Cardiac release and kinetics of cytokines after elective bare metal coronary stenting.

The study was designed to assess the cardiac release kinetics of the cytokines interleukin-1ß (IL-1ß), interleukin-6 (IL-6) and tumor-necrosis-factor-α (TNF-α) in patients with significant stenosis of the ramus interventricularis anterior. Ten patients were treated by bare metal stent implantation, 11 patients who underwent a diagnostic coronary angiography without intervention served as a control group. Cytokines paired blood samples were withdrawn from the coronary sinus and a peripheral vein immediately before and 1, 2, 6 h after the intervention. Myocardial ischemia was monitored by means of cardiac lactate metabolism and 12-lead electrocardiogram. After coronary intervention IL-6 gradually increased from a common baseline level of 1.34 ± 1.56 pg/ml to a maximum of 10.58 ± 5.7 pg/ml in the peripheral vein and 15.81 ± 6.98 pg/ml in the coronary sinus within 6 h with persistent higher levels in the coronary sinus indicating coronary IL-6 release. After 12 h the peripheral venous concentration of IL-6 returned to baseline levels. Neither in the study group for IL-1ß and TNF-α nor in the control group for any cytokine level significant changes were found. Myocardial ischemia was excluded in all patients. Uncomplicated percutaneous coronary intervention (PCI) was followed by a significant cardiac IL-6 release due to endothelial injury and not to myocardial ischemia.

Evidence of pathological coronary flow patterns in patients with isolated coronary artery aneurysms.

OBJECTIVES: Aim of our study was to evaluate the coronary flow patterns and therapeutic effects of nitroglycerin (NTG) in patients with isolated large coronary artery aneurysms (CA). CA are defined as nonobstructive lesions of the epicardial coronary arteries with a luminal dilation >or=two-fold of the normal diameters. The pathophysiology of a potential coronary insufficiency in this entity is still unknown. METHODS: A coronary sinus study with incremental atrial pacing before and after the administration of 0.2 mg NTG was performed in 19 patients with bilateral large fusiform nonstenotic CA to evaluate an exercise-induced myocardial ischemia. The average peak velocity in the aneurysmatic segment of the proximal left anterior descending artery was simultaneously measured by a 14/1000 inch Doppler flow wire. The coronary flow volumes and vascular resistances were calculated. RESULTS: Evidence of exercise-induced myocardial ischemia was found in all patients presenting with a frank cardiac lactate production (10.2+/-3.3%) which was significantly aggravated by NTG (26.0+/-7.5%, P<0.003). 0.2 mg NTG provoked a long-lasting and significant decrease in coronary flow volume (from 140.2+/-34.2 to 91.2+/-21.8 ml/min, P<0.002), a marked increase in coronary vascular resistance (from 0.62 to 0.92 mmHG x ml/min(-1), P<0.002) and an inadequate increase in coronary flow volume under cardiac pacing. CONCLUSION: CA were identified as an entity of nonobstructive ischemic coronary artery disease with an exercise-induced myocardial ischemia and impaired flow volume. NTG exerted an adverse vasoactive effect in CA.

Detection of diverse bacterial signatures in atherosclerotic lesions of patients with coronary heart disease.

BACKGROUND: Bacterial infection has been discussed as a potential etiologic factor in the pathophysiology of coronary heart disease (CHD). This study analyzes molecular phylogenies to systematically explore the presence, frequency, and diversity of bacteria in atherosclerotic lesions in patients with CHD. METHODS AND RESULTS: We investigated 16S rDNA signatures in atherosclerotic tissue obtained through catheter-based atherectomy of 38 patients with CHD, control material from postmortem patients (n=15), and heart-beating organ donors (n=11) using clone libraries, denaturating gradient gel analysis, and fluorescence in situ hybridization. Bacterial DNA was found in all CHD patients by conserved PCR but not in control material or in any of the normal/unaffected coronary arteries. Presence of bacteria in atherosclerotic lesions was confirmed by fluorescence in situ hybridization. A high overall bacterial diversity of >50 different species, among them Staphylococcus species, Proteus vulgaris, Klebsiella pneumoniae, and Streptococcus species, was demonstrated in >1500 clones from a combined library and confirmed by denaturating gradient gel analysis. Mean bacterial diversity in atheromas was high, with a score of 12.33+/-3.81 (range, 5 to 22). A specific PCR detected Chlamydia species in 51.5% of CHD patients. CONCLUSIONS: Detection of a broad variety of molecular signatures in all CHD specimens suggests that diverse bacterial colonization may be more important than a single pathogen. Our observation does not allow us to conclude that bacteria are the causative agent in the etiopathogenesis of CHD. However, bacterial agents could have secondarily colonized atheromatous lesions and could act as an additional factor accelerating disease progression.

Randomized comparison of success and adverse event rates and cost effectiveness of one long versus two short stents for treatment of long coronary narrowings.

Long stents of high flexibility and low profile have become widely available. Treatment of long coronary lesions by 1 long stent may require less interventional efforts and reduce the rate of restenosis due to a lack of overlapping stent segments. This study sought to evaluate the use of 1 long stent compared with 2 short stents for treatment of long coronary lesions. One-hundred twenty-four patients with a coronary lesion 20 to 40 mm in length, in a vessel 2.5 to 4.0 mm in diameter, were randomly assigned to treatment with 1 long stent (GFX II stents or S670 of 24, 30, or 40 mm lengths; n = 62) or 2 stents (GFX II or S670 stents, n = 62) of equal length. Procedural success, interventional costs, as well as long-term clinical and angiographic outcomes were evaluated. Lesion characteristics were similar for the 2 treatment groups. Stent placement was possible as assigned by randomization in 61 of 62 cases (98%) in the 1-long-stent group and 100% of cases in the 2-short-stents group. There was crossover to successful short-stent placement in 1 case. The in-hospital success rate was 97% for the 1-long-stent group and 98% for the 2-short-stents group. Acute angiographic results were similar for both groups after intervention. The angiographic restenosis rate at 6 months was 38.5% in the 1-long-stent group and 37.5% in the 2-short-stents group (p = 0.919). Intervention time was less, and the need for a contrast agent had a tendency to be lower in the long-stent group. Procedural costs were significantly less in the long-stent group. In conclusion, 1 long stent can be used with identical procedural success and adverse event rates as 2 short stents in long, atherosclerotic coronary lesions. The restenosis rate is not reduced by the use of 1 long stent compared with 2 stents. However, long stent placement is highly cost effective.

Intravascular ultrasound study and evidence of pathological coronary flow reserve in patients with isolated coronary artery aneurysms.

OBJECTIVES: Isolated coronary artery aneurysms (CA) are defined as non-obstructive lesions with luminal dilation > or =2-fold of normal coronary diameters. METHODS: A coronary sinus study with incremental atrial pacing was performed in 19 patients with bilateral fusiform CA to investigate myocardial ischemia. Intravascular ultrasound was performed to characterize the lesions morphology. The average peak velocity in the aneurysmatic segment of the left anterior descending artery was simultaneously measured by a Doppler flow wire. Coronary flow volumes, vascular resistances and flow reserve after administration of papaverin were calculated. Ten patients without heart disease served as a control group (CG). RESULTS: Intravascular ultrasound revealed large true CA with a cross-sectional area of 34.2 +/- 4.1 mm(2) and only slight atherosclerosis. Exercise-induced myocardial ischemia was found in CA presenting with a cardiac lactate production and an only 1.6-fold increase in coronary blood flow. A significant smaller coronary flow reserve of 1.51 was revealed in CA when compared with CG (2.86, P < 0.02) corresponding to a coronary vascular resistance of 0.59 versus 0.35 (P < 0.03) mmHg (ml/min) after papaverin. CONCLUSIONS: Coronary artery aneurysms were unequivocally identified as an entity of ischemic non-obstructive coronary artery disease with a markedly reduced flow reserve.

Midterm follow-up after minimally invasive direct coronary artery bypass grafting versus percutaneous coronary intervention techniques.

BACKGROUND: Revascularization of the left anterior descending coronary artery can be performed by minimally invasive direct coronary artery bypass grafting (MIDCAB) or percutaneous coronary intervention techniques (PCI). The study compared the midterm results of both techniques. METHODS: The outcome of 206 consecutive MIDCAB and 256 PCI patients treated from 1998 until 2001 was retrospectively analyzed. Cardiologists determined the primary patient allocation for the distinct revascularization technique. Periprocedural complications and midterm follow-up, including quality-of-life assessment (SF-36), was reported up to 5.2 years (3.4 +/- 0.7 years). RESULTS: Periprocedural and overall mortality (p = 0.206) showed no differences. Four MIDCAB patients required early reoperation but not for repeated target vessel revascularization. In 16 patients secondary PCI (7.8%) of other coronary vessels was performed. Repeated revascularization of the left anterior descending coronary artery was necessary in 24.2% of patients in the PCI group (p < 0.001), with 4.7% finally requiring surgical revascularization. The incidence of major adverse cardiac events, including myocardial infarction (p = 0.581), repeated target vessel revascularization (p < 0.001), or death (p = 0.206) was higher in the PCI group. This difference consisted basically of the need for repeated target vessel revascularization. Patient-based quality-of-life assessment (SF-36) was independent from the primary chosen revascularization method. CONCLUSIONS: At midterm follow up, MIDCAB resulted in significantly superior results regarding the need for repeated target vessel revascularization compared with PCI, with no significant differences regarding other major cardiac events.