Anomalous origin of coronary arteries: when one sinus fits all.

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.

Coronary artery perforation in patients undergoing percutaneous coronary intervention: a single-centre report.

The present study reports the incidence, management and clinical outcome of coronary perforations in 5 of 2991 patients (0.1%) undergoing percutaneous coronary intervention, with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques. There was 1 type I, 1 type II and 3 type III perforations. One perforation was guidewire related, 2 perforations occurred after stent deployment and two occurred during stent-post dilatation with balloons. Restoration was obtained by prolong balloon inflation in three cases. Subsequent cardiac tamponade occurred in 2 patients, requiring pericardiocentesis. One patient died in the cath lab. due to electromechanical dissociation. At follow-up, 3 out of 4 patients were asymptomatic and one had bypass surgery for restenosis. Treatment of coronary perforation requires rapid detection, angiographic classification, and immediate occlusion of perforation site, pericardiocentesis, haemodynamic support and reversal of heparin anticoagulation.

Prospective native coronary artery stenosis treated with sirolimus-eluting stent (ONASSIS) registry--acute results and mid-term outcomes: a single-center experience.

BACKGROUND: Encouraging results with the use of the sirolimus-eluting stent (SES) have been recently presented in several multi-center trials. In the present study, the short- and mid-term clinical outcomes of the SES in everyday clinical practice of interventional cardiology were compared with a strategy using conventional bare metal stents. METHODS: In a total of 530 consecutive patients (males 86%, mean age 61 +/- 10 years) who had been treated with a SES were compared with a control group of 398 patients (males 87%, mean age 59 +/- 11 years) treated with a bare metal stent before the use of SES. In-hospital results and clinical outcomes during follow-up (11.22 +/- 3.4 versus 11.41 +/- 3.1 months) were obtained. RESULTS: Patients treated with SES had more risk factors for coronary artery disease or multivessel disease compared to those with treated bare metal stent. The clinical success rate was 99.6% in the SES group and 98.5% in the bare metal stent group (p = ns), and non-Q-wave myocardial infarction (MI) occurred in 5.7% and 4.0% of patients, respectively. The incidence of death or MI during follow-up was not different (1.1% versus 1.3% and 0.8% versus 1.8%; p = ns). Percutaneous or surgical revascularization for target lesion restenosis was required in 2.1% of patients treated with SES and in 10.1% of those with bare metal stents (p < 0.001), and the event-free survival from death, cerebrovascular accident, MI or any percutaneous or surgical revascularization was 93.13% and 83.63%, respectively (p < 0.01). CONCLUSIONS: The implantation of the SES is associated with excellent in-hospital and mid-term results, mainly because of dramatic reductions in the need for repeat revascularization, despite a higher risk factor profile and more complex lesion characteristics.

Diabetes mellitus and unstable coronary artery disease: improved clinical outcome of coronary artery stenting in an era of glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy.

OBJECTIVE: The short- and long-term clinical outcomes of coronary artery stenting in diabetic patients with unstable coronary artery disease were assessed and compared with a cohort of non-diabetic patients in the context of platelet glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy. METHODS: The study population comprised 252 consecutive patients with unstable angina who underwent coronary artery stenting; of these 46 were diabetic and 206 were non-diabetic. In-hospital results and clinical outcome during follow-up (24 +/- 13 months, range 7-56 months) were obtained in all patients without major in-hospital complications. Survival curves and multivariate models for any late clinical event were reported. RESULTS: A high clinical success rate and no difference in in-hospital complications between the two groups of patients were observed. Complete revascularization rate was similar in diabetic and non-diabetic patients (48% compared with 52%). A greater proportion of diabetic than non-diabetic patients received IIb/IIIa inhibitors during the procedure and lipid-lowering drugs at hospital discharge (87% compared with 46%, P=0.001 and 83% compared with 61%, P=0.006 respectively). At 2-year clinical follow-up, the incidences of death and myocardial infarction were similar in both groups; the need for any revascularization was only slightly higher in diabetic patients (P=NS). Incomplete revascularization and multi-vessel disease were independent predictors of any revascularization. CONCLUSIONS: Coronary artery stenting combined with glycoprotein IIb/IIIa inhibitor infusion and long-term lipid-lowering therapy is an effective therapeutic strategy in diabetic patients with unstable coronary artery disease and is associated with good short- and long-term results, comparable to those observed in non-diabetic patients.

The effect of rapid decreases of blood pressure by different mechanisms on coronary flow and flow reserve in normal coronary arteries.

BACKGROUND: Changes in mean blood pressure (MBP) alter coronary blood flow (CBF). We evaluated the acute effects of three hypotensive medications on CBF parameters in angiographically normal coronary arteries. METHODS: We performed CBF measurements using the Doppler wire at rest and during hyperemia produced by intracoronary adenosine (18 microg) as follows: 1) in the normal left circumflex coronary artery in 20 patients with coronary artery disease (measurements were performed without drugs, and after intravenous infusion of nitroprusside [0.5 to 2 microg/kg/min] and nitroglycerin [10 to 90 microg/min]; drugs were titrated to decrease MBP 20% to 25% below the control values, and heart rate was held constant using right atrial pacing); and 2) in the normal left anterior descending coronary artery in 19 patients without coronary artery disease (measurements were performed before and after intravenous clonidine infusion [150 microg in 5 min]; time-averaged peak velocity [APV], CBF, and coronary flow reserve [CFR] were measured). RESULTS: Similar decreases in MBP were obtained in the two patient groups. Lumen diameter at the site of Doppler measurements increased after all medications (P <.005), whereas CBF did not change significantly. The CFR decreased after nitroprusside (1.79 +/- 0.48 v 2.54 +/- 0.45, P=.000), did not change significantly after nitroglycerin (2.74 +/- 0.43 v 2.54 +/- 0.45, P =.097), and increased after clonidine (3.12 +/- 0.70 v 2.76 +/- 0.75, P =.006). CONCLUSIONS: In normal coronary arteries the infusion of three hypotensive medications to produce the same decreases in MBP is associated with different effects on CFR (increase with clonidine, decrease with nitroprusside, and no change with nitroglycerin).

Relative coronary flow velocity reserve improves correlation with stress myocardial perfusion imaging in assessment of coronary artery stenoses.

STUDY OBJECTIVE: To evaluate the angiographic and coronary flow velocity parameters that best correlate with the results of stress myocardial perfusion imaging. DESIGN: Criterion standard. SETTING: Tertiary care center. PATIENTS: Forty-eight patients undergoing diagnostic coronary angiography for angina or silent ischemia. INTERVENTIONS: We performed angiographic and coronary flow velocity measurements at rest and during hyperemia at the post-stenotic segment and in the adjacent angiographically normal branch of the left coronary artery. Relative coronary flow velocity reserve (RCFVR) was calculated as the ratio of post-stenotic to reference vessel coronary flow velocity reserve (CFVR). The best cutoff points for reversible perfusion defects were calculated using receiver operating characteristic curves. MEASUREMENTS AND RESULTS: Post-stenotic CFVR showed fairly good correlations with minimal lumen diameter and percentage of diameter stenosis (r = 0.57 and r = 0.55, respectively; p < 0.001). RCFVR showed stronger correlations with these angiographic indexes of stenosis severity (r = 0.66 and r = 0.68, respectively; p < 0.0001). Based on receiver operating characteristic cutoff values (1.67 for post-stenotic CFVR and 0.64 for RCFVR), RCFVR had better agreement with myocardial perfusion imaging results, compared to post-stenotic CFVR (92% vs 75%, respectively). This agreement was more meaningful in patients with moderate coronary artery stenoses (50 to 75%). The area under the curve was 0.65 (not significant) for post-stenotic CFVR and 0.88 (p < 0.01) for RCFVR. CONCLUSIONS: RCFVR describes better than post-stenotic CFVR the functional significance of coronary artery stenoses.

The effect of co-administration of simvastatin and alcohol in rats.

INTRODUCTION: The effect of chronic co-administration of alcohol (Alc) and lipid-lowering drugs on hepatic function has not been extensively evaluated. We studied the effects of administering Alc together with a 3-hydroxy-3 methylglutaryl coenzyme A reductase inhibitor [simvastatin (S)]. MATERIALS AND METHODS: Male Wistar rats (8 weeks old) were randomized and divided into 4 groups of 10 each. They were fed (once a day) via a stomach tube with: 1) 2 ml of olive oil; group Oil, 2) with Oil + 2 ml of 25% v/v pure Alc in water; group Alc + Oil, 3) with Oil + S (65 micrograms/100 g body weight); group S + Oil, 4) with Oil + Alc + S; group S + Alc + Oil. Another 13 male Wistar rats were only fed a standard laboratory diet (control group). After 8 weeks blood samples were drawn and the livers were removed. Blood glucose, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), total protein, albumin, total cholesterol (TC) and triglycerides (TG) were measured. Liver histopathology was also assessed. RESULTS: Differences were found between the control group and tube-fed groups in glucose (p < 0.001). No differences were found among tube-fed groups in blood glucose, ALT, total protein, albumin, AP and TC. AST activity was significantly higher in the Alc + Oil than in the Oil or S + Oil groups (p < 0.001 for both comparisons) demonstrating the effect of Alc on AST. The AST did not differ significantly in the Oil or S + Oil groups indicating a lack of effect of S. Furthermore, S significantly reduced the Alc-induced increase in AST (Alc + Oil vs S + Alc + Oil; p = 0.042). The TG concentration was significantly higher in the Alc + Oil group compared to the Oil, S + Oil and S + Alc + Oil groups (p = 0.02). Therefore, S significantly decreased the alcoholinduced increase in TG. Liver histopathology was similar in all groups and within the normal range. CONCLUSION: A moderate amount of Alc daily together with S is safe in rats. Additionally, S administration in Wistar rats diminishes the Alc-induced TG and AST rises.

Long-term clinical outcome of coronary artery stenting in elderly patients.

BACKGROUND: The elderly constitute a rapidly expanding segment of our population and cardiovascular disease becomes more prevalent with increasing age. Existing data have shown that percutaneous coronary interventions in the elderly are associated with an increase risk of in-hospital complications compared to younger patients. In the present study we retrospectively assessed the long-term clinical outcome of coronary artery stenting in an elderly population and compared them with the cohort of younger patients. METHODS: The study population included 402 consecutive patients with coronary artery disease who underwent coronary artery stenting; of these 69 were elderly (age > 70 years, group I) and 333 were younger (age

Association of apolipoprotein E polymorphism with myocardial infarction in Greek patients with coronary artery disease.

Studies in several populations have indicated that genetic variation at the apolipoprotein E (apoE) structural locus influences the risk of coronary artery disease (CAD) and myocardial infarction (MI). This study aimed at investigating whether apoE polymorphism has an allelic and/or genotypic impact on the risk of MI in Greek patients with CAD. We compared apoE gene polymorphism in a group of patients with angiographically confirmed CAD but not MI [CAD/MI (-)-group, n = 143] and a group of age and sex-matched CAD patients who had experienced a non-fatal Ml [CAD/MI (+)-group, n = 124]. The patients were also compared with a group of healthy younger individuals (n = 240) with no family history of CAD. The apoE genotype distribution differed significantly between the two groups of CAD patients (p = 0.02). The epsilon2 allele was 5.3-fold less frequent in the CAD/ MI (+)-group compared with the CAD/MI (-)-group (1.2% vs. 6.3%, p = 0.01). The frequency of the epsilon2 allele in healthy subjects was 8.1%, which is 6.8-fold higher than in CAD/MI (+)-patients (p = 0.001) and twice as high compared with all CAD patients (p = 0.02). No differences in epsilon4 allele frequencies were observed between CAD/MI (+)- and CAD/MI (-)-patients (10.9% vs. 9.8%), or between patients with CAD and healthy subjects (10.3% vs. 10.2%). In summary, the epsilon4 allele was not found to be associated with an increased risk for CAD or MI. In contrast, a negative association of the epsilon2 allele with Ml was observed among Greek patients with CAD.