Instrumental validation of percutaneous transmyocardial revascularization: follow-up data at one year.

BACKGROUND: Despite the clinical efficacy of percutaneous transmyocardial revascularization (PTMR), up to date there are still no instrumental validations to demonstrate both the improved perfusion of treated areas and cardiac function. METHODS: During the first year of follow-up after PTMR, 27 patients (group A) underwent 99mTc MIBI exercise-single photon emission tomography (SPET), while 30 patients (group B) underwent serial transthoracic echocardiography (TTE) evaluations with analysis of cardiac volumes and subendocardial layer thickness in systole. RESULTS: All 57 patients had a significant angina Canadian Cardiovascular Society (CCS) class improvement. Group A patients (75%) had improved exercise-SPET perfusion in treated areas at 12 weeks after PTMR, and at the next follow-up. Group B patients had non-significant reduction in global volume and no significant change in ejection fraction. However, there was an improvement in thickness of the subendocardial-treated areas in systole that persisted during follow-up. CONCLUSIONS: The use of SPET and TTE validates the clinical efficacy of PTMR.

Italian BiodivYsio open registry (BiodivYsio PC-coated stent): study of clinical outcomes of the implant of a PC-coated coronary stent.

UNLABELLED: Rapid technological developments have made new materials available for percutaneous coronary intervention procedures. The coronary stent in particular has undergone progressive structural improvements leading to the recent availability of a third generation of stents, namely, coated stents. The rapid evolution of the stent has often made its evaluation problematical, since trials are frequently confined to small groups of patients in single centers. The purpose of this registry was to verify the safety and efficacy of the BiodivYsio stent (a stent coated with phosphorylcholine polymer) in a broad population of patients who reflect the daily reality of coronary intervention in a cardiac catheterization laboratory. METHODS AND RESULTS: The registry was designed to collect the principal angiographic and clinical data of a consecutive series of Oreal worldO patients. Patients were treated with a BiodivYsio stent (Biocompatibles, Galway, United Kingdom) in 12 centers (11 Italian and 1 Swiss) between January 1998 and January 1999. Procedural, in-hospital, 30-day and six-month follow-up data were collected. The monitoring, data entry and statistical analyses were carried out by an independent center. During the study, 218 patients were enrolled; 165 (76%) male and 53 (24%) female, with an average age of 61.6 +/- 9.4 years (range, 36Eth 84 years). A total of 258 stents were implanted in 233 lesions (1.1 stents per lesion), of which 233 (90%) were the BiodivYsio PC coated stent, the remaining 25 implants were of other stent types. The percutaneous transluminal coronary angioplasty and stenting procedure were carried out in 109 (50%) patients with unstable angina, 65 (30%) with stable angina, 29 (13%) with acute myocardial infarction, and 15 (7%) patients with silent ischemia. Procedural success was achieved in 217/218 (99.5%) patients. Optimal results were achieved in 212 (97.7%) patients. In 34 (15.6%) cases, patients were treated with periprocedural abciximab. During the hospitalization period, one (0.4%) death occurred on day 7 due to subacute occlusion of the stent, and 3 (1.4%) myocardial infarctions were reported. At 30-day follow-up, 211 (97.2%) patients were asymptomatic, as were 189 (87%) patients at clinical follow-up at 6 months. CONCLUSIONS: This study evaluated the safety and efficacy of a third-generation stent. The results demonstrate a high procedural success rate and a low incidence of major adverse cardiac events at short- and medium-term follow-up. It appears that the BiodivYsio stent should be considered safe in clinical and/or anatomical situations with a high risk of complications, confirming the hypothesis that PC may have non-thrombogenic properties. To corroborate these results, an appropriately designed study would be required to measure the stentOs efficacy in the most suitable clinical context, i.e., clinical situations that are at the highest risk of ischemic relapse.

Lack of NO Formation Is Involved in the Vasodilative Response to Contrast Media.

Intravascular injection of angiographic contrast media results in peripheral vasodilation and hypotension. The mechanisms underlying these hemodynamic changes are not entirely clear. We hypothesized that increased formation of nitric oxide (NO) could be involved in the vasodilatory response to contrast media. To address this assumption we have investigated whether N(G)-monomethyl-L-arginine (L-NMMA, 200 mg/kg) and N(G)-nitro-L-arginine methyl ester (L-NAME, 50 mg/kg), two specific NO formation inhibitors, can abolish the hypotensive response to intravascular injection of isopaque amin (1 g/kg), a contrast medium, as well as bradykinin (10 µg/kg), a NO-dependent vasodilator, in anaesthetized normotensive rats. In rats before pretreatment with L-NMMA and L-NAME, the absolute values of the average fall in mean arterial pressure (MAP) induced by intravascular injection of isopaque amin and bradykinin were 21.3 +/- 2.1 and 37.2 +/- 4.4 mmHg, respectively. Pretreatment with L-NMMA and L-NAME failed to affect the hypotensive response to isopaque amin; by administering isopaque amin in rats pretreated with L-NMMA and L-NAME the absolute values of the average fall in MAP were 25.6 +/- 4.9 and 23.4 +/- 3.9 mmHg, respectively, similar to the average fall in MAP before treatment with NO formation inhibitors. In contrast, the hypotensive response to bradykinin was significantly inhibited; by administering bradykinin in rats pretreated by L-NMMA and L-NAME, the absolute values of the average fall in MAP were 10.2 +/- 2.8 and 7.2 +/- 2.2 mmHg, respectively, much less than the average fall in MAP before treatment with NO formation inhibitors. We conclude that intravascular injection of isopaque amin causes reduction in systemic arterial pressure. However, this vasodilative effect seems unrelated majorly to augmented endothelium-derived NO formation.

[Bifurcation stenting of unprotected common trunk: a case report and review of the literature]. / Stenting di biforcazione del TC non protetto: caso clinico e riflessioni sulla letteratura.

Left main disease is the most severe form of atherosclerotic heart disease, with severe prognostic implications in the short-medium term. The traditional therapeutic approach has been surgical, with placement of bypass grafts both on the LAD and the circumflex artery. Published experience with the percutaneous approach to left main disease has been disappointing because of acute procedural problems and poor long-term outcome. On the other hand, a review of the literature shows a strong negative selection of patients offered PTCA of left main-stem lesions: most published series are composed of extremely high-risk patients, often in cardiogenic shock or with severe extracardiac multisystem disease, with a prohibitive surgical risk and an inherently poor acute and mid-term prognosis. We describe such a patient, a 77-year-old woman with end-stage renal disease on hemodialysis, who developed unstable angina due to distal critical left main disease, with involvement of the origin of both the LAD and the circumflex branch. Angina did not stabilize with medical therapy; the patient was denied surgery because of a prohibitively high surgical risk. A bifurcation stenting procedure was performed with no acute complications, a satisfactory one-month angiographic follow-up and no recurrence of angina until the death of the patient 4 months after the procedure for extracardiac reasons. As indicated by a recent paper by M. Leon, we likewise suggest that left main disease (especially in its simpler proximal variants) may actually be a good target for state-of-the-art transcatheter interventions, including primary stenting, under close angiographic follow-up and careful positive (instead of negative) selection of patients.

Surgical timing in aortic regurgitation: left ventricular function analysis by contractility score.

In 32 patients with aortic regurgitation, angiographic evaluation of global left ventricular performance before and after aortic valve replacement was carried out by means of a computer-analyzed contractility scoring system. A strong correlation was detected between the preoperative and postoperative contractility score. Postoperatively, the score decreased in all but 3 patients, becoming normal or near normal in 21 of 27 patients whose preoperative value had been less than 40. However, all 5 patients with a preoperative contractility score of 40 or greater exhibited a persistently elevated score after operation that indicated the presence of irreversible contractile dysfunction. Patients in groups A and B (preoperative score, 0 to 40) experienced a good surgical outcome, and at 5-year follow-up were in New York Heart Association functional class I. Patients in group C (preoperative score, > 40) altogether had a very poor surgical outcome, although they did experience a short to midterm period of symptomatic relief. It is important to offer aortic valve replacement to patients with aortic regurgitation before their chances for a good functional result are lost. The computer-analyzed contractility score may be a useful index for determining the optimal timing of operation in these patients, particularly those who show features consistent with impaired left ventricular function but are asymptomatic and who should undergo aortic valve replacement before symptoms of definitive left ventricular failure develop.

Endoneural vessel involvement in hypothyroidism.

Light-microscope findings and pathological ultrastructural changes in sural nerve biopsies from two patients affected by hypothyroidism, one with overt signs of peripheral neuropathy, the other asymptomatic, were studied. In both patients the endoneural vessels showed clear pathological changes similar to those of other metabolic neuropathies, but more marked in the symptomatic patient. It is proposed that the changes observed in the nerve fibers in hypothyroid neuropathy are secondary to changes in the endothelial cells and in the vessel wall.