Simplified hybrid algorithms for pressure wire interrogation exploiting advantages of a baseline and contrast Pd/Pa ratio indexes to predict stenosis significance: Insight from the SPARE multicenter prospective study.

BACKGROUND: Simplification of functional stenosis assessment with pressure guidewires may facilitate adoption of physiology-guided revascularization. An important step in this regard is the avoidance of hyperemic agents, required for fractional flow reserve (FFR) calculation. We evaluate the merits of a hybrid algorithms that combines the translesional pressure ratio (Pd/Pa) obtained at rest, after contrast medium injection (cFFR) and after adenosine administration (FFR). METHODS AND RESULTS: Eighty-six patients with 108 de novo intermediate coronary stenoses were included in this prospective, multicenter study. Using prespecified cut-off values that correctly identified stenosis with a 95% of agreement (<0.89 and >0.96 for Pd/Pa; <0.84 and > 0.87 for cFFR) we tested the efficiency of three different multi-step strategies combining the three indices to classify stenosis severity, using FFR-only measurement as reference. All three different hybrid algorithms (Pd/Pa-FFR; cFFR-FFR; Pd/Pa-cFFR-FFR) have more than 95% of agreement with FFR. Yet, the novel Pd/Pa-cFFR-FFR hybrid strategy demonstrated the best performance, avoiding the need of adenosine and medium contrast in 90% and 48% of cases, respectively. CONCLUSIONS: A hybrid Pd/Pa-cFFR-FFR decision-making algorithm could be an alternative and valuable strategy to increase the adoption of a physiology-guided PCI using conventional pressure guidewires and consoles.

Subacute left ventricular free-wall rupture in early course of acute myocardial infarction. Clinical report of two cases and review of the literature.

Left ventricular free wall rupture (LVFWR) may complicate an acute myocardial infarction (AMI); its frequency ranges from 1 to 6 percent. In the era of coronary care units, LVFWR is the second cause of in-hospital death, after pump failure. The subacute presentation accounts for 2-3 percent of total hospital admissions for AMI. Heart rupture may not be suddenly fatal and sometimes there is enough time for surgical repair. Electromechanical dissociation is neither the only nor the main clinical presentation. More subtle symptoms occurring hours or days before the final event include unexplained hypotension and transient bradycardia and some ECG features such as persistent ST-segment elevation with T-waves failing to invert in the same leads. On echocardiographic subcostal view, pericardial effusion of more than 5-10 mm, with echo-dense masses overlying the heart independently of cardiac tamponade, is highly suggestive of heart rupture. If pericardiocentesis yields hemorrhagic fluid, surgical intervention is mandatory, providing both diagnostic confirmation and definitive treatment. Medical management strategies (prolonged bed rest, beta-blockade therapy) are still experimental but could become suitable for particular subsets of patients (elderly patients and patients at a high surgical risk). We report two cases of subacute LVFWR and review the currently available literature.

[Isolated infarction of the right ventricle caused by occlusion of the non-dominant right coronary artery. Role of sequential atrioventricular stimulation]. / Infarto isolato del ventricolo destro da occlusione di un'arteria coronaria destra non dominante. Ruolo della stimolazione atrioventricolare sequenziale.

AIM: Description of a case report. PATIENT: The case of a 66-year old woman with cardiogenic shock due to isolated acute right ventricular infarction caused by occlusion of a diminutive right coronary artery is described. RESULTS: Her ECG showed the presence of junctional rhythm and ST elevation in V1-V2 and right precordial leads. Despite infusion of plasma expanders, atropine and inotropic agents, clinical conditions did not improve, but success was only achieved by means of atrioventricular (AV) sequential pacing which allowed good hemodynamic stabilization of the patient. CONCLUSIONS: It is noteworthy that occlusion even of a diminutive right coronary artery can induce cardiogenic shock, and that restoration of the physiological AV synchrony--although somewhat impaired by prolonged atrial stunning--has a markedly positive effect on the hemodynamic balance.

[Coronary rotational atherectomy: initial experience at a hospital without a special department for heart surgery]. / Aterectomia rotazionale coronarica: esperienza iniziale in un ospedale privo di cardiochirurgia.

BACKGROUND: Percutaneous transluminal coronary angioplasty (POBA) of complex lesions is hindered by a lower success rate and a higher risk of complications. New devices are now available for treatment of this type of lesions (type B-C of the modified AHA/ACC classification). We present our experience in the treatment of calcified, ostial, angled and long coronary lesions by means of percutaneous transluminal coronary rotational ablation (PTCRA, Rotablator Heart Technology, Bellevue, Washington). MATERIAL AND METHODS: From June 1991 to November 1995 we performed 71 procedures of rotational atherectomy on 72 lesions in 62 patients. Twenty-three patients presented stable angina, 30 patients unstable angina and 9 silent myocardial ischemia. Thirty-five patients had single, 16 double and 11 triple vessel coronary artery disease. Left ventricular mean ejection fraction was 58 +/- 8%. The lesions attempted were classified as type A in 2 cases, B1 in 23 cases, B2 in 31 cases and C in 16 cases according to the AHA/ACC modified classification. Calcifications detected at coronary angiography were present in 66 lesions; 53 lesions were longer than 10 mm; 12 were more than 45 degrees angulated; 9 were at a bifurcation site and 3 were ostial in location. The vessels treated were in 1 case a protected Left Main Trunk, in 40 the Left Anterior Descending, in 9 the Circumflex and in 22 the Right Coronary Artery. We did not treat lesions containing visible thrombus or located on old saphenous vein grafts because of the high risk of peripheral embolization. An average of 2 +/- 1 burrs was used; the mean burr/vessel diameter ratio was 0.59 +/- .07. "Complementary" low pressure PTCA was performed in all but 4 cases ("stand alone procedure"). RESULTS: Primary success was obtained in 62/71 procedures (92%) and in 67/72 lesions (94%). There were two major cardiac events during the hospital stay: one death and one acute myocardial infarction which occurred respectively at four days and 48 hours after the procedure due to late occlusion of the vessel treated with primary success. In three cases the procedure was unsuccessful but uncomplicated: In one the stenosis could not be crossed, in a second case a residual stenosis > 50% was present, in a third case the procedure resulted in dissection and occlusion of a vessel served by good intercoronary collaterals. No emergency or elective coronary artery bypass surgery was necessary. Coronary spasm occurred in 6 cases (9%). In two of them spasm was refractory to intracoronary nitrates and Verapamil, and stent implantation was required. Urapidil, a selective alpha 1 blocker, completely abolished the occurrence of coronary vasospasm in the last 16 cases. A no reflow phenomenon was observed in two cases associated with mild CK-MB elevation. In conclusions: our experience suggests that rotational atherectomy performed on lesions with complex morphology, most of them calcified, is a safe and effective procedure which therefore can be undertaken even in hospitals without on site cardiac surgery. Our data on late restenosis are inconclusive because of the lack of angiographic follow up.

[Effects of simvastatin on plasma levels of lipids, lipoproteins and apolipoproteins in primary hypercholesterolemia]. / Effetti del simvastatin sui livelli plasmatici dei lipidi, delle lipoproteine e delle apolipoproteine nell'ipercolesterolemia primitiva.

To evaluate the effectiveness, tolerance and safety of simvastatin (MK 733), a new HMG-CoA reductase inhibitor, a 28-week, single blind study with placebo was carried out on 10 patients suffering from primary hypercholesterolaemia. All patients followed the AHA Phase 1 or Phase 2 diet and underwent active treatment for 24 weeks with increasing doses of simvastatin from 10 to 40 mg in a single evening administration. A reduction in plasma levels of total cholesterol (-29%, p less than 0.001 and -41%, p less than 0.001), LDL cholesterol (-35%, p less than 0.001 and -49%, p less than 0.001), VLDL cholesterol (-9%, ns and -38%, ns), Apo-B (-27%, p less than 0.005 and -37%, p less than 0.001), Apo-A2 (-3%, ns and -3%, ns), and triglycerides (+2%, ns and -10%, ns), was obtained in the VIth and XXIVth week. There was also an increase in HDL cholesterol (+4%, ns and +17%, p less than 0.05), HDL2 subfractions (+9%, p less than 0.05 and +36%, p less than 0.05), HDL3 (+3%, ns and +11%, ns) and Apo-A1 (+7%, ns and +4%, ns). In all patients, simvastatin was generally tolerated and there were no clinical, laboratory or ophthalmological side-effects related to the drug. If long-term studies confirm its safety, simvastatin will offer excellent prospects for the prevention of ischaemic cardiopathy.

[The lipid hypothesis in the etiopathogenesis of ischemic heart disease: confirmations and doubts resulting from primary prevention trials]. / L'ipotesi lipidica nell'eziopatogenesi della cardiopatia ischemica: conferme e dubbi dai trials di prevenzione primaria.

Sufficient evidence exists today pointing to the relationship between high levels of plasma cholesterol and coronary atherosclerosis. Up to now, however, the last criterion for validating the aetiopathogenetic relationship between dyslipidemia and CHD, i.e., the demonstration that reduction of plasma cholesterol reduced the formation or progression of the plaque and the incidence of its fatal or non-fatal cardiac and vascular complications, has been lacking. For more than two decades, numerous trials have had this aim in mind but until very recently results have not been substantiated owing to various deficiencies in the method. Before publication of the NHLBI Task Force of Atherosclerosis, eleven major randomised clinical studies based on hypolipidemia interventions were completed. The three studies involving dietetic interventions were considered non-conclusive overall because of the lack of a double-blind factor and of other important epidemiological criteria. Of three pharmacological trials only two involved studies of primary prevention carried out on a population of hypercholesterolaemics. These produced partial results on certain cardiac end-points but not on total deaths and at times not even on deaths from CHD. Multifactorial studies, finally, were even less demonstrative. Taken together, however, the trials based on hypolipidemia interventions point to interesting though not definitive evidence of a reduction in blood cholesterol levels to reduce the incidence and mortality from CHD. According to the NHLBI, many of these studies lacked important features that were codified and suggested for later studies.(ABSTRACT TRUNCATED AT 250 WORDS)