Angiographic and clinical outcome following sirolimus-eluting stent (Cypher) implantation. A single center experience.

OBJECTIVES: To investigate the late outcomes of sirolimus-eluting stent implantation in patients with coronary artery disease. BACKGROUND: Drug-eluting stents reduce intimal hyperplasia, which is the main cause of in-stent restenosis. Sirolimus-eluting stents significantly reduce clinical and angiographic restenosis and improve event-free survival. METHODS: The study population consisted of 207 patients (273 stents) who had undergone coronary Cypher stent implantation. Patients were eligible for enrollment if there was symptomatic coronary artery disease or positive exercise testing, and angiographic evidence of single or multivessel disease with a target lesion stenosis of > or = 70% in a > or = 2.25 mm vessel. Follow-up coronary angiography was performed 18 months after stent deployment. Patients were followed-up for a mean of 24.7 +/- 7.4 months. RESULTS: All patients survived after stent implantation, but 5 (2.4%) patients experienced acute ST elevation myocardial infarction and 4 (1.9%) patients developed non-Q wave myocardial infarction following angioplasty. Recurrent angina pectoris was observed in 16 (7.7%) patients (11 stable angina pectoris and 5 unstable angina pectoris). Angiographic evidence of restenosis was observed in these 20 (9.66%) patients. The 5 other patients had noncritical angiographic restenosis. Eleven (5.3%) patients underwent angioplasty because of restenosis, and coronary artery bypass grafting was conducted in the other 9 (4.3%) patients. CONCLUSION: The results of the present study indicate that Cypher stents could be implanted with a very high success rate and have encouraging long-term angiographic and clinical results.

Coronary angioplasty induced oxidative stress and its relation with metoprolol use and plasma homocysteine levels.

OBJECTIVE: Short episodes of myocardial ischemia during coronary angioplasty may induce oxidative stress and increase lipid peroxidation. The aim of this study was to determine the effect of metoprolol on lipid peroxidation by measurements of malondialdehyde (MDA) and total antioxidant capacity (TRAP) in patients undergoing angioplasty. The relations between homocysteine level and lipid peroxidation were also studied. METHODS: Forty-six patients (mean age 57 years, 37 males) undergoing elective angioplasty were enrolled. Metoprolol treatment was initiated in 27 patients (group 1), meanwhile 19 patients could not take metoprolol due to diverse contraindications (group 2). RESULTS: Following angioplasty, while venous MDA levels decreased in group 1 (0.188+/-0.021 vs. 0.159+/-0.020 nmol/ml, p=0.05), an increase was detected in group 2 (0.203+/-0.025 vs. 0.229+/-0.024 nmol/ml, p=0.045) as compared with baseline levels. In group 1, TRAP levels markedly increased after angioplasty in venous samples (1.201+/-0.036 vs. 1.478+/-0.044 mmol/L, p=0.0001). However, small increase was observed for TRAP in group 2 (1.274+/-0.043 vs. 1.363+/-0.053 mmol/L, p=0.05). There was no significant change in plasma homocysteine levels with angioplasty. There was no significant correlation between homocysteine, changes in MDA and TRAP levels either. CONCLUSION: Administration of metoprolol may cause a reduction in the oxidative stress and an increase in the antioxidant activity in patients undergoing elective angioplasty.

FX minirail balloon angioplasty for the treatment of patients with in-stent restenosis: a matched comparison of 6 months' outcome with conventional balloon angioplasty.

The optimal treatment for in-stent restenosis (ISR) is a subject of controversy. Recently, FX minirail balloon angioplasty (BA) has emerged as a management tool for ISR. We assessed the hypothesis that the FX minirail BA has advantages over conventional percutaneous transluminal balloon angioplasty (PTCA) in the treatment of ISR. FX minirail BA or PTCA were applied to 116 patients with ISR (145 lesions) at our institution. Using a computer algorithm, an attempt was made to match each lesion in the FX minirail BA group with a corresponding lesion in the PTCA group. The lesion pairs should match with respect to the patients' age and sex, type of target vessel and stent, reference vessel diameter, and baseline minimal lumen diameter (MLD). Following the matching process, 46 ISR lesion pairs were identified. Baseline patient characteristics were similar among the groups (P=not significant). There was no difference in the in-hospital major adverse cardiac events (MACE) between the groups, whereas MACE at follow-up were significantly lower in the FX minirail BA group than in the PTCA group (19.6% vs 41.3%, P <0.05). The recurrent ISR rate was significantly lower in the FX minirail BA group than in the PTCA group (19.6% vs 39.1%, P <0.05). Also, a diffuse pattern of recurrence was more common in lesions treated with PTCA, whereas the focal pattern of recurrence was more common in the FX minirail BA group (22.2% vs 50%, P <0.05). The MLD at follow-up, the acute gain, and net gain were significantly higher in the group of lesions treated with the FX minirail BA than in the PTCA group. In addition, a significantly higher late loss and loss index at follow-up were observed in the PTCA group compared in the FX minirail BA group. The FX minirail BA has advantages over PTCA in the treatment of patients with ISR, with better immediate and follow-up angiographic outcomes, and a better clinical outcome on follow-up.

Elevated plasma endothelin-1 levels in coronary sinus during rapid right atrial pacing in patients with slow coronary flow.

The aim of the study was to evaluate whether there was an imbalance between endothelin-1 (ET-1) and nitric oxide (NOx) release and diffuse atherosclerotic changes existed in patients with slow coronary flow (SCF). Baseline and post-atrial pacing coronary sinus ET-1 and NOx levels were measured in 19 patients with SCF (11 female, 56 +/- 9 years) and in 14 control subjects (nine female, 54 +/- 7 years). All patients underwent subsequent intravascular ultrasound (IVUS) investigation at the same setting with right atrial pacing. Baseline arterial (12.4 +/- 9.9 vs. 6.3 +/- 5.1 pg/ml, P<0.005) and coronary sinus (12.2 +/- 11.1 vs. 6.4 +/- 6.9 pg/ml, P<0.005) ET-1 plasma levels were higher in patients than in controls. After atrial pacing, concentration of ET-1 level from coronary sinus (24.7 +/- 14.6) significantly increased as compared to baseline (12.4 +/- 9.9, P<0.0001) and control levels (5.3 +/- 6.3, P<0.0001). Additionally, coronary sinus ET-1 level increased significantly with atrial pacing compared to femoral artery ET-1 level (16.3 +/- 8.5, P<0.005) in patients with SCF. After atrial pacing, the femoral artery ET-1 level also increased in patients compared to control level (P<0.0001). No significant differences in arterial and coronary sinus NOx plasma levels were found between the two groups, both at baseline and after pacing. Upon IVUS investigation, the common finding was longitudinally extended massive calcification throughout the epicardial arteries in patients with SCF. Mean intimal thickness was 0.59 +/- 0.18 mm. The data of this study suggest that increased ET-1 levels and insufficient NOx response, as well as the pathological data of IVUS may be associated with coronary microvascular dysfunction and may be the manifestation of early diffuse epicardial atherosclerosis in these patients with SCF.

Endothelin-1 and nitric oxide levels in patients with mitral annulus calcification.

Mitral annulus calcification (MAC) is a chronic degenerative noninflammatory process. The goal of this study was to determine endothelin-1 (ET-1) and nitric oxide (NOx) levels in patients with MAC and compare them with those in normal subjects. The study group included 39 patients [26 females (66%), age, 63 +/- 8 years] with MAC and 20 [11 females (55%), age, 61 +/- 7 years] healthy subjects. The patients were divided into two subgroups, group A with severe MAC and group B with mild MAC, according to the severity of the MAC. Plasma ET-1 levels were higher and NOx levels were lower in patients than controls [(6.5 +/- 5.6 pg/mL vs 3.7 +/- 2.9 pg/mL for ET-1 and 35.0 +/- 10.6 micromol/L vs 42.3 +/- 9.9 micromol/L for NOx; P < 0.05 for both)]. In the subgroups, ET-1 levels were higher in group A than group B (8.65 +/- 6.84 pg/mL vs 4.74 +/- 3.45 pg/mL, P < 0.05) and the control group (8.65 +/- 6.84 pg/mL vs 3.70 +/- 2.88 pg/mL, P < 0.05). There was no difference between group B and the control group. Plasma NOx levels were significantly decreased in group A compared to controls (32.22 +/- 11.88 micromol/L vs 42.25 +/- 9.99 micromol/L, P < 0.05). However, no significant difference was observed between group B (37.38 +/- 9.06 micromol/L) and the other groups. Diabetes mellitus, coronary artery disease, and dyslipidemia were significantly associated with ET-1 levels. However, this association was not observed for NOx. In conclusion, patients with MAC have increased ET-1 and decreased NOx levels. This seems to be more prominent in patients with severe MAC.

Slow coronary flow may be a sign of diffuse atherosclerosis. Contribution of FFR and IVUS.

OBJECTIVE: Slow coronary flow (SCF) is a phenomenon characterized by delayed opacification of coronary arteries in the absence of epicardial occlusive disease, in which many aetiological factors such as microvascular and endothelial dysfunction, and small vessel disease have been implicated. We aimed to investigate the epicardial resistance in relation with SCF by using fractional flow reserve (FFR) and intravascular ultrasound (IVUS). Both have been combined to disclose the related epicardial flow resistance and the arterial anatomy. METHODS AND RESULTS: Coronary pressure and FFR measurement were performed in 19 (8 (42.1%) men, 11 (57.9%) women; age = 55.9 +/- 9.4 years) patients with SCF. All patients underwent subsequent IVUS investigation at the same setting. As compared with expected normal values, FFR values were significantly lower (1.0 vs. 0.83 +/- 0.13, p < 0.0001). In patients with SCF, a strong negative correlation was seen between TIMI frame count and FFR (r = -0.551, p < 0.05). Upon IVUS investigation, the common finding was longitudinally extended massive calcification throughout the epicardial arteries and increased intimal thickness (0.59 +/- 0.18 mm). A negative correlation between intimal thickness and FFR was determined (r = -467, p < 0.05). CONCLUSION: We have demonstrated the decreased FFR in the patients with SCF. Decreased FFR levels have been attributed to increased resistance in the epicardial coronary arteries due to diffuse atherosclerotic disease which has been demonstrated by IVUS.

[Femoral vascular complications after percutaneous coronary interventions]. / Perkütan koroner girisimler sonrasi femoral vasküler komplikasyonlar.

OBJECTIVE: We aimed to investigate peripheral vascular complications and their relation with treatment and clinical parameters in percutaneous transluminal coronary angioplasty (PTCA) patients. METHODS: We included into the study 321 patients (aged 57+/-11 years) underwent PTCA between November 2001-August 2002. The age, gender, glycoprotein 2b/3a use, thrombolytic use, intraaortic balloon treatment, transient pacemaker treatment, reintervention history, hypertension, diabetes mellitus, smoking status, family history and the correlations of these parameters with local vascular complications were assessed in all patients. RESULTS: Pseudoaneurysm incidence was significantly correlated with; age [(n=13, 68.0%) p=0.0001, OR 8.38], female gender [(n=12, 63.1%) p<0.015, OR 0.32], reintervention [(n=10, 52.1%) p<0.004, OR 3.6], venous sheath usage [(n=12, 63%) p<0.0001, OR 9.07], thrombolytic treatment [(n=5, 26.3%) p<0.0001, OR 7.9], and intraaortic balloon adjustment [(n=6, 31.5%) p<0.0001, OR 7.2]. No correlation was found between pseudoaneurysm incidence and glycoprotein 2b/3a treatment, smoking, diabetes mellitus, hypertension and family history. CONCLUSION: The present study showed that patients of female gender, with reintervention, thrombolytic treatment, venous sheath use and intraaortic balloon adjustment are at high risk for serious femoral vascular complications, especially when they are aged. Additionally, glycoprotein 2b/3a agents can be used without increased risk of peripheral vascular complications.

Early and late angiographic and clinical outcome following helistent stent implantation.

There is still a lack of data on the influence of different stent designs on long-term restenosis rates and major adverse cardiac events (MACE) with the use of new antithrombotic regimens. We evaluated the midterm (6 months) clinical and angiographic and lateterm (2 years) clinical outcome of Helistent stent implantation. The study population consisted of 150 patients with high risk factor rates who had single or multivessel disease and had undergone coronary Helistent stent implantation with new antiplatelet regimens. The control coronary angiographies were done at 6 months and they were followed clinically to the end of 2 years. In 150 patients, 236 Helistent stents were implanted for 224 lesions. Helistent stent implantation was associated with a very high success rate (99%). The angiographic re-stenosis rate was 11.3% at 6 months. Only 16% of the patients experienced target lesion revascularization, 20% of the patients experienced MACE and of them, only 3.3% died at the end of two year follow-up period. The results demonstrate that the Helistent stent can be implanted with a high success rate with encouraging 6 month angiographic and late clinical outcomes.

The relationship between plasma endothelin-1, nitric oxide levels, and heart rate variability in patients with coronary slow flow.

BACKGROUND: Coronary slow flow (CSF) is characterized by delayed opacification of coronary arteries in the absence of epicardial occlusive disease. In this study, we aimed to determine endothelin-1 (ET-1), nitric oxide (NOx) levels and time domain heart rate variability (HRV) parameters in patients with CSF and relationship among these parameters. METHODS: Thirty-three patients with CSF detected in the coronary angiography (17 females; mean age 55 +/- 7) and 19 patients with normal coronary flow (10 females; mean age 54 +/- 11) as a control group were enrolled in the study. Patients were divided into two groups according to exercise testing as if positive (group A, n = 8) or negative (group B, n = 25). RESULTS: Plasma ET-1 levels were higher in the group A patients (28.7 +/- 17.4 pg/ml) than that of group B (15.9 +/- 10.6 pg/ml) and control group (6.0 +/- 5.7 pg/ml); and higher in group B patients than that of control group (P < 0.05). Although groups A and B did not differ according to plasma NOx levels (23.4 +/- 13.5 micromol/L vs. 32.8 +/- 22.7 micromol/L, P > 0.05), NOx levels in group A were lower than the control group (23.4 +/- 13.5 micromol/L versus 42.5 +/- 15.9 micromol/L, P < 0.05). Time domain HRV parameters were decreased in all patient groups. This was more prominent in group A. Additionally, HRV parameters were negatively correlated with ET-1 and TIMI frame counts. TIMI frame count was also significantly correlated with ET-1 and NOx levels (r = 0.61, P < 0.0001, r =-0.30, P < 0.05). Upon intravascular ultrasonography investigation, the common finding was longitudinally extended massive calcification throughout the epicardial arteries. Mean intimal thickness was 0.50 +/- 0.13 mm (group A; 0.58 +/- 0.11 mm, group B 0.47 +/- 0.12 mm, P = 0.029). CONCLUSIONS: The present study demonstrated that in patients with CSF, both increased plasma ET-1, decreased plasma NOx and diffuse atherosclerosis may cause the decrease in HRV by effecting myocardial blood flow.

Endothelin-1 and nitric oxide concentrations and their response to exercise in patients with slow coronary flow.

In this study, the endothelin-1 (ET-1) and nitric oxide (NO) concentrations in slow coronary flow (SCF) patients were assessed before and at the peak of the exercise stress test and compared with the values from healthy controls. The study population was 25 patients who underwent coronary angiography and were diagnosed as SCF (11 females (44%), aged 56.7+/-9.8 years), and 20 normal subjects (9 females (45%), aged 54.3+/-9.2 years). Mean TIMI frame count in the patients was 54.1+/-13.4. Blood samples were drawn at rest and immediately at the end of exercise testing. The baseline ET-1 concentrations of the control subjects were lower than those of the patients (7.0+/-4.5 pg/ml vs 11.1+/-5.9 pg/ml p<0.0001) and this difference increased after exercise (6.2+/-4.3 pg/ml vs 20.1 +/-10.4 pg/ml, p<0.0001). Post-exercise ET-1 concentrations were significantly higher than baseline in patients with SCF (p<0.0001) and a reduction in the ET-1 concentrations was observed in control subjects (p<0.05). Baseline NO concentrations of the patients were lower than those of the control subjects (27 +/-5.1 micromol/L vs 31.2+/-4.9 micromol/L, p=0.0001). Although the NO concentrations in both groups were significantly increased after exercise (29.4 +/-5.9 micromol/L vs 33.3+/-5.6 micromol/L, p<0.05 for both), the difference was not significant. A significant negative correlation among post-exercise ET-1 concentrations and maximal heart rate, exercise duration and exercise rate - pressure product, and a significant positive correlation among post-exercise NO concentrations and maximal heart rate and exercise duration were observed in both groups. The results of this study show that endothelial function (assessed by ET-1 and NO concentrations) and its response to exercise were abnormal in SCF patients compared with healthy subjects, and this may play some pathophysiologic role.

Long-term effects of beta blocker therapy on P-wave duration and dispersion in congestive heart failure patients: a new effect?

Atrial fibrillation (AF) is associated with heart failure in approximately 20%-50% of patients with increased morbidity and mortality. P-wave maximum duration (PWM) and P-wave dispersion (PWD) are recent ECG markers and reflect increased risk of AF. The aim of our study was to investigate the long-term effects of metoprolol on atrial conduction abnormalities as estimated by PWM and PWD, which were calculated on 12-derivation surface ECG in heart failure patients. Forty-two NYHA class 3 to 4 patients (23 males, 19 females and aged 52.9 +/- 11.2) were enrolled in the study. At the end of the 6 months, PWM and PWD values were significantly decreased (for PWM: from 115.2 +/- 12.6 to 105.4 +/- 13.5; for PWD: from 39.3 +/- 9.1 to 28.6 +/- 10.5; P <.001 for both). Metoprolol treatment is associated with a decreased duration of PWM and PWD and this may reflect a reduction in the probability of atrial fibrillation in heart failure patients.

Diffuse intimal thickening of coronary arteries in slow coronary flow.

Intravascular ultrasound imaging can detect intimal thickening and is suitable for detection of early atherosclerosis, which cannot be detected by conventional angiography. The aim of the present study was to investigate the epicardial coronary morphology and intracoronary pressure in relation to slow coronary flow (SCF). The study population consisted of 19 patients with SCF [11 (57.9%) females; 55.95 +/- 9.42 years]. Proximal, middle, distal and mean total vessel area, lumen area, intima + media area (IMA), percent IMA, and maximal intima + media (I + M) thickness were calculated and compared to healthy subjects. Proximal, middle, distal and mean I + M thickness, IMA, and % IMA of patients with SCF were found to be significantly higher than those of control subjects. Longitudinally extended massive calcification throughout the epicardial arteries was found in 13 (68.49%) patients with SCF and regional calcification was found in 6 (31.6%) patients with SCF. Proximal and distal pressure gradients of patients with SCF were determined to be 15.84 +/- 12.11 mmHg in the intracoronary pressure measurements. Fractional flow reserve values were significantly lower than the normal population (0.83 +/- 0.13, P < 0.0001). This study indicates that patients with SCF have diffuse intimal thickening, widespread calcification along the vessel wall and atheroma which does not cause luminal irregularities in coronary angiography, and a pressure gradient between proximal and distal segments of epicardial coronary arteries with SCF. Based on these results, we believe that SCF may be a form of diffuse atherosclerosis involving both the microvascular system and epicardial coronary arteries.