Excimer laser in acute myocardial infarction: single centre experience on 66 patients.

BACKGROUND: Pulsed-wave ultraviolet excimer laser light at 308 nm can vaporise thrombus, suppress platelet aggregation, and, unlike other thrombectomy devices, ablates the underlying plaque. AIM: To evaluate both safety and efficacy of laser ablation in patients presenting with Acute Myocardial Infarction (AMI) complicated by persistent thrombotic occlusion. METHODS: From May 2003 to October 2006, we enrolled 66 AMI patients (age 59+/-11 years; 57 men) presenting complete thrombotic occlusion of the infarct related vessel. All patients were treated with laser. Primary acute angiographic end-points was corrected TIMI frame count. Secondary echocardiographic end-point was left ventricular remodeling defined as an increase in end-diastolic volume >/=20% 6 months after infarction. Tertiary clinical endpoint was event-free survival at 6 months follow-up. RESULTS: There were no intra-procedural death or coronary perforation. One primary angiographic failure was observed during lasing. Major dissection occurred in 1 (1.5%) and distal embolization in 4 patients (6%). Corrected TIMI frame count was 100 at baseline, 29+/-0.6 after lasing and 22+/-3 after stenting. At 6-months follow-up, left ventricular remodeling occurred in 8% patients. Event-free survival was 95% at 6-months follow-up. CONCLUSION: Laser angioplasty is feasible, safe and effective for the challenging treatment of patients with AMI and thrombus-laden lesions. The acute effects on coronary epicardial and myocardial reperfusion are excellent.

Stress induced cardiomyopathy presenting as acute coronary syndrome: Tako-Tsubo in Mercogliano, Southern Italy.

BACKGROUND: Tako-tsubo syndrome (TTS) in its typical (apical) and atypical (non-apical) forms is being increasingly recognized in the West owing to early systematic coronary angiography in acute coronary syndromes (ACS). AIM OF THE STUDY: To assess the incidence, the clinical characteristics and the outcome of TTS in a single high volume cath lab in Southern Italy over the last 6 years. METHODS: Among 1674 consecutive patients (pts) referred to our coronary care units in the last 6 years (2001-2006) for ACS we selected 6 (0.5%) pts (6 women; age 57 +/- 6 years) who fulfilled the following 4 criteria: 1) transient left ventricular wall motion abnormalities resulting in ballooning at contrast ventricolographic or echocardiographic evaluation; 2) normal coronary artery on coronary angiography performed 5 +/- 9 hours from hospitalization; 3) new electrocardiographic ischemic-like abnormalities (either ST-segment elevation or T-wave inversion) and 4) emotional or physical trigger event. RESULTS: At admission all pts had presumptive diagnosis of ACS and ECG revealed ST elevation in 3 (50%) and T wave inversion with QT elongation in 3 (50%). In the acute phase cardiogenic shock occurred in 2 (33%) and heart failure in 1(16%). Presenting symptoms were chest pain in 6 (100%), dyspnoea in 2 (33%) and lipotimia in 1 (16%). At echocardiographic-ventricolographic assessment, the mechanical dysfunction (ballooning) was apical in all 6 pts ("classic" TTS). In all patients wall motion abnormalities completely reversed within 4.5 +/- 1.5 days. The region of initial recovery was the anterior and lateral wall in 4 cases and the lateral wall in 2 cases. Ejection fraction was 35 +/- 8% in the acute phase and increased progressively at discharge (55 +/- 6%) and at 41 +/- 20 months follow-up (60 +/- 4%, p < 0.001 vs. baseline). All patients remained asymptomatic with minimal (aspirin, beta blockers, antihypertensive and antidislipidemic therapy) treatment. CONCLUSION: Classic TTS is a frequent serendipitous diagnosis after coronary angiography showed "surprisingly" normal findings in a clinical setting mimicking an ACS. Despite its long-term good prognosis life threatening complications in the acute phase can occur.

Radiation dose exposure during cardiac and peripheral arteries catheterisation.

BACKGROUND: Ionising radiation carries an oncogenic risk which is linearly related to the dose. An estimation of the effective dose can be obtained from the measurements of the dose-area product (DAP), which is a measure of stochastic risk and a potential quality indicator. AIM: To assess radiation exposure of patients in a large volume cardiac cath-lab. METHODS: A retrospective analysis of adult cardiac and peripheral percutaneous procedures (April to December 2004) was carried out to determine the DAP and estimated risk of malignancy. We identified 6 groups: Group 1 (n=100, coronary angiography and ventriculography); Group 2 (n=50, carotid stenting); Group 3 (n=50, aortography+coronary angiography+ventriculography); Group 4 (n=100, inferior extremities angiography+predilatation and stenting); Group 5 (n=100, coronary angiography+ventriculography+direct coronary stenting); Group 6 (n=100, coronary angiography+ventriculography+coronary predilation and stenting). Dose-area product meter attached on the X-ray unit was used for the estimation of the radiation dose received by the patient during the procedures. RESULTS: DAP values (mean+/-S.D.) ranged from 41+/-30 Gy cm2 in Group 1 (lowest) to 118+/-89 Gy cm2 in Group 6 (highest). Within each group, individual radiation exposure varies substantially: from 11 to 200 Gy cm2 in Group 1, and from 30 to 733 Gy cm2 in Group 6 patients. Average exposure in a Group 6 patient corresponds to a risk of mortality from a malignancy of about 1 in 1000. CONCLUSION: The radiation dose varies substantially across different types of procedures and up to tenfold within the same procedure. The enhanced knowledge of radiation dose might help the cardiologist to implement radiation sparing procedures eventually minimizing patient and operator radiation hazards in invasive cardiology.

PRIAMUS--proximal flow blockage cerebral protectIon during carotid stenting: results from a multicenter Italian registry.

AIM: The aim of this Italian prospective registry was to evaluate the applicability and efficacy of the Mo.Ma Device (Invatec, Roncadelle, Italy) for the prevention of cerebral embolization during carotid artery stenting (CAS) in a real world population. METHODS: In 4 Italian centers, 416 patients (300 men; mean age 71.6+/-9 years) between October 2001 and March 2005 were enrolled in a prospective registry. Two-hundred and sixty-four symptomatic (63.46%) with >50% diameter stenosis and 152 (36.54%) asymptomatic patients with >70% diameter stenosis were included. The Mo.Ma Proximal Flow Blockage Embolic Protection System was used to perform protected CAS, achieving cerebral protection by endovascular clamping of the common carotid artery (CCA) and of the external carotid artery (ECA). RESULTS: Technical success, defined as the ability to establish protection with the Mo.Ma device and to deploy the stent, was achieved in 412 cases (99.03%). The mean duration of flow blockage was 4.91+/-1.1 min. Transient intolerances to flow blockage were observed in 24 patients (5.76%), but in all cases the procedure was successfully completed. No peri-procedural strokes and deaths were observed. Complications during hospitalization included 16 minor strokes (3.84%), 3 transient ischemic attacks (0.72%), 2 deaths (0.48%) and 1 major stroke (0.24%). This resulted in a cumulative rate at discharge of 4.56% all strokes and deaths, and of 0.72% major strokes and deaths. All the patients underwent thirty-day follow-up. At thirty-day follow-up, there were no deaths and no minor and major strokes, confirming the overall cumulative 4.56% incidence of all strokes and deaths rate, and of 0.72% rate of major strokes and deaths at follow up. In 245 cases (58.89%) there was macroscopic evidence of debris after filtration of the aspirated blood. CONCLUSIONS: This Italian multicenter registry confirms and further supports the efficacy and applicability of the endovascular clamping concept with proximal flow blockage in a broad patient series. Results match favorably with current available studies on carotid stenting with cerebral protection.

[Unprotected left main angioplasty: a case report]. / Angioplastica del tronco comune non protetto: un caso clinico.

Left main angioplasty is considered a very high-risk procedure and consequently, surgical treatment remains the first choice for left main critical disease. Recently, the advent of new devices such as directional atherectomy, rotablator atherectomy and stent implantation have modified this point of view. In fact, in selected groups of patients for whom CABG is not suitable, left main percutaneous angioplasty can be performed with stent implantation, yielding good final results with a residual stenosis less than 20-30% and a long-term survival comparable to surgery. In conclusion, in some selected cases left main angioplasty, also if unprotected, can be performed safely with satisfactory results.

Comparative analysis of two systems for HCV genotyping.

The HCV genotype can be determined by PCR using nested primers to structural or non-structural HCV regions, followed by hybridization analysis of the amplified products. In this study, two different systems, both based on PCR and hybridization analysis, were used to determine HCV genotype in 32 HCV positive patients at the Clinic of Infectious Diseases, University of Chieti. The main difference between these commercially available systems lies in the different PCR target. Amplification of PCR targets was obtained from all samples. Hybridization analysis gave unequivocal results for all samples with both methods, yielding a 100% rate of genotype determination, with a complete correlation at the genotype level. A lower concordance at subtype level (65% concordance) was found, due only to two types of discrepancies. Both methods proved easy to use in our hands, adding evidence to their potential usefulness and reliability in clinical settings.

Power spectral analysis of heart period variability in hypertensive patients with left ventricular hypertrophy.

This study aimed to characterize sympathovagal balance by heart period power spectrum analysis in hypertensive patients with echocardiographic evidence of left ventricular hypertrophy. Twenty ambulatory patients (11 men and 9 women), aged 50 +/- 10 years, with established essential hypertension and echocardiographic left ventricular hypertrophy, performed 24-h blood pressure monitoring and electrocardiogram Holter recording on 2 consecutive days. Twenty age- and sex-matched normal subjects comprised the control group. Power spectrum analysis, performed using the fast Fourier transform algorithm, demonstrated lower values of low and high frequency power in hypertensives than in controls, while ultralow and very low frequency power were similar in the two groups. Very low frequency, low frequency, and high frequency power increased during the night in both groups, showing a similar circadian pattern. We found a direct correlation between daytime systolic (r = 0.51; P < .05) and diastolic (r = 0.52; P < .05) blood pressure and left ventricular mass index. Moreover, negative correlations were found between left ventricular mass index and low frequency (r = -0.47; P < .05) and high frequency power (r = -0.47; P < .05). There was a direct correlation between nighttime decrease in systolic blood pressure and nighttime increase in high frequency power (r = 0.45; P < .05). As 24-h low frequency and high frequency power, obtained using the Fourier transform algorithm, both reflect the parasympathetic modulation of heart rate, our results demonstrate that hypertensive patients with left ventricular hypertrophy are characterized by a sympathovagal imbalance with a reduction of vagal tone that is more evident with increasing severity of hypertension.

Assessment of cardiac autonomic control by heart period variability in patients with early-onset familial obesity.

For quantitative assessment of cardiac autonomic control, time and frequency domain measures of heart period variability were calculated by 24 h Holter recording in 10 young obese women with early-onset familial obesity and in 10 control subjects. Ultra low frequency and very low frequency power were lower in obese subjects than in controls (P < 0.05). High frequency power, a pure measure of vagal tone, was comparable between the two groups. However, low frequency power, which analysed over a 24 h Holter recording reflects parasympathetic more than sympathetic activity, was slightly lower in obese subjects than in controls (P = 0.06). Body mass index showed an inverse correlation with total power (r = -0.62; P < 0.05) and separately with ultra low (r = -0.59; P < 0.01), very low (r = -0.64; P < 0.005), low (r = -0.61; P < 0.005) and high frequency power (r = -0.53; P < 0.05). These results demonstrate a parasympathetic withdrawal increasing body weight. The reduction of ultra low frequency and very low frequency power, which are associated with sudden death, may help to explain the higher cardiovascular risk in obesity.

[Effects of coronary angioplasty on heart rate variability explored in the domain of time and frequency in patients with one-vessel coronary disease]. / Effetti dell'angioplastica coronarica sulla variabilità della frequenza cardiaca esplorata nel dominio del tempo e della frequenza in pazienti con coronaropatia monovasale.

BACKGROUND: Heart period variability is frequently reduced in patients with coronary artery disease. Although the mechanism for this reduction is still unclear, it seems to reflect alterations in cardiac autonomic control. In this study we have evaluated the relation between reversible segmental left ventricular dysfunction and time and frequency domain measures of heart period variability in patients with coronary artery disease. METHODS AND RESULTS: Echocardiographic segmental left ventricular wall motion and time and frequency domain measures of heart period variability were evaluated in 32 patients with one-vessel coronary artery disease before and 16-24 days after successful percutaneous transluminal coronary angioplasty (PTCA). At baseline examination 12 patients (Group A) had normal and 20 (Group B) abnormal regional wall motion. Prevalence of previous myocardial infarction was higher and mean angiographic ejection fraction lower in Group B than in Group A. At baseline, time domain measures were comparable between the 2 groups, while low frequency (LF) and high frequency (HF) power were lower in Group B than in Group A. After PTCA, in Group A regional wall motion and time and frequency domain measures of heart period variability were unchanged. In Group B summed segment score improved from 17.1 +/- 3.6 to 12.8 +/- 2.0 (p < 0.01) and a significant increase occurred in standard deviation of the average normal RR (NN) intervals for all 5-minute segments of a 24-hour recording (SDNN index), in root mean square successive difference (r-MSSD) and in the percentage of differences between adjacent NN intervals > 50 msec (pNN50). In this group also LF and HF power (logarithmic units) increased from 6.14 +/- 0.23 to 6.35 +/- 0.34 (p < 0.01) and from 5.43 +/- 0.32 to 5.68 +/- 0.52 (p < 0.01) respectively. There was no correlation between measures of heart period variability, summed segment score, and left ventricular ejection fraction. CONCLUSIONS: This study demonstrates that segmental left ventricular dysfunction is involved in determining sympathovagal imbalance in patients with one-vessel coronary artery disease; the reversal of left ventricular dysfunction by successful PTCA improves heart period variability. These findings support the hypothesis that alterations in cardiac geometry may influence the discharge of afferent sympathetic mechanoreceptors, thus contributing to the derangement in autonomic control of heart rate.

Effects of converting enzyme inhibition on heart period variability in patients with acute myocardial infarction.

BACKGROUND: Heart period variability provides useful prognostic information on autonomic cardiac control, and a strong association has been demonstrated after myocardial infarction (MI) between cardiac mortality, sudden death, and reduced total power, ultralow-frequency (ULF) power, and very-low-frequency (VLF) power. Converting enzyme inhibitors are widely used in MI patients, but their influence on heart period variability remains to be defined. METHODS AND RESULTS: Time- and frequency-domain measures of heart period variability were calculated from 24-hour Holter monitoring in 40 patients with a first uncomplicated MI. After baseline examination between 48 and 72 hours after symptom onset, patients were randomly assigned to placebo or captopril administration, and on the third day, 24-hour Holter monitoring was repeated. No changes in time and frequency domain were detectable after placebo. After captopril, the SD of all normal RR (NN) intervals (SDNN) increased from 90 +/- 29 to 105 +/- 30 milliseconds (P < .01); the SD of the average NN intervals for all 5-minute segments (SDANN index) and the mean of the SDs of all NN intervals for all 5-minute segments (SDNN index) also increased from 74 +/- 24 to 90 +/- 26 milliseconds (P < .01) and from 45 +/- 17 to 49 +/- 15 milliseconds (P < .05), respectively. The root mean square successive difference (r-MSSD) and the percent of differences between adjacent NN intervals > 50 milliseconds (pNN50) remained unchanged. In regard to frequency-domain measures, after captopril, total power (ln unit) increased from 8.28 +/- 0.42 to 8.47 +/- 0.30 (P < .01); considering the frequency bands, a significant increase was observed in ULF (P < .01), VLF (P < .05), and low-frequency (LF) power (P < .05), whereas high-frequency (HF) power remained unchanged. CONCLUSIONS: This study supports the hypothesis that the renin-angiotensin system modulates the amplitude of ULF and VLF power. Furthermore, it demonstrates that in MI patients, converting enzyme inhibition favorably modifies measures of heart period variability strongly associated with a poor prognosis.

Prognostic value of myocardial hypoperfusion indexes in patients with suspected or known coronary artery disease.

BACKGROUND: We evaluated the prognostic value of exercise 201Tl indexes of myocardial hypoperfusion in patients with suspected or known coronary artery disease. METHODS AND RESULTS: Patients were divided into two groups: group I consisted of 332 patients with diagnostic electrocardiographic stress test results and group II consisted of 144 patients with nondiagnostic (inadequate or uninterpretable) stress electrocardiograms. At the 2-year follow-up, 20 hard events (16 cardiac deaths and 4 nonfatal myocardial infarctions) and 80 soft events (coronary revascularization procedures) occurred in group I. Considering total events, thallium imaging provided significant prognostic information in addition to clinical and exercise stress test data in the total study population (p < 0.001) and in patients with previous myocardial infarction (p < 0.001); in patients without previous infarction, thallium imaging added incremental prognostic value only in those with positive electrocardiographic stress test results (p < 0.01). When only hard events were considered, thallium variables added further information only in patients with previous myocardial infarction (p < 0.05). In group II at the end of follow-up, 15 hard and 39 soft events had occurred. In these patients occurrence of total (p < 0.001), hard (p < 0.05), and soft (p < 0.001) events was higher in those with abnormal thallium scintigraphic results than in those without. Moreover, no clinical and exercise variable, except history of myocardial infarction, was significantly related to outcome, whereas both indexes of extent and severity of hypoperfusion were significant. CONCLUSIONS: The results of this study demonstrate that scintigraphic indexes of myocardial hypoperfusion obtained by qualitative planar thallium imaging give unique prognostic information in patients with nondiagnostic electrocardiographic stress test results. Thallium imaging provides incremental prognostic information even in patients with diagnostic electrocardiographic stress test results but not in the low-risk subset of patients without previous infarction who have negative electrocardiographic stress test results.

Left ventricular remodelling in the year after myocardial infarction: an echocardiographic, haemodynamic, and radionuclide angiographic study.

BACKGROUND: The factors that influence infarct expansion early after myocardial infarction have been identified; however, there is less information about late-phase left ventricular enlargement. This study was designed to identify the clinical, haemodynamic, echocardiographic, and radionuclide angiographic criteria that predict the progress of left ventricular dilation after discharge for a first-anterior myocardial infarction. METHODS: Sixty-seven patients with first Q-wave acute anterior myocardial infarction not treated with thrombolytic agents underwent baseline echocardiographic, haemodynamic, and radionuclide angiographic evaluation 4-7 days after the onset of symptoms. The echocardiographic and radionuclide evaluations were repeated after 1 year in the 55 patients who completed the follow-up. By multivariate stepwise linear regression analysis, left ventricular end-diastolic volume after 1 year and change from baseline were modelled as a function of baseline left ventricular end-diastolic volume and other potential predictors. RESULTS: A model including left ventricular end-diastolic pressure, global wall motion score, baseline left ventricular end-diastolic volume, and a Thrombolysis in Myocardial Infarction (TIMI) score of 0-1 was able to predict 84% of the left ventricular end-diastolic volume at the follow-up; a TIMI score of 0-1, the transverse end-diastolic diameter, global wall motion score, and the number of coronary vessels with 70% stenosis accounted for 81% of the variation in left ventricular end-diastolic volume from baseline, while the transverse end-diastolic diameter was inversely related to this parameter. CONCLUSIONS: The results of this study demonstrate that after an anterior myocardial infarction, the patency of the infarct-related artery is the major determinant of late left ventricular dilation, while left ventricular end-diastolic pressure influences early left ventricular dilation and baseline end-diastolic volume. Therefore, to improve left ventricular remodelling, it appears necessary to increase the patency of the infarct-related artery and improve the diastolic loading of the left ventricle at an early stage in the infarction. The inverse relationship between baseline left ventricular transverse diameter and the change in left ventricular volume after discharge indicates that the higher the baseline left ventricular volume, the less it changed during the follow-up. The global wall motion score appears to be a non-invasive parameter that is useful for identifying patients with a high risk of progressive left ventricular dilation.

Continuous electrocardiographic monitoring for more than one hour does not improve the prognostic value of ventricular arrhythmias in survivors of first acute myocardial infarction.

This study was designed to compare the prognostic value of predischarge ambulatory electrocardiographic monitoring for 1, 6 and 24 hours in 188 patients surviving a first acute myocardial infarction. Ventricular premature complexes (VPCs) were considered as a mean hourly rate or classified using Lown and Moss grading systems. During the 1-year follow-up 20 cardiac deaths occurred. For all 3 monitoring times, a higher number of VPCs/hour and a higher Moss grade were associated with mortality, whereas a Lown grading system gave prognostic information only for the first hour of recording. Monitoring time did not influence specificity or sensitivity in predicting mortality; > or = 3 VPCs/hour showed a higher sensitivity than > or = 10 VPCs/hour (p < 0.05) with a comparable specificity. After 1-hour data entered the model, neither the 6- or the 24-hour data entry improved the overall likelihood ratio statistic, regardless of what VPC grading system was used. These results demonstrate that continuous electrocardiographic recordings of > 1 hour are unnecessary when they are to be used for detecting ventricular arrhythmia as a predictor of mortality in patients surviving a first acute myocardial infarction.