RESUMEN
The study aims to use cholesterol (Chol) + DOTAP liposome (CD liposome) based human vascular endothelial growth factor-165 (VEGF(165)) gene transfer into skeletal myoblasts (SkMs) for treatment of acute hind limb ischaemia in a rabbit model. The feasibility and efficacy of CD liposome mediated gene transfer with rabbit SkMs were characterized using plasmid carrying enhanced green fluorescent protein (pEGFP) and assessed by flow cytometry. After optimization, SkMs were transfected with CD lipoplexes carrying plasmid-VEGF(165) (CD-pVEGF(165)) and transplanted into rabbit ischaemic limb. Animals were randomized to receive intramuscular injection of Medium199 (M199; group 1), non-transfected SkM (group 2) or CD-pVEGF(165) transfected SkM (group 3). Flow cytometry revealed that up to 16% rabbit SkMs were successfully transfected with pEGFP. Based on the optimized transfection condition, transfected rabbit SkM expressed VEGF(165) up to day 18 with peak at day 2. SkMs were observed in all cell-transplanted groups, as visualized with 6-diamidino-2-phenylindole and bromodeoxyuridine. Angiographic blood vessel score revealed increased collateral vessel development in group 3 (39.7 +/- 2.0) compared with group 2 (21.6 +/- 1.1%, P < 0.001) and group 1 (16.9 +/- 1.1%, P < 0.001). Immunostaining for CD31 showed significantly increased capillary density in group 3 (14.88 +/- 0.9) compared with group 2 (8.5 +/- 0.49, P < 0.001) and group 1 (5.69 +/- 0.3, P < 0.001). Improved blood flow (ml/min./g) was achieved in animal group 3 (0.173 +/- 0.04) as compared with animal group 2 (0.122 +/- 0.016; P= 0.047) and group 1 (0.062 +/- 0.012; P < 0.001). In conclusion, CD liposome mediated VEGF(165) gene transfer with SkMs effectively induced neovascularization in the ischaemic hind limb and may serve as a safe and new therapeutic modality for the repair of acute ischaemic limb disease.
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Extremidades , Isquemia/terapia , Liposomas/metabolismo , Mioblastos Esqueléticos/fisiología , Transfección , Factor A de Crecimiento Endotelial Vascular/metabolismo , Factor A de Crecimiento Endotelial Vascular/uso terapéutico , Animales , Trasplante de Células , Extremidades/irrigación sanguínea , Extremidades/patología , Extremidades/fisiopatología , Femenino , Humanos , Liposomas/ultraestructura , Mioblastos Esqueléticos/citología , Neovascularización Fisiológica , Tamaño de la Partícula , Conejos , Flujo Sanguíneo Regional , Transfección/métodos , Factor A de Crecimiento Endotelial Vascular/genéticaRESUMEN
BACKGROUND: We investigated the feasibility and efficacy of polyethylenimine (PEI) based human vascular endothelial growth factor-165 (hVEGF165) gene transfer into human skeletal myoblasts (HSM) for cell based delivery to the infarcted myocardium. METHODS AND RESULTS: Based on optimized transfection procedure using enhanced green fluorescent protein (pEGFP), HSM were transfected with plasmid-hVEGF165 (phVEGF165) carried by PEI (PEI-phVEGF165) nanoparticles. The transfected HSM were characterized for transfection and expression of hVEGF165 in vitro and transplanted into rat heart model of acute myocardial infarction (AMI): group-1=DMEM injection, group-2= HSM transplantation, group-3= PEI-phVEGF165-transfected HSM (PEI-phVEGF165 myoblast) transplantation. A total of 48 rats received cyclosporine injection from 3 days before and until 4 weeks after cell transplantation. Echocardiography was performed to assess the heart function. Animals were sacrificed for molecular and histological studies on the heart tissue at 4 weeks after treatment. Based on optimized transfection conditions, transfected HSM expressed hVEGF165 for 18 days with >90% cell viability in vitro. Apoptotic index was reduced in group-2 and group-3 as compared with group-1. Blood vessel density (x400) by immunostaining for PECAM-1 in group-3 was significantly higher (P=0.043 for both) as compared with group-1 and group-2 at 4 weeks. Regional blood flow (ml/min/g) in the left ventricular anterior wall was higher in group-3 (P=0.043 for both) as compared with group-1 and group-2. Improved ejection fraction was achieved in group-3 (58.44+/-4.92%) as compared with group-1 (P=0.004). CONCLUSION: PEI nanoparticle mediated hVEGF165 gene transfer into HSM is feasible and safe. It may serve as a novel and efficient alternative for angiomyogenesis in cardiac repair.
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Mioblastos Esqueléticos/trasplante , Infarto del Miocardio/genética , Nanopartículas/administración & dosificación , Transfección/métodos , Factor A de Crecimiento Endotelial Vascular/administración & dosificación , Factor A de Crecimiento Endotelial Vascular/genética , Animales , Supervivencia Celular/genética , Trasplante de Células/métodos , Femenino , Técnicas de Transferencia de Gen , Humanos , Mioblastos Esqueléticos/fisiología , Infarto del Miocardio/cirugía , Tamaño de la Partícula , Ratas , Ratas Wistar , Factor A de Crecimiento Endotelial Vascular/biosíntesisRESUMEN
BACKGROUND: Studies on balloon angioplasty, atherectomy, and bare metal stent have shown a direct relation between residual plaque burden and restenosis. We investigated the relation between residual plaque burden and neointimal proliferation after drug-eluting stent (DES) implantation. METHODS: Over a period of 12 months, 65 patients (Cypher, n = 25; Taxus, n = 28; Endeavor, n = 12) from two centers underwent intravascular ultrasound (IVUS) examination at 8.2 (interquartile range 6.8-9.5) months after coronary stent implantation in native de novo coronary arteries. IVUS images were acquired with motorized pullback at 0.5 mm/s, and cross-sectional measurements were performed within the stents at 1-mm intervals. The following measurements were obtained: (1) lumen area (LA), (2) stent area (SA), (3) external elastic membrane area (EEMA), (4) percent neointimal hyperplasia area (SA-LA/SA) x 100, and (5) percent residual plaque area (EEMA-SA)/EEMA x 100. RESULTS: The analysis of 1,173 cross sections (Cypher, n = 436; Taxus, n = 532, Endeavor, n = 205) using mixed model to account for intrasubject correlation showed an absence of relation between percent residual plaque area and percent neointimal hyperplasia area (P = 0.189). Mean residual plaque burden outside the stent for Cypher, Taxus, and Endeavor groups was similar (45.7%, 44.8%, and 42.4%, respectively). Mean percent neointimal hyperplasia area for the Cypher, Taxus, and Endeavor groups was 12.0%, 15.0%, and 16.2%, respectively (P = 0.163). CONCLUSION: In patients after first-generation DES implantation and without significant in-stent restenosis, late in-stent neointimal proliferation is not related to the amount of residual plaque burden after stent implantation. This suggests against routine plaque removal before DES implantation to reduce neointimal proliferation.
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Reestenosis Coronaria/epidemiología , Reestenosis Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Stents Liberadores de Fármacos , Anciano , Angiografía Coronaria , Reestenosis Coronaria/diagnóstico por imagen , Bases de Datos Factuales , Femenino , Hospitales , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Taxus , UltrasonografíaRESUMEN
BACKGROUND: Clinical studies have evaluated the safety and efficacy of adjunctive X-sizer (EndiCOR Inc, San Clemente, CA) in percutaneous coronary intervention (PCI). However, patient and lesion subsets were highly selected, and extrapolation of the results to daily practice is problematic. METHODS: X-sizer thrombectomy was performed in 200 procedures from August 2000 to July 2005. The indications for the procedures were primary PCI in 71%. Device failure was defined as the occurrence of 1 or more of the following conditions: (a) failure of the X-sizer to reach the target segment, (b) failure to achieve final thrombolysis in myocardial infarction 3 flow, (c) slow flow or no-reflow, (d) distal embolization, and (e) coronary perforation. RESULTS: Device failure occurred in 48 procedures, giving a device failure rate of 24%. Logistic regression analysis showed that ostial lesion was the only independent predictor of device failure (OR 4.89, 95% CI 1.23-19.51, P = .024). A total of 19 patients had developed 22 adverse events, giving a 30-day adverse event rate of 9.5%. Among these, there were 13 deaths, 4 strokes, 2 reinfarctions, 2 repeat PCIs, and 1 coronary artery bypass grafting. Logistic regression analysis showed that X-sizer device failure was independently associated with 30-day adverse events (OR 3.42, 95% CI 1.04-11.25, P = .043). CONCLUSIONS: The incidence of device failure of X-sizer thrombectomy was 24%. Ostial lesion was an independent predictor of device failure. Notably, X-sizer device failure was independently associated with 30-day adverse event. These highlight the importance of case selection and the problem with its use in ostial lesions.
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Angioplastia Coronaria con Balón/instrumentación , Infarto del Miocardio/terapia , Trombectomía/instrumentación , Cateterismo Cardíaco/instrumentación , Angiografía Coronaria , Electrocardiografía , Análisis de Falla de Equipo , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Flujo Sanguíneo Regional , Análisis de SupervivenciaRESUMEN
INTRODUCTION: Atherosclerotic coronary artery thrombosis is the most common cause of acute myocardial infarction. CLINICAL PICTURE: A 30-year-old lady presented with acute peripartum massive anterior ST segment myocardial infarction and cardiogenic shock. This was due to acute Stanford type A aortic dissection with the intimal flap occluding the left coronary ostium. The initial diagnosis was not apparent. Echocardiography confirmed the diagnosis. TREATMENT AND OUTCOME: She underwent emergency surgical repair (Bentall procedure). Pathology confirmed underlying idiopathic cystic medial degeneration. CONCLUSION: A high index of clinical suspicion is required in acute myocardial infarction presenting without traditional cardiovascular risk factors.
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Aneurisma de la Aorta/complicaciones , Disección Aórtica/complicaciones , Infarto del Miocardio/etiología , Infarto del Miocardio/fisiopatología , Complicaciones Cardiovasculares del Embarazo , Enfermedad Aguda , Adulto , Disección Aórtica/diagnóstico , Disección Aórtica/cirugía , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/cirugía , Ecocardiografía , Electrocardiografía , Femenino , Humanos , Embarazo , Choque Cardiogénico/etiologíaRESUMEN
The WISDOM Registry tracked clinical outcomes in patients receiving a slow-release, polymer-based, paclitaxel-eluting stent during the transition from randomized trials to commercial use in everyday interventional cardiology practice. Although randomized trials of drug-eluting stents have demonstrated the safety and effectiveness of these devices in less complicated, de novo lesions, observation of long-term clinical outcomes is required to monitor safety as use of this revolutionary technology expands to broader patient populations. In total, 778 patients were enrolled at 22 sites in 9 countries where the TAXUS paclitaxel-eluting stent first received market approval. Patients with de novo or restenotic coronary lesions eligible for stenting were enrolled. Clinical follow-up was conducted by telephone at 3, 6, 9, and 12 months after the procedure to capture reported stent thrombosis and major cardiac events (death, myocardial infarction, and reintervention on the target lesion). Clinical follow-up at 12 months was completed for 92% of patients. The 12-month rate of physician-reported major cardiac events was 5.2%, with a target lesion reintervention rate of 2.0%. The low overall stent thrombosis rate of 0.6% included no stent thromboses >30 days after the index procedure. Low target lesion reintervention rates were also observed in the high-risk subgroups: patients with diabetes (4.0%), vessels <2.5 mm (2.5%), lesions >20 mm (3.6%), and multiple stents in a lesion (1.4%). In conclusion, the paclitaxel-eluting TAXUS slow-release stent exhibits long-term safety and efficacy in uncomplicated and higher risk patients and lesions seen in everyday clinical practice.
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Enfermedad Coronaria/terapia , Paclitaxel/administración & dosificación , Sistema de Registros , Stents , Moduladores de Tubulina/administración & dosificación , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/mortalidad , Complicaciones de la Diabetes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Mitral valve repair (MVRr) has become the mainstay of surgical treatment for mitral valvular regurgitation. Evaluation of MVRr by intraoperative transesophageal echocardiography (IOE) has been routinely employed to guide the operation. While the main objective of IOE is to assess for residual mitral regurgitation, it is also important to exclude significant mitral stenosis. Utilisation of pressure half-time (PHT) to estimate mitral valve area (MVA) has been shown to be reliable in normal clinical situations. However, in MVRr, the accuracy of MVA calculation by PHT needs to be ascertained. METHODS AND RESULTS: Data from IOE and post-MVRr transthoracic echocardiography (TTE) from the year 1998 to 2002 were analysed and when required, offline PHT measurements were made. The mean time interval between the two echocardiographic examinations was 10.6 (1 to 56) weeks. In our 36 cases, the IOE MVA was found to be 2.1+/-0.5 cm2, with the corresponding TTE MVA to be 2.7+/-1.0 cm2. MVA by PHT with IOE underestimated TTE findings by 0.6+/-0.9 cm2 (95% CI: -0.85 to -0.24, P=0.001). In 6 patients, the IOE MVA was moderately reduced. Subsequent TTE in these patients showed that the MVA was adequate and was significantly underestimated by IOE in 5 of these patients. In all these cases, IOE underestimated MVA by a margin, which may result in a need to revise the repair. CONCLUSION: We find that IOE immediately after MVRr tends to underestimate MVA by PHT calculation. The underestimation by IOE may have clinical importance in cases when MVA by IOE is moderately reduced. Therefore, pressure half-time measurement should not be used to assess mitral valve areas during mitral valve repair.
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Ecocardiografía Transesofágica , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Pesos y Medidas Corporales , Femenino , Hemodinámica , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , PresiónRESUMEN
BACKGROUND: Animal studies suggest that cell transplantation, including bone marrow-derived cells, can ameliorate left ventricular remodeling following myocardial ischemia. Clinical evaluation of the potential benefits of this approach is limited by the lack of safety and feasibility studies. We have assessed the safety and feasibility of intramyocardial transplantation of autologous bone marrow-derived cells in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS: Between December 2001 and May 2002 7 patients, scheduled for CABG, consented to the trial. All had CABG using hypothermic cardiopulmonary bypass (CPB) and cold cardioplegic arrest. An average of 21 10(6) (8.6 10(6) to 35.1 10(6)) nucleated cells, and 4.2 10(4) (2.5 10(4) to 8.1 10(4)) CD34+ cells were injected into the anterior-lateral wall of the left ventricle, after discontinuation of cardiopulmonary bypass. The end points to assess safety included death, massive bleeding, electrocardiographic or biochemical evidence of myocardial infarction, ventricular dysrhythmia, myocardial perfusion, ventricular function, and the patients' functional status. All patients recovered well without ventricular arrhythmia, bleeding, or other major peri-operative complications. The average intensive care unit (ICU) and hospital stay was 1 and 7 days, respectively. Repeat Technetium-99m myocardial perfusion stress imaging and echocardiography 6 weeks after surgery showed improvement in tissue perfusion, and an average improvement of left ventricular function of 13.5% +/- 11.54% (the mean pre- and post-operative left ventricular EF were 32.5% +/- 15.46% and 46% +/- 18.55%, respectively). Twenty-four hours Holter monitoring showed no significant arrhythmia, 3 months post-operatively. All patients with narrow QRS complex showed no evidence of late potential, on signal-averaged electrocardiogram. At 4 to 9 months after surgery patients were in NYHA functional class "I". CONCLUSIONS: This early clinical experience shows that autologous bone marrow-derived cell transplantation into myocardium is feasible and relatively safe. Further clinical trials to assess the role of cell transplantation for myocardial repair are required.
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Trasplante de Médula Ósea , Puente de Arteria Coronaria , Enfermedad Coronaria/cirugía , Anciano , Trasplante de Médula Ósea/efectos adversos , Circulación Coronaria , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/fisiopatología , Ecocardiografía , Electrocardiografía , Electrocardiografía Ambulatoria , Estudios de Factibilidad , Corazón/diagnóstico por imagen , Humanos , Persona de Mediana Edad , Periodo Posoperatorio , Cintigrafía , Tecnecio , Trasplante Autólogo , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
BACKGROUND: Commonly occurring genetic variants in CYP2C9 are known to reduce catalytic activity and are associated with enhanced patient sensitivity to warfarin. Interethnic differences in warfarin dose requirement have been described in the Asian population, and we postulate that this could be related to genetic variants of CYP2C9 that are unique to ethnic groups. METHODS: We prospectively genotyped 125 patients who were receiving a stable daily warfarin dose to maintain international normalized ratio values between 2 and 3 through comprehensive sequencing of the promoter and coding regions of the CYP2C9 gene. RESULTS: The mean weight-adjusted warfarin maintenance dose was significantly lower for Malay and Chinese subjects than Indian subjects ( P <.001 and.014, respectively). Warfarin dose negatively correlated with age (r = -0.4, P <.001) but not with sex. Multiple variants were detected in the promoter, exonic, intronic, and 3'-untranslated regions of CYP2C9, of which 16 were novel, including 7 nonsynonymous exonic variants ( 208G>C, 374G>A, 485C>A, 895A>G, 1144C>T, 1190A>C, and 1362G>C ). CYP2C9*3, but not CYP2C9*2, was found in Chinese and Malay patients, and carriers of the CYP2C9*3 variant in Chinese ( P <.01) and Indian ( P <.01) patients, but not Malay patients ( P =.77), required less warfarin. The influence of the novel exonic variants on warfarin dose requirement was unclear, because they were rare, but the lower warfarin dose requirement for Chinese and Malay patients existed despite omission of individuals with any coding region variants from analysis. CONCLUSIONS: Interethnic differences in warfarin dosing in Asian subjects may result from other genetic, dietary, or environmental influences; however, these novel variants in the gene warrant further characterization through functional studies.
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Anticoagulantes/administración & dosificación , Hidrocarburo de Aril Hidroxilasas/genética , Warfarina/administración & dosificación , Adulto , Anciano , Alelos , Pueblo Asiatico , Citocromo P-450 CYP2C9 , Exones , Femenino , Ligamiento Genético , Genotipo , Humanos , Intrones , Masculino , Persona de Mediana Edad , Regiones Promotoras Genéticas , Estudios ProspectivosRESUMEN
The purpose of this study is to demonstrate safety and effectiveness of the S-Stent in de novo coronary lesions treated with conventional percutaneous coronary balloon angioplasty. Between January 2000 and June 2001, 120 patients were prospectively enrolled at four study centers. Patients were treated with coronary stenting in a total of 137 lesions. Procedural success was achieved in 100% of 137 attempted lesions. Clinical success was 99.8%. In-hospital mortality was 0.8%; myocardial infarction occurred in 0.8% and stent thrombosis in 0.8%. After stent implantation, the minimal lumen diameter increased from 0.92 +/- 0.43 to 2.74 +/- 0.36 mm (P < 0.0001) and the percent diameter stenosis decreased from 68.0 +/- 16.2 to 4.5 +/- 12.0 (P < 0.0001). At 6-month follow-up, the percent diameter stenosis was 33.5 +/- 21.3 and the angiographic restenosis rate was 16.5%. Target lesion revascularization was required in 12 patients (10.1%). We conclude that the use of S-Stent for coronary intervention resulted in a high procedural success rate and low angiographic restenosis at 6 months after implantation.
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Angioplastia Coronaria con Balón/efectos adversos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/etiología , Trombosis Coronaria/etiología , Infarto del Miocardio/etiología , Stents , Anciano , Angioplastia Coronaria con Balón/instrumentación , Asia Sudoriental/epidemiología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Reestenosis Coronaria/epidemiología , Trombosis Coronaria/epidemiología , Estudios de Factibilidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Estudios Prospectivos , Diseño de Prótesis , Proyectos de Investigación , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
We conducted a randomized feasibility pilot study comparing combined fibrinolysis with immediate rescue angioplasty vs. primary angioplasty with adjunctive abciximab in patients with acute myocardial infarction (AMI). Seventy patients with ST segment elevation AMI of = 6 hr were randomized to either 50 mg of alteplase and abciximab (n = 34) or primary angioplasty with adjunctive abciximab (n = 36). Coronary angiography was performed at 60 min in the combined lytic group and TIMI 3 flow was present in 65% of patients as compared to 25% (P = 0.001) in the primary angioplasty group prior to intervention. Treatment success, defined as TIMI 3 flow, was achieved in 83% of patients in the primary angioplasty group (P = 0.075 compared to 65% in combined lytic group before rescue angioplasty). There was no difference in overall treatment success between primary angioplasty and combined lytic group with rescue angioplasty (83% vs. 94%; P = NS). Major adverse cardiac events at 1 month were not significant (15% vs. 11%; P = NS), but there was a trend toward more events in the combined lytic group at 6 months (32% vs. 14%; P = 0.066), particularly in target vessel revascularization. In this feasibility pilot study, high rate of TIMI 3 flow was attained in patients with AMI with both combined fibrinolysis and primary angioplasty with adjunctive abciximab. A larger randomized trial is currently ongoing to compare these two strategies.
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Angioplastia Coronaria con Balón , Anticuerpos Monoclonales/uso terapéutico , Fibrinolíticos/uso terapéutico , Fragmentos Fab de Inmunoglobulinas/uso terapéutico , Infarto del Miocardio/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Stents , Activador de Tejido Plasminógeno/uso terapéutico , Abciximab , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/instrumentación , Anticuerpos Monoclonales/efectos adversos , Enfermedades Cardiovasculares/etiología , Terapia Combinada , Angiografía Coronaria , Circulación Coronaria , Quimioterapia Combinada , Estudios de Factibilidad , Femenino , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Humanos , Fragmentos Fab de Inmunoglobulinas/efectos adversos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/fisiopatología , Proyectos Piloto , Inhibidores de Agregación Plaquetaria/efectos adversos , Proyectos de Investigación , Singapur , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: Occlusion of the circumflex coronary artery may present with either ST elevation typical of inferior or lateral myocardial infarction, ST depression or a normal 12-lead electrocardiogram (ECG). In patients presenting with ST depression, concomitant ST elevation in the posterior leads V7, V8 and V9 is believed to reflect ST-elevation myocardial infarction of the posterior wall. However, to be confident of this diagnosis, it is necessary to know that posterior ST depression does not occur in acute subendocardial ischaemia. METHODS AND RESULTS: We have prospectively recorded leads V7, V8 and V9 simultaneously with the standard 12-lead ECG in patients who underwent treadmill stress test. Group A consists of 35 patients who showed ischaemic praecordial ST depression in their 12-lead ECGs during treadmill stress test and subsequent angiographic documentation of significant coronary artery disease. Group B consists of 35 subjects who showed normal ECG findings during treadmill stress test. In none of the Group A or B patients was there ST elevation in leads V7, V8 or V9 either at rest or at peak exercise. ST depression was seen in 69% in V7, 31% in V8 and 11% in V9 in the Group A patients at peak exercise. CONCLUSION: ST elevation in leads V7, V8 and V9 is uncommon in patients presenting with subendocardial ischaemia. Therefore, in patients presenting with acute chest pain and ST depression in the 12-lead ECG, concomitant posterior ST elevation may be a reliable indicator of ST elevation posterior MI. This is likely due to circumflex artery occlusion and may require thrombolytic therapy.
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Isquemia Miocárdica/diagnóstico , Adolescente , Adulto , Anciano , Electrocardiografía , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/etiologíaRESUMEN
The association of coronary artery spasm and myocardial bridging is very uncommon and may represent a distinct clinical entity. Three patients are described, presenting with acute coronary syndrome associated with myocardial bridging and coronary artery spasm. The relationship and respective roles of myocardial bridging and spasm, however, remain uncertain and may be consequent to a direct effect on endothelial function from the compressive effect of myocardial bridging. The role of intracoronary nitroglycerin in these patients is unresolved.
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Angina Inestable/etiología , Vasoespasmo Coronario/complicaciones , Anomalías de los Vasos Coronarios/complicaciones , Infarto del Miocardio/etiología , Enfermedad Aguda , Femenino , Humanos , Persona de Mediana Edad , SíndromeRESUMEN
The endothelial progenitor cell (EPC)-capture stent promotes endothelialization and preliminary studies have suggested its safety and feasibility in ST-elevation myocardial infarction (STEMI). Detailed late clinical follow-up and angiographic analyses are, however, limited. We sought to determine late angiographic and clinical outcomes of the Genous EPC-capture stent in primary angioplasty. EPC-capture stents were implanted during primary angioplasty in 489 consecutive patients presenting with STEMI from 2004 through 2008. The first 100 consenting patients undergoing successful stent implantation scheduled to undergo relook coronary angiography at 6 to 12 months were enrolled. Ninety-five patients with 96 lesions were analyzed independently. Mean duration of follow-up coronary angiography was 245 days. In-stent late luminal loss measured 0.87 ± 0.67 mm. Binary restenosis (defined as >50% diameter stenosis) was 28%, with diffuse in-stent restenosis (Mehran class II) as the predominant pattern. Of 27 patients with binary restenosis, 14 (52%) were symptomatic, with 10 patients undergoing target lesion revascularization. Asymptomatic patients had significantly larger reference vessel and in-stent minimal luminal diameters (2.77 ± 0.39 vs 2.54 ± 0.44 mm, p = 0.040; 2.74 ± 0.34 vs 2.31 ± 0.72 mm, p = 0.004, respectively). Follow-up late loss and diameter stenoses were also in favor of the asymptomatic group. Major adverse cardiac event rate was 16% at a mean follow-up of 34 months. There were no cases of Academic Research Consortium-defined stent thrombosis. In conclusion, implantation of the EPC-capture stent during primary angioplasty is associated with a favorable late clinical outcome but with higher than anticipated angiographic late loss.
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Angioplastia Coronaria con Balón , Materiales Biocompatibles Revestidos , Estenosis Coronaria/terapia , Células Madre , Stents , Angiografía Coronaria , Reestenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/diagnóstico por imagen , Endotelio Vascular/citología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapiaRESUMEN
BACKGROUND: We sought to report the incidence of angiographic no-reflow and clinical outcomes of elderly patients who have undergone primary percutaneous coronary intervention at a tertiary institution in Singapore over a period of 10 years. METHODS: A total of 141 patients (60% male) aged 75 or above underwent primary PCI between 1998 and 2007. Their average age was 80+/-5 years. Cardiogenic shock complicating STEMI on presentation accounted for 15% of the patients. RESULTS: At baseline, 103 (73%) patients have impaired TIMI flow grade (TIMI 0-2), and 38 (27%) have normal flow (TIMI 3). At the end of the procedure, 44 (31.2%) patients had no-reflow phenomenon (TIMI 0-2), whereas 97 (68.8%) achieved normal antegrade flow. Post-procedure corrected TIMI frame count was analyzable in 66% (n=93) of the patients. Post-procedure corrected TIMI frame count was>28 in 37.6% (n=35) of patients. In-hospital, 30-day and six-month mortalities were 20.6, 25.5% and 27.7%, respectively. Multivariable analysis showed that age 80 or above, low systolic blood pressure and final TIMI 0-2 flow independently predicted six-month mortality. CONCLUSIONS: We found that one-third of the treated patients developed no-reflow phenomenon. Six-month mortality was 27.7%, most were cardiac deaths that occurred during index hospitalization.
Asunto(s)
Angioplastia Coronaria con Balón , Pueblo Asiatico , Fenómeno de no Reflujo/epidemiología , Fenómeno de no Reflujo/terapia , Factores de Edad , Anciano , Estudios de Cohortes , Angiografía Coronaria , Femenino , Humanos , Incidencia , Masculino , Fenómeno de no Reflujo/diagnóstico por imagen , Estudios Retrospectivos , Singapur , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
INTRODUCTION: The Framingham Risk Score (FRS) is a well-validated epidemiologic tool used to assess the risk for a fi rst cardiac event. Because young patients presenting with a fi rst myocardial infarction (MI) tend to have less significant risk profiles compared with older patients, we hypothesized that FRS may underestimate cardiac risk in these patients. MATERIALS AND METHODS: We studied 1267 patients between January 2002 and November 2007 presenting with a fi rst MI. Patients with pre-existing diabetes mellitus and vascular disease were excluded. FRS was calculated for each patient. Patients were divided based on their age: group A (<40 years), group B (40 to 64 years) and group C (> or =65 years). RESULTS: The mean age was 54.7 +/- 11 years, 88.4% of the patients were males. Younger patients were more likely to be assigned with lower scores. Based on FRS, 63.0%, 29.3% and 14.2% of group A, B and C patients were classified as low risk (10-year risk for cardiac events<10%) respectively, P <0.001. The sensitivity of FRS in identifying at least intermediate risk subjects (10-year risk for cardiac events >10%) was 37.0% in group A vs 85.8% in group C (P <0.001). The incidence of newly diagnosed diabetes mellitus was higher in younger patients (12.0% vs 13.2% vs 7.1 % in groups A, B and C respectively, P = 0.027). CONCLUSIONS: FRS inadequately predicts cardiac risk in young patients presenting with a fi rst MI. This could be because a significant proportion of these young patients have undiagnosed diabetes mellitus, a coronary artery disease risk equivalent.
Asunto(s)
Complicaciones de la Diabetes , Infarto del Miocardio/complicaciones , Adulto , Factores de Edad , Anciano , Algoritmos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores SexualesRESUMEN
BACKGROUND: Drug-eluting stents (DESs) are effective in reducing restenosis and the need for repeat revascularization procedures in patients who undergo percutaneous coronary intervention (PCI). There is however an increased concern with the safety of DES with regard to stent thrombosis (ST). We examined the incidence of ST among patients who received DES and determined the clinical predictors. METHODS: All patients who underwent PCI in our centre were prospectively enrolled in a cardiovascular database. All cases of ST, as defined by 2006 Academic Research Consortium (ARC) hierarchical classification as definite and probable, from August 2002 to August 2006 were reviewed and analyzed. The clinical, angiographic and procedural characteristics of patients who developed ST were compared with those who did not. RESULTS: The study population comprised 1580 patients who received DES implantation. The cumulative incidence of ST was 1.5%: acute ST 0.2%, subacute ST 0.9%, late ST 0.2% and very late ST 0.2%. Mortality and myocardial infarction occurred in 16% and 84% of patients, respectively, as a consequence of ST. Multivariate analysis showed that patients presenting with cardiogenic shock, acute coronary syndrome, presence of multivessel disease, impaired baseline TIMI flow and higher number of stents implanted per lesion were predictive of ST. CONCLUSION: The incidence of DES ST in our 'real world' registry was low. There were clinical and angiographic characteristics identified as independent predictors of ST.
Asunto(s)
Angioplastia Coronaria con Balón/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/epidemiología , Stents Liberadores de Fármacos/efectos adversos , Stents Liberadores de Fármacos/estadística & datos numéricos , Estudios de Cohortes , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Reestenosis Coronaria/diagnóstico por imagen , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Trombosis/diagnóstico por imagen , Trombosis/epidemiologíaRESUMEN
Isolated coronary artery spasm without atherosclerotic obstruction is an unusual cause of myocardial infarction (MI). A middle-aged woman presented to our institution in 2001 with acute inferior MI due to coronary artery spasm at the mid segment of the dominant left circumflex coronary artery. After being well for 6 years, she was readmitted again in 2007 with the same type of severe retrosternal chest pain. Electrocardiography (ECG) showed ST-segment elevation over the inferior leads. The chest pain resolved with sublingual nitroglycerin and emergency diagnostic coronary angiography showed normal coronary arteries. Two months later, the patient developed another episode of severe retrosternal chest pain at home, followed by cardiac arrest. An onsite ECG showed ventricular fibrillation and immediate defibrillation was carried out. She was readmitted to the hospital and recovered over the next few days. In view of the recurrent coronary artery spasm causing myocardial infarction and ventricular fibrillation, an implantable cardioverter defibrillator was implanted. The patient was well at 2-month follow up.
Asunto(s)
Fibrilación Atrial/complicaciones , Vasoespasmo Coronario/complicaciones , Desfibriladores Implantables , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Infarto del Miocardio/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/terapia , Angiografía Coronaria , Vasoespasmo Coronario/diagnóstico , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/terapia , Recurrencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: We present our clinical experience of StarClose in patients undergoing coronary interventions, including its use in patients after repeated puncture of the same femoral access site. BACKGROUND: The StarClose is a novel vascular closure device that deploys a small, flexible, circumferential nitinol clip onto the femoral artery surface. METHODS: In this study, 103 consecutive patients (24% with repeated punctures) who underwent percutaneous coronary intervention and received a StarClose were followed up prospectively. The patients were assessed for vascular complications prior to hospital discharge. Device success, based on time-to-hemostasis, was divided into (1) immediate success: hemostasis achieved immediately after StarClose deployment without the need for adjunctive manual compression, (2) partial success: occurrence of minor oozing after StarClose deployment and hemostasis achieved after <3 minutes of manual compression, and (3) device failure: need for adjunctive manual compression for >3 minutes. RESULTS: Immediate success, partial success, and device failure rates were 74% (n = 68), 16% (n = 15), and 10% (n = 9), respectively. There were no major complications attributable to the StarClose device. There were 10 (9.7%) cases of minor complications; all were recurrent wound bleeding requiring manual compression in the wards. Among these 10 cases of recurrent bleeding, 5 (50%) had initial device success (immediate success, n = 2, partial success, n = 3) in the catheterization laboratory. The risk for recurrent bleeding was 2.9% after immediate device success and 20.0% after partial device success. CONCLUSION: Our study found no major complications but a 10% failure rate and a 9.7% rate of minor complications. Close surveillance is important as there is a risk for recurrent bleeding, especially in patients with partial device success as defined in this report.
Asunto(s)
Catéteres de Permanencia , Arteria Femoral , Técnicas Hemostáticas/instrumentación , Recurrencia , Instrumentos Quirúrgicos , Técnicas de Sutura/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón , Seguridad de Equipos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Punciones , Factores de Riesgo , Factores de TiempoRESUMEN
AIMS: Zotarolimus-eluting stents (ZESs) have been shown to be safe and effective in randomised trials. We sought to report the clinical outcomes after implantation of ZES in real-world clinical practice. METHODS AND RESULTS: ZES have been approved for clinical use in Singapore since April 2005. Until December 31, 2007, a total of 219 patients had undergone implantation of ZES. After excluding 11 foreign patients with whom contact was lost, 208 patients (246 lesions, 305 stents) formed the study cohort. A high-proportion of diabetic patients (n=90, 43.3%) was included. Recommended dual antiplatelet therapy was at least 3 months (n=147) for patients treated before or 12 months (n=61) after January 2007. As of January 2008, the median follow-up duration was 19 months (range: 1 to 33 months). There were 10 (4.8%) deaths, including 7 (3.4%) cardiac deaths. Myocardial infarction occurred in 11 (5.3%) patients. The numbers of patients requiring target vessel revascularisation and target lesion revascularisation were 10 (4.8%) and 5 (2.4%) respectively. Using the ARC definition, there were two cases of definite stent thrombosis on days 7 and 17, and one case of probable stent thrombosis on day 15. CONCLUSIONS: In this real-world clinical experience, ZES was associated with a low incidence of adverse cardiac events at a medium follow-up of one and half years.