in the absence of hydration. The relative energies of many conformations and the width of some low-energy regions of the (ø, Psi) conformational maps are altered when the free energy of nonspecific hydration is included. The term for specific hydration causes large charges of the energy, but only in some regions of the maps. Observed vicinal coupling constants are approximated better by the computation when hydration is included. Conformational preferences of the individual residues in hydrated dipeptides are similar to those computed for the hydrated single residues, showing that intraresidue interactions predominate in dipeptides. This supports the concept of the importance of short-range interactions in proteins. Bend probabilities were computed and compared with observed frequencies of occurrence of bends in proteins of known structure. Computed values improve only for some of the dipeptides containing polar residues or glycine when hydration is included. For bends involving two nonpolar residues, computations omitting hydration give better results.

Specific binding of the muscarinic antagonist [3H]quinuclidinyl benzilate is not associated with preganglionic motor neurons in the dorsal motor nucleus of the vagus.

The present study evaluates the binding of [3H]quinuclidinyl benzilate, [3H]QNB, as a measure of cholinergic muscarinic binding in six areas of the rat medulla oblongata associated with the cranial nerves. In an experimental group, the right vagus nerve was severed in the neck in order to determine whether the specific muscarinic binding sites might be located on cells that contribute efferent fibers to the vagus nerve. The level of activity of choline acetyltransferase (ChAT) also was determined in the same six areas. Additional experiments utilizing the retrograde transport of toxic ricin, a 60,000 dalton agglutinin that acts as a potent ribosomal toxin, was carried out to further evaluate localization of specific muscarinic binding in the DMN after destruction of the preganglionic efferent cells. These results support the conclusion that specific binding of the muscarinic antagonist [3H]QNB observed in the DMN of the vagus of the rat is not associated with the large cells that contribute efferent fibers into the vagus nerve. We suggest that the specific cholinergic muscarinic binding is located on interneuronal cell surfaces, on afferent terminals of local circuit neurons, or on afferent terminals of long projection axons which arise from neurons in the brainstem, hypothalamus, or forebrain.

Assessment of the results of percutaneous transluminal coronary angioplasty using an integrated ultrasound imaging-angioplasty catheter.

To evaluate the results percutaneous transluminal coronary angioplasty (PTCA), intravascular ultrasound imaging was performed in 32 proximal coronary arterial segments and in 16 atherosclerotic lesions after PTCA in 13 patients using a 5 Fr balloon catheter with an ultrasound transducer mounted just proximal to the balloon. Simultaneous angiographic measurements of vessel diameter were also performed using electronic calipers from contrast cine angiograms. There was good correlation between ultrasound and angiographic minimum luminal diameters of the normal proximal vessel (y = 0.59x + 1.49, r = 0.70, P < 0.01, n = 32). However, the luminal diameter measured by intravascular ultrasound was significantly greater than when measured by contrast angiography (2.81 +/- 0.10 vs. 2.34 +/- 0.12mm, n = 16, P < 0.001, mean +/- SEM). Post-PTCA, there was good correlation between ultrasound and angiographic minimum luminal diameters of the lesion (y = 0.62x + 1.42, r = 0.76, P < 0.001, n = 16), but again luminal diameters were significantly greater when measured by intravascular ultrasound compared to contrast angiography (2.61 +/- 0.08 vs. 1.89 +/- 0.10mm, n = 16, P < 0.001). Furthermore, residual stenosis was significantly less when determined by intravascular ultrasound than by contrast angiography (7.3 +/- 2.0 vs. 18.1 +/- 2.1%, n = 16, P < 0.001). Intravascular ultrasound was able to detect coronary calcification that was not evident by contrast coronary angiography in 8 of 16 lesions. Post-PTCA, dissection was evident in four lesions by ultrasound, whereas dissection was appreciated in only three lesions by contrast angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Multicenter evaluation of a new fixed-wire coronary angioplasty catheter system: clinical and angiographic characteristics and results.

Coronary angioplasty is increasingly used as an attempt to revascularize patients with severe coronary artery disease. To determine the efficacy of such treatment, a new fixed wire angioplasty catheter was evaluated by a multicenter group in a non-randomized fashion in 50 patients, average 58 +/- 11 years (+/- 1 SD), 58% men. Forty-four percent had a prior revascularization procedure (28% angioplasty, 16% coronary bypass surgery), 38% had a prior Q-wave myocardial infarction, 43% had grade 4 angina, and 60% multiple vessel disease. Angioplasty was attempted in 63 lesions which were located in a mid to distal location in 69%, with a proximal tortuosity score of 1.8 (2 = 45-60 degrees entrance angle), and lesion angulation of 1.4 (1 = 45 degrees lesion bend). In 88%, the device was the primary catheter used and in 6%, it was chosen when another system failed. The balloon was able to successfully cross 94% of all lesions attempted. Six lesions were crossed and dilated but significant residual stenoses remained. There were no significant device malfunctions, or angiographic or clinical complications. This feasibility evaluation of this new fixed wire system yielded excellent angiographic results. Although not a comparative study, this analysis suggests that this new generation of angioplasty catheter may improve the safety and efficacy of complex coronary angioplasty.

Successful excimer laser angioplasty following unsuccessful primary balloon angioplasty.

We report five patients where excimer laser coronary angioplasty facilitated successful balloon dilatation of heavily calcified lesions that could not be dilated by conventional angioplasty techniques alone. In each case, the lesion was crossed successfully with a guide wire. Conventional angioplasty failed because of inability to cross the lesion with a balloon (four lesions) or inability to dilate the lesion with balloon inflation (two lesions). These cases illustrate an indication for excimer laser coronary angioplasty as an adjunctive procedure in heavily calcified coronary stenoses.

Conformational characteristics of the N-acetyl-N'-methylamides of the four (Lys, Tyr) dipeptides.

The conformational properties of the N-acetyl-N'-methylamides of the dipeptides lysyl-lysine, lysyl-tyrosine, tyrosyl-lysine, and tyrosyl-tyrosine were studied by means of conformational energy calculations, by n.m.r. measurements in deuterated dimethylsulfoxide, and by circular dichroism in water, methanol, dioxane-water, and trifluoroethanol. Since these four dipeptides occur occasionally as bends in proteins, it was of interest to see whether short-range interactions, acting within the terminally blocked dipeptides, are sufficient to stabilize bend conformations significantly over other conformations. It was found that the four dipeptides exist as ensembles of conformations in solution. Therefore, it appears that longer-range interactions, such as those present in proteins, are required if bend conformations of these dipeptide sequences are to exist as stable conformations. Three of the dipeptides behave rather similarly. Both the CD and the n.m.r. experiments and computations indicate that the fourth (Lys-Tyr) differs from the others. It has a preference for compact conformations that appear to be stabilized by strong favorable interactions, primarily hydrogen bonds, between the tyrosyl and the lysyl side chains. The computations suggest that the presence of these interactions, and hence the existence of preferred conformations, is strongly solvent-dependent, and that these interactions are weakened in aqueous solution.

Radiation exposure: comparison of rapid exchange and conventional over-the-wire coronary angioplasty systems.

The growth of coronary angioplasty has resulted in increased fluoroscopy time to patients, staff, and physicians. Rapid exchange-type catheters have purported to reduce fluoroscopy time and procedure time compared to conventional over-the-wire systems. Of 150 consecutive patients, 54 were treated solely with rapid-exchange catheters and 84 were treated solely with over-the-wire catheters. Excluding 12 cases treated with fixed wire or combination catheters, the following data were found: [table: see text] Overall procedural success was obtained in 98.5% (136/138) of patients, 1.5% (2) requiring emergency coronary artery bypass graft surgery. A significant 35% reduction in fluoroscopy time and 13% reduction in procedure time were found when rapid-exchange catheters were used, with identical success rates, number of balloons used per case, and complication rates compared to over-the-wire catheters. Rapid-exchange catheters should be considered as part of an overall effort to reduce radiation exposure in the interventional cardiology laboratory.