Type Ia tricuspid atresia with extensive coronary artery abnormalities in a living 22 year old woman.

Type Ia tricuspid atresia, with extensive coronary artery abnormalities, is identified in the oldest living patient with this condition, a 22 year old woman. Clinical characteristics include severe cyanosis, effort dyspnea, myocardial infarction in the past and persistent angina pectoris. "Ideal" pulmonary flow and adequate left ventricular function, despite an akinetic apical segment, are substantive factors for this exceptional longevity. Coronary abnormalities consist of: 1) total proximal occlusion of the left anterior descending coronary artery; and 2) partial diversion of coronary artery flow to a segmental pulmonary artery branch. Nonvisualization of the coronary sinus is also noted. Factors other than atherosclerosis may account for total proximal occlusion of the left anterior descending coronary artery. Survival is threatened by adverse effects of ongoing ischemic coronary events.

Effectiveness of decremental diameter balloon catheters (tapered balloon).

Natural tapering of coronary arteries from larger proximal to smaller distal diameters often creates a dilemma for optimal balloon sizing during percutaneous transluminal coronary angioplasty (PTCA). To demonstrate the need for new dilating catheters suitable for tapered coronary anatomy, 100 consecutive coronary arteries were measured by videodensitometry, 1 cm proximal and distal to the stenosis. In 23 arteries there was a 1 mm or greater taper and 19 arteries showed a 0.5 to 0.99 mm taper. Only 50 arteries showed a nearly uniform diameter at the site of the stenosis, and 8 arteries demonstrated reverse taper, i.e., distal was greater than proximal diameter. To avoid balloon size mismatch with significant tapering, decremental diameter balloon catheters were developed. Series I tapers from 3.5 to 3.0 mm and series II from 3.0 to 2.5 mm over a balloon length of 25 mm. Tapered balloons were used in 80 patients with 94 tapered coronary arteries. Before PTCA, proximal, stenotic and distal mean diameters measured 3.6, 1.1 and 2.6 mm, respectively; after PTCA, proximal, stenotic and distal diameters measured 3.6, 2.8 and 2.5 mm, respectively, thus maintaining the natural tapering after effective dilatation. Only 2 arteries (2.1%) showed significant dissection, with no abrupt occlusions, and none requiring bypass surgery. In summary, decremental diameter balloon catheters provide optimal dilation in tapered arterial segments with few complications and offer a new approach to balloon sizing.

Prevention of restenosis by lovastatin after successful coronary angioplasty.

Prevention of restenosis after successful percutaneous transluminal coronary angioplasty (PTCA) remains a major challenge. To determine whether lovastatin could prevent restenosis, between December 1987 and July 1988, a total of 157 patients undergoing successful PTCA were randomly and prospectively assigned to the lovastatin group or a control group. Seventy-nine patients received lovastatin (20 mg daily if the serum cholesterol level was less than 300 mg/dl and 40 mg daily if the serum cholesterol level was greater than or equal to 300 mg/dl) in addition to conventional therapy (lovastatin group). Seventy-eight patients received conventional therapy alone (control group). Fifty patients in the lovastatin group and 29 in the control group were evaluated with coronary angiography at an interval of 2 to 10 months (mean 4 months). The restenosis rate was evaluated according to the number of patients showing restenosis, the number of vessels restenosed, and the number of PTCA sites restenosed. Restenosis was defined as the presence of greater than 50% stenosis of the PTCA site. In the lovastatin group 6 of 50 patients (12%) had restenosis compared with 13 of 29 patients (44.4%) in the control group (p less than 0.001). When the number of vessels restenosed was considered, only 9 of 72 vessels (12.5%) restenosed in the lovastatin group compared with 13 of 34 vessels (38.2%) in the control group (p less than 0.002). Similarly, 10 of 80 (12.5%) PTCA sites restenosed in the lovastatin group compared with 15 of 36 (41.7%) in the control group (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Progressive coronary dilation: an angioplasty technique that creates controlled arterial injury and reduces complications.

The incidence of dissection or acute closure during coronary angioplasty has remained unchanged in spite of increased operator experience and technologic advances. To test the hypothesis that progressive coronary dilation, that is, predilation of the stenosis with a smaller balloon (2.0 or 2.5 mm) and then maximal dilation with an optimally sized (3.0, 3.25, 3.5, 3.75, or 4.0 mm) balloon may produce controlled injury and thus reduce the incidence of major complications, the procedural success rate and acute complications of progressive coronary dilation were analyzed in 1087 patients (1486 vessels) and compared with other large series. To determine whether progressive coronary dilation would improve success rates for complex lesions, the last 167 vessels were also prospectively characterized by American College of Cardiology/American Heart Association criteria. Of the 1248 vessels with partial occlusions, the success rate was 98.7%. Attempts to dilate total occlusions in 16% (353) of vessels yielded a success rate of 88%. The primary success rates for types A, B, and C lesions were 100%, 97%, and 91%, respectively. Multivessel angioplasty with progressive coronary dilation was done in 32.4% of cases. Acute closure, major dissection, emergency coronary bypass, periprocedural myocardial infarction, and in-hospital death were noted in 1.4%, 1.3%, 0.7%, 0.8%, and 0.09% of the patients, respectively; the incidence was significantly lower than in previously reported series. Mean residual stenosis was 20.0% +/- 10.6%. Thus progressive coronary dilation by controlled injury to the plaque offers a high primary success rate; low residual stenosis; and markedly lower incidence of acute closure, major dissection, emergency coronary bypass, and death in dilation of both simple and complex lesions.

Severe calcific pulmonic valve stenosis and restrictive ventricular septal defect in a 64-year-old man. Results of percutaneous double balloon valvuloplasty.

The clinical and hemodynamic features of a 64-year-old symptomatic man with severe calcific pulmonic valve stenosis and restrictive ventricular septal defect are reported. Successful double balloon percutaneous pulmonic valvuloplasty immediately produced excellent symptomatic benefit and introduced expected and well tolerated hemodynamic changes. The transpulmonic valve peak systolic pressure gradient was reduced from 130 to 30 mmHg and pulmonary artery pressure increased to top normal levels acquiring normal pulse wave configuration. A left-to-right shunt, negligible prior to valvuloplasty, increased appreciably producing a pulmonary to systemic flow ratio of 1.7. Reevaluation at 5 months revealed sustained hemodynamic profile. Symptomatic benefit and tolerance to ordinary physical activities have remained excellent at 1 year follow-up.