Predictors of mortality in patients undergoing percutaneous aortic valve implantation.

AIM: Transcatheter aortic valve implantation (TAVI) became an attractive alternative to surgery for patients with severe aortic stenosis and high operative risk. The first multicenter randomized trial, conducted in such high risk cohort, showed 20% reduction in mortality in the group treated with TAVI compared to those treated with medical therapy (30.7% vs. 50.7% P=0.001) and a non-inferiority of TAVI compared to traditional valve surgical replacement for all-cause mortality at 1 year with, similar improvement of symptoms and physical performance. However, mortality rate of TAVI remains high (20-30% at one year). The purpose of this prospective single center study was to identify predictors of mortality and adverse events in patients undergoing TAVI in order to be able to select the ones who benefit most from the procedure. METHODS: Between June 2009 and June of 2011, 118 patients with severe aortic stenosis treated with TAVI at IRCCS Humanitas Clinical Institute were included in a prospective registry. Pre procedural clinical and ecocardiographic evaluations, surgical risk estimation, and procedural complications, defined by VASC criteria, were recorded. Clinical and echocardiographic evaluations were performed at 1, 6 and 12 months after the implants. To investigate the predictors of mortality, clinical and anatomical characteristics of alive patients were compared with those of death ones at one month and one year follow-up. RESULTS: The procedural success occurred in 92.4% of procedures; vascular complications (33%), bleeding complications (22%), postimplant paravalvolar grade ≥2 AR (20.4%) a new permanent pacemaker implant (19.7%), were the most common complications. Survival for the whole cohort at 30 days was 6.8%, survival at one year was 82.2%. In the logistic regression test, one month mortality was significantly adversely affected by the renal functional status (odd ratio 0.9356), by a previous history of coronary artery bypass grafting (odd ratio 39) and by the mean aortic annular diameter (odd ratio 0.512) (P=0.0005). One year mortality was influenced by high EuroSCORE (odd ratio 1.0399) and the presence of hemodynamically significant prosthetic regurgitation (odd ratio 3.8438). CONCLUSION: TAVI procedure, in high risk patients with critical aortic stenosis, can be accomplished with low procedural mortality. The worst outcome affects particularly patients with renal insufficiency and previous coronary bypass. However, the long-term mortality remains high due to the poor baseline conditions, mainly related to co-morbidity and to the presence of residual post-procedural aortic insufficiency.

Percutaneous aortic valve in severe valvular regurgitation caused by infective endocarditis.

Recently, the feasibility and safety of percutaneous aortic valve replacement (PAVR) have been reported in the treatment of degenerative aortic valve stenosis in patients at high-risk for surgical aortic valve replacement (AVR). However, so far this therapy has been limited to patients with severe stenosis of the native valve. We report the case of an 84 year old patient with severe aortic regurgitation caused by infective endocarditis who was successfully treated by implantation of a CoreValve (CoreValve Inc, Irvine. Calif) prosthesis with a totally percutaneous approach.

A case of platypnea-orthodeoxia syndrome caused by the interaction between the presence of corrected transposition of the great arteries and patent foramen ovale.

A 42-year-old was admitted to our institution for recurrent episodic dyspnea on exertion. The patient had also a history of recurrent transient ischemic attacks. Careful history taking revealed that she developed dyspnea in an upright position, whereas the symptoms were relieved in a supine position (platypnea). The patient was given the diagnosis of platypnea-orthodeoxia syndrome. Transthoracic echocardiography showed cardiac situs solitus levocardia with great artery transposition with intact interventricular septum, patent foramen ovale (PFO) and moderate right atrial dilatation. Agitated saline contrast injection demonstrated the presence of spontaneous right-to-left shunt. The patient underwent transcatheter closure of PFO. After percutaneous closure of PFO patient became asymptomatic and hypoxemia induced by orthostatic conditions did not appear again. A transthoracic echocardiography performed after two months, showed the complete closure of PFO, without residual shunt.

Anatomical patterns of patent foramen ovale (PFO): do they matter for percutaneous closure?

AIM: The aim of this study was to describe and classify the various anatomical pattern of patent foramen ovale (PFO) with transesophageal echocardiography (TEE) and to relate such classification to the selection of PFO closure devices. METHODS: This study enrolled 216 PFO patients (118 females) mostly with previous cryptogenic stroke or transitory ischemic attack (TIA) who underwent percutaneous closure of PFO with deep sedation under TEE control. Anatomical patterns were classified as follows: simple: PFO characterised by central/superior eccentric shunt or with a valve mechanism (45%); reduse: widely redundant septum primum (22%); ASA: atrial septal aneurysm (11%); EASA: entire atrial septal aneurysm (1.4%); CRIB: cribriform septum primum (9%); tunnel: tunnel between septum primum and secundum >10 mm (11%). Degree of right-to-left shunt, either at basal condition or at Valsalva manoeuvre, was classified as: 1=mild (45%); 2=moderate (42%); 3=severe (13%). Additional right-atrium anatomical features are also described. RESULTS: Procedure was successful in 100% of the cases. At follow-up recurrent TIA occurred in two patients. Residual shunts were present in 4.9% of the patients after Valsalva manoeuvre. Palpitations were reported in 4%. CONCLUSIONS: Closing the PFO choosing the device following strict anatomical criteria based on TEE assessment allowed excellent immediate and late results minimizing residual shunts.

Admission glycemia and markers of inflammation are independent outcome predictors in primary PCI in non-diabetic patients.

AIM: To assess the prognostic value of admission plasma glucose (APG) respect to clinical variables and inflammatory markers in a selected population of non-diabetic patients with ST elevation myocardial infarction (STEMI) treated with primary angioplasty (primary coronary intervention, PCI). METHODS: A total of 188 consecutive non-diabetic STEMI patients undergoing primary PCI were divided into four quartiles based on APG (<117, 117-140, 141-170, >170 mg/dL). Combined end-point of major adverse cardiac events (MACE) was defined as death, acute heart failure, re-infarction, unstable angina or inducible ischemia. RESULTS: Event-free survival from MACE was significantly (P<0.001) correlated with APG quartiles and decrease from the lowest to the highest: 6 months event-free survival was 89.3%, 77.4%, 59.1%, 42.5%. Patients with higher APG were characterized by a significantly higher Killip class (P<0.001), higher serum creatinine (P<0.05) on admission, and a lower rate of thrombolysis in myocardial infarction (TIMI) 3 flow after PCI (P<0.05). Multivariate analysis showed APG>170 mg/dL (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.24 to 4.65, P<0.01), admission high-sensitivity C-reactive protein level (HR 1.19, 95% CI 1.07 to 1.31, P<0.001), white blood cells count (HR 1.07, 95% CI 1.00 to 1.14, P<0.04) and heart rate (HR 1.02, 95% CI 1.00 to 1.04, P<0.02) to be independent predictors of MACE. CONCLUSION: Admission glycemia and inflammatory markers are independent predictors of MACE in the mid-term follow-up in non-diabetic STEMI treated with primary PCI. Further investigations are needed to study the pathogenesis of stress hyperglycaemia, interactions with mechanisms of inflammation and whether early and aggressive treatment with insulin may influence outcome of primary PCI.

DES implantation in saphenous vein and left internal mammary grafts.

Forty percent of patients treated with CABG need further revascularizations after 10 years mainly due to saphenous--more than arterial--graft disease. In this issue, the Authors make a critical review of current available literature on the treatment of saphenous and arterial graft disease, a subset of lesions for which a clear consensus for DES use is still lacking. The Authors examine both the positive and negative aspects of DES use in this setting. Percutaneous revascularizations with DES are feasible and safe. The antiproliferative properties of DES seem to be effective even in the treatment of bypass disease, in particular in saphenous grafts. The clinical efficacy of a treatment with DES is expressed mainly in the reduction of in-stent restenosis and, therefore, in the rates of target lesion revascularization (TLR). Moreover, the use of DES is not associated to higher rates of stent thrombosis and, in case of reintervention, recurrence rates seem to be limited. However, the benefit provided by DES in prevention of restenosis may be limited by the progression of the disease in other segments than those treated with stents. Percutaneous treatment of arterial bypass with DES is feasible and safe. Most of available data on DES are on anastomotic disease (data on bypass ostium and shaft are too scarce to draw any conclusion). In this case, where the use of stents is imperative, there is no evidence of advantages gained by the use of DES over BMS in terms of new revascularizations. Some unanswered questions on DES use in this setting still remain. For this reason new randomized trials are required to definitively give a reliable answer on DES efficacy in this subset of lesions.

Endovascular intervention in the treatment of congenital heart disease in adults.

Over the last years, endovascular intervention have become an important part of treatment in patients with congenital heart disease particularly for residual defects after surgery done in infancy. These transcatheter procedures can be described as dilatation of stenotic sites (angioplasty, endovascular stenting and valvuloplasty) or as a closure of anomalous openings (device closure defects and vascular embolisation). Balloon valvuloplasty, without or with stent, is the procedure of choice in adults with pulmonary valve stenosis, pulmonary arteries stenosis, bicuspid aortic valve stenosis without calcification, aortic re-coarctation. Treatment of native aortic coarctation is still under debate. Devices for closing atrial and ventricular septal defects or patent ductus arteriosus have been developed and are now widely used. Transcatheter, plug or coil occlusion is nowadays the goal treatment in a wide range of arterial and venous vascular connections. This review describes the current role of each major catheter-directed therapy in the treatment of congenital heart disease in adults.

Low testosterone levels are associated with coronary artery disease in male patients with angina.

Historically, high androgen levels have been linked with an increased risk for coronary artery disease (CAD). However, more recent data suggest that low androgen levels are associated with adverse cardiovascular risk factors, including an atherogenic lipid profile, obesity and insulin resistance. The aim of the present study was to evaluate the relationship between plasma sex hormone levels and presence and degree of CAD in patients undergoing coronary angiography and in matched controls. We evaluated 129 consecutive male patients (mean age 58+/-4 years, range 43-72 years) referred for diagnostic coronary angiography because of symptoms suggestive of CAD, but without acute coronary syndromes or prior diagnosis of hypogonadism. Patients were matched with healthy volunteers. Out of 129 patients, 119 had proven CAD; in particular, 32 of them had one, 63 had two and 24 had three vessel disease, respectively. Patients had significantly lower levels of testosterone than controls (9.8+/-6.5 and 13.5+/-5.4 nmol/l, P<0.01) and higher levels of gonadotrophin (12.0+/-1.5 vs 6.6+/-1.9 IU/l and 7.9+/-2.1 vs 4.4+/-1.4, P<0.01 for follicle-stimulating hormone and luteinizing hormone, respectively). Also, both bioavailable testosterone and plasma oestradiol levels were lower in patients as compared to controls (0.84+/-0.45 vs 1.19+/-0.74 nmol/l, P<0.01 and 10.7+/-1.4 vs 13.3+/-3.5 pg/ml, P<0.05). Hormone levels were compared in cases with one, two or three vessel disease showing significant differences associated with increasing severity of coronary disease. An inverse relationship between the degree of CAD and plasma testosterone levels was found (r=-0.52, P<0.01). In conclusion, patients with CAD have lower testosterone and oestradiol levels than healthy controls. These changes are inversely correlated to the degree of CAD, suggesting that low plasma testosterone may be involved with the increased risk of CAD in men.

Drug-eluting stents: towards new endpoints.

Drug-eluting stents (DES) have significantly reduced the rates of in-stent restenosis (ISR). As previously observed with bare-metal stents (BMS), either patient's clinical characteristics and lesion morphology may influence the risk of recurrence even with DES. In this review we will focus on the most recent available data on clinical settings where DES efficacy on long-term outcomes are largely unknown. In particular, we report on very complex lesions (bifurcations, small vessels, chronic total occlusions, in-stent restenosis) myocardial infarction, multivessel disease, treatment of bypass graft and of unprotected left main disease. Several issues are still open on DES routinary use for these indications, mainly as far as stent thrombosis is concerned. Recent pathological studies show that DES are characterized by chronic inflammatory infiltrates and delayed endothelialization. Therefore, this effect could translate in a ''vulnerable period'' for thromboses longer than with BMS. Even though large meta-analysis have excluded higher rates of stent thrombosis with DES rather than with BMS, few cases of unusual very late stent thrombosis have been described, pointing out that this problem seems to be still unsolved. Although DES provide better angiographic outcomes in each clinical setting, further randomized studies are running to assess their safety and efficacy on currently off-label indications.

How to treat diabetic patients with multivesseal disease in the DES era.

Patients with type 2 diabetes mellitus represent the 25% of those requiring myocardial revascularization. Choice of treatment in diabetic patients is much more controversial than in non-diabetics: this because coronary artery disease is more often complex and diffuse, left ventricular function is depressed, and concomitant multiple risk factors are present. These subset of patients experience worse outcomes than non diabetic patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). Large randomized trials performed both in the early era of PCI and in the stent era suggest that CABG is superior to bare metal stent implantation in the treatment of diabetic patients with multivessel coronary artery disease. These findings are reflected in current guidelines, which favor CABG over PCI in most diabetics who require revascularization. However, substantial variability exists in practice patterns among individual hospital, suggesting a lack of clinical consensus. The major advantage of CABG over bare metal stent implantation in diabetic patients is the lower risk of repeat revascularization procedures through the follow-up. Better angiographic results have been demonstrated in the new era of drug-eluting stents (DES). Data from both the sirolimus and paclitaxel-eluting stents trials support the potential advantage of DES implantation both in diabetic and non-diabetic patients. Preliminary data from studies comparing DES versus CABG in diabetic patients with multivessel coronary artery disease suggests that 1) no significant difference exists in the 12-month rate of death, myocardial infarction and cerebrovascular events in patients treated with DES as compared to off-pump bypass surgery, 2) a difference of 7.1% in the rate of repeat revascularization at 12-month exists in favor of bypass surgery and 3) diabetic retinopathy identifies a subgroup with poor outcome after both percutaneous and surgical myocardial revascularization.

Drug eluting stents in acute myocardial infarction.

Routine stent-implantation in primary coronary intervention (PCI) for acute myocardial infarction (AMI) has been shown to have a better clinical outcome than balloon angioplasty mainly because of reduction in restenosis rate and reocclusion. Drug eluting stents (DES) have recently been proven to further reduce restenosis and revascularization rate in comparison to bare metal stent (BMS) in elective procedures. Delayed endothelialization of these stents raises concern about a possible increase of thrombotic complications in the setting of AMI. Randomized studies with DES in the treatment of elective patients have shown at 9-12 months follow-up a thrombosis rate of 0-2% comparable to the one of BMS. Sirolimus eluting stents (SES) in AMI have been used in small series of consecutive pts not randomized or in registries with very high successful rate and a stent thrombosis varying between 0 and 4.7%. Paclitaxel eluting stent (PES) have also shown in small series a good immediate performance with a thrombosis rate between 0 and 4.8%. Predictors of acute and subacute stent thrombosis are the same than for BMS: residual dissection, long or overlapping stents, biforcation lesions and discontinuation of antiplatelets treatment. Providing effective mechanical reperfusion with similar results to the current therapeutic standard and decreasing the incidence of late complications, DES appear as an attractive approach for patients admitted with AMI.

Clinical utility of IVUS in 2005.

Intravascular ultrasounds (IVUS) allowed an innovative visualization of coronary artery disease. This technique developed first in the research field and, then, it was introduced in clinical practice as a supplement to coronary angiography in diagnosis of the severity of ischemic heart disease. The characteristic tomographic view of coronary plaque supplied by IVUS allowed to overcome the limitations of coronary angiography and to add important supplemental information in understanding the mechanism of action of several interventional devices. In this review we analyze current indications of use of IVUS in clinical practice and the future applications of IVUS-related techniques for the diagnosis of coronary artery disease.

Procedural and long-term results of sirolimus-eluting stent in patients at high risk for restenosis.

AIM: In-stent restenosis still affects 10-50% of long-term outcome after percutaneous coronary intervention (PCI). Large clinical trials have shown that sirolimus-eluting stents (SES) have reduced restenosis rate to 0-9% in lesions at low-moderate risk. The aim of this study was to evaluate long-term clinical and angiographic outcome of SES in a real world population, at very high risk of restenosis. METHODS: Ninety lesions at high risk of restenosis (lesion length >20 mm, target vessel diameter <2.5 mm, in-stent diffuse restenosis, total occlusions and complex lesions on bypass grafts and bifurcations) were treated in 75 patients. A follow-up was scheduled at 6 months. RESULTS: Restenosis rate was 16.6% with a focal pattern of presentation in most cases. Subacute in-stent thrombosis occurred in 2.2%. Resteno-sis occurred mainly in small vessels, diabetic patients and in vessels previously treated with brachytherapy. CONCLUSION: The treatment of lesions at high risk of restenosis with SES is safe with a low restenosis rate at follow-up. An aggressive and prolonged antiplatelet regimen is mandatory because of high subacute in-stent thrombosis rates.

Clinical and angiographic outcome of directional atherectomy followed by stent implantation in de novo lesions located at the ostium of the left anterior descending coronary artery.

BACKGROUND: Lesions located at the ostium of the left anterior descending coronary artery (LAD) are considered an ideal target for directional atherectomy (DCA), but few data are available about the value of using this strategy before stenting in comparison with stenting alone. OBJECTIVES: To investigate the immediate and mid term clinical and angiographic results of DCA followed by stent implantation for ostial LAD lesions. DESIGN: Retrospective comparison of the immediate and mid term angiographic and clinical results of a series of 117 consecutive patients with de novo lesions located at the ostium of the LAD. Of these, 46 underwent DCA before stenting and 71 were treated with stenting alone. RESULTS: Technical success in the two groups was similar at around 98%. DCA plus stenting provided a larger minimum lumen diameter at the end of the procedure than stenting alone (3.57 (0.59) mm v 3.33 (0.49) mm, p = 0.022). There were no differences for in-hospital major adverse events (MACE) (7.5% for atherectomy plus stenting, and 5.3% for stenting alone; p = 0.41). All patients had clinical follow up at a mean of 7.9 (2.7) months. Angiographic follow up was done in 89 patients (76%) at a mean of 5.9 (2.2) months. The atherectomy plus stenting group had a larger minimum lumen diameter than the stenting group (2.79 (0.64) mm v 2.26 (0.85) mm, p = 0.004) and a lower binary restenosis rate (13.8% v 33.3%, p = 0.031). Six month MACE were reduced in the atherectomy plus stenting group (8.7% v 23.9%, p = 0.048). CONCLUSIONS: Debulking before stenting in de novo lesions located at the ostium of the LAD is safe and is associated with a high rate of technical success. Follow up data show that DCA plus stenting results in a significantly larger minimum lumen diameter and a lower incidence of restenosis than stenting alone.

Immediate and long-term clinical and angiographic results from Wiktor stent treatment for true bifurcation narrowings.

From January 1996 to December 1998, 90 consecutive patients with true bifurcation lesions underwent percutaneous coronary angioplasty with Wiktor stent implantation in our centers. In 1 group (group I, n = 45), a simple approach (main vessel stenting and balloon angioplasty of the side branch) was pursued. In the other group (group II, n = 45), both the main vessel and the side branch were stented ("T" technique). There was no significant difference in clinical and angiographic characteristics between the 2 groups. Angiographic and procedural successes were 100% and 95.6%, respectively, in both groups. Angiographic results for the side branch were better in group II than in group I. In-hospital and long-term (12 month) major cardiac events were similar in the 2 groups. Target lesion revascularization was 15.5% in group I and 35.5% in group II (p = 0.12). In the main vessel, restenosis rate was 12.5% in group I and 25% in group II (p = 0.15). In the side branch, restenosis rate was 37.5% in group II and 12.5% in group I (p = <0.05; odds ratio 2.42; 95% confidence interval 1.05 to 6.26). Event-free probability at 12 months was 61% in group II and 80% in group I (p = 0.10). When dealing with true bifurcation lesions, a simple strategy is associated with a lower risk of restenosis in the side branch. In contrast, a complex approach does not appear to give any benefit in terms of early or long-term outcome or restenosis rate.

Anti-ischemic effect of chronic oestrogen replacement therapy alone or in combination with medroxyprogesterone acetate in different replacement schemes.

BACKGROUND: Oestrogen replacement therapy in postmenopausal women has a protective effect upon the cardiovascular system and improves exercise-induced myocardial ischemia. Although in hormone replacement schemes progestins are required to reduce the likelihood of uterine malignancies, little is known on the cardiovascular effect of progestins. The purpose of this study was to evaluate the effect of oestrogen replacement alone and two different estrogen-progestin replacement therapy schemes upon exercise induced myocardial ischemia. MATERIAL AND METHOD: The study population included 18 female menopausal patients with coronary artery disease. After a baseline exercise test patients received conjugated equine estrogens (CEE) 0.625 mg alone for 30 days when they underwent a second exercise test and were randomized to receive in a cross-over design medroxyprogesterone acetate (MPA) either in continuous combined therapy (2.5 mg/daily) for 28 days or in cyclical therapy (10 mg o.d. from day 16 to day 28). RESULTS: After CEE alone two patients with a previously positive exercise test showed a negative exercise test. CEE increased time to 1 mm ST compared to baseline (352+/-185 vs 265+/-133 s, P<0.01). In the 2 pts in whom the exercise test was negative after CEE the test remained negative during continuous combined MPA therapy while become positive during cyclical MPA. CEE+continuous combined MPA increased both time to 1 mm ST and exercise time compared to baseline (386+/-165 vs 265+/-133 s, P<0.01 and 545+/-198 vs 465+/-186 s, P<0.05, respectively). No difference was found between baseline and CEE+cyclical MPA in either time to 1 mm ST or exercise time (268+/-164 vs 265+/-133 s, P=NS and 455+/-223 vs 465+/-186 s, P=NS, respectively). CONCLUSION: Continuous combined therapy with CEE+MPA improves exercise-induced myocardial ischemia in female patients with coronary artery disease while the beneficial effect of CEE is reduced by cyclical therapy.

Time course and determinants of left ventricular function recovery after primary angioplasty in patients with acute myocardial infarction.

OBJECTIVES: We sought to evaluate the importance of time in relation to treatment, time course and determinants of recovery of left ventricular (LV) function in patients with acute myocardial infarction (AMI) undergoing primary percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Myocardial salvage has been shown to be dependent on the time elapsed from the onset of AMI to reperfusion. METHODS: Left ventricular function was evaluated at hospital admission, after angioplasty, at 24 h and 6 months by both echocardiography and angiography and at 1, 7, 30, 90 and 180 days by echocardiography in 101 consecutive patients. RESULTS: Patients were allocated to three groups according to interval between symptom onset and angioplasty: <2 h (group A), 2 to 4 h (group B) and >4 h (group C). Patients in groups A and B showed a progressive improvement of LV function between day 7 and day 90, which became statistically significant at day 30 (p < 0.01). No LV function changes were noted in group C patients. Thrombolysis In Myocardial Infarction (TIMI) flow grade <3 at 24 h was not associated with any significant change in LV volume and function during the six-month follow-up period. Restenosis, when associated with TIMI flow grade 3 in the infarct-related vessel, did not influence LV function. Flow grade <3 of the infarct-related artery was not associated with any improvement of cardiac events independently from the time to treatment at the initial procedure. CONCLUSIONS: Patients undergoing primary PTCA for AMI have a good recovery of LV function if TIMI flow grade 3 is restored within 4 h. Coronary angioplasty limits further remodeling of the LV in patients treated after 4 h.

Emergency stenting to treat neurological complications occurring after carotid endarterectomy.

OBJECTIVES: The purpose of this study was to assess the efficacy of emergency stent implantation for the treatment of perioperative stroke after carotid endarterectomy (CEA). BACKGROUND: Carotid endarterectomy has been proven safe and effective in reducing the risk of stroke in symptomatic and asymptomatic patients with >60% carotid artery stenosis. However, perioperative stroke has been reported in 1.5% to 9% of CEA cases. The management of such a complication is challenging. Recently, percutaneous transluminal carotid angioplasty with stent deployment has emerged as a valuable and alternative strategy for the treatment of carotid artery disease. METHODS: Between April 1998 and February 2000, 18 of the 995 patients (1.8%) who had CEA in our institution experienced perioperative major or minor neurological complications. Of these, 13 patients underwent emergency carotid angiogram and eventual stent implantation, whereas the remaining five had surgery re-exploration. RESULTS: Carotid angiogram was performed within 20+/-10 min and revealed vessel flow-limiting dissection (five cases) or thrombosis (eight cases). Percutaneous transluminal carotid angioplasty with direct stenting (self-expandable stent) was performed in all 13 cases. Angiographic success was 100%. Complete remission of neurological symptoms occurred in 11 of the 13 patients treated by stent implantation and in one of the five patients treated by surgical re-exploration (p = 0.024). CONCLUSIONS: Stent implantation seems to be a safe and effective strategy in the treatment of perioperative stroke complicating CEA, especially when carotid dissection represents the main anatomic problem.

Acute electrophysiologic effect of estradiol 17beta in menopausal women.

Sixteen postmenopausal women underwent electrophysiologic study before and 20 minutes after the administration of sublingual estradiol 17beta or placebo. Estradiol 17beta significantly affected electrophysiologic parameters, thereby suggesting its role in the development of palpitations in women.

Predictors of long-term clinical outcome in patients undergoing multiple vessel stenting for coronary artery disease.

BACKGROUND: Coronary artery stenting reduces the restenosis rate compared to coronary angioplasty alone. With the increased number of procedures completed with stent placement there has been a parallel increase in the number of procedures performed in patients with multivessel disease and therefore a rise in the number of patients receiving multiple stents. The clinical outcome and the predictors of the outcome of patients receiving multiple stents are not known. METHODS: To evaluate the clinical outcome of patients with multivessel coronary artery disease undergoing multiple stenting we studied 133 consecutive patients who had received > 1 stent in at least two vessels. A total of 375 coronary stents (2.8 stent per patient) were implanted in elective procedure situations. Clinical follow-up was complete in 100%. RESULTS: During follow-up 2 patients (1.5%) died (1 cardiac death), 4 patients (3%) had acute myocardial infarction, 96 patients (72.1%) remained angina-free, and 31 patients (23.3 %) had recurrence of angina. Repeat revascularization procedure was performed in 45 patients (33.8%); 43 patients (32.3%) underwent coronary angioplasty; 2 patients (1.5%) underwent coronary artery bypass grafting. The female gender and the presence of diabetes were significant (p < 0.05) predictors for coronary angioplasty or coronary artery bypass grafting procedures during follow-up. Recurrence of angina was also significantly (p < 0.05) associated with unstable angina at the time of the first procedure as well as diabetes and the female gender. Diabetes, the female gender and unstable angina were highly predictive factors of major adverse cardiac events during follow-up. CONCLUSIONS: Multiple vessel stenting in patients with multivessel coronary artery disease is associated with an acceptable immediate and long-term clinical outcome and could be considered as an alternative therapeutic option in these patients. Predictors of an adverse long-term outcome are the female gender and the presence of diabetes mellitus.