Impact of coronary artery disease on in-hospital mortality in patients with aortic valve disease. Results from the German ALKK registry.

OBJECTIVE: Although aortic valve disease (AVD) is frequently associated with coronary artery disease (CAD), little is known about the impact of significant coronary artery disease on mortality after diagnostic cardiac catheterization in patients with AVD. METHODS: We analyzed data of the coronary angiography registry of the "Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte" (ALKK) in Germany. The primary endpoint was in-hospital mortality. RESULTS: A total of 1427 consecutive patients with AVD (438 patients with CAD versus 989 patients without CAD) underwent diagnostic catheterization in 2006 in 42 hospitals. All cause in-hospital mortality was more than threefold higher in patients with CAD (16/438; 3.7%) as compared to patients without CAD (12/989; 1.2%; p < 0.01; OR 3.09, 95% CI 1.45-6.58). Even after adjustment for age, sex, presence of diabetes mellitus and renal insufficiency, in-hospital all cause mortality remained statistically significant different between the two groups (OR 2.4; 95% CI 1.09-5.28; p < 0.01). Several factors, such as transient ischemic attack/stroke, volume of contrast agent, and left heart catheter-associated complications could not be identified as possible causes for the increase in mortality. CONCLUSION: This analysis in patients with the leading diagnosis of AVD shows a significantly higher in-hospital mortality after diagnostic cardiac catheterization in case of an accompanying CAD. However, further studies are necessary to identify the driving force for the increase in mortality.

[Hypoxemia 4 month after right-sided pneumonectomy]. / Hypoxämie 4 Monate nach rechtsseitiger Pneumektomie.

A 64-year-old male reported worsening dyspnea four months after right-sided pneumonectomy, due to lung cancer. Platypneu-or-thodeoxie syndrome was suspected due to a decrease in oxygen-saturation while the patient was in upright position. The shift of the right hemidiaphragm and liver caused compression of the right atrium and a shunt over a persistent foramen ovale. The right-to-left shunt was proven during right heart catheter. Interventional closure of the shunt resulted in immediate improvement of arterial oxygenation and a decrease in dyspnea.

Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

[Clinical value of dual source computerized tomography in primary diagnosis of coronary heart disease]. / Klinische Wertigkeit der Dual-Source-Computertomographie (DSCT) in der Primärdiagnostik der koronaren Herzkrankheit.

UNLABELLED: Dual-source-CT-technology (DSCT) improves temporal resolution of cardiac computed tomography to 83 ms per heart-phase. In this study, the clinical performance of this new method is evaluated. MATERIALS AND METHODS: In fifty patients (33 male, 17 female; age 50 +/- 13 years) with suspected coronary heart disease, CT angiography (slice thickness 0.75 mm, contrast-agent 60-80 ml iomeprol) was performed with a Somatom Definition scanner. Based on the coronary 15-segment-model of the AHA, scores for image quality and lumen reduction were established to enable the observer, to give recommendations for further therapy. RESULTS: Out of 750 possible AHA-segments, 655 were depicted (87.3%). 591 segments (90.2%) were assessed without any limitation of quality, 49 (7.5%) segments showed moderate, and 15 (2.3%) segments severe limitation in image quality. 508 (77.6%) segments were without pathological findings, 92 (14.0%) segments had minimal atherosclerotic lesions, 42 (6.4%) segments suffered from stenoses with lumen reduction less than 70%, and 13 (2.0%) showed significant stenoses of more than 70%. In 31 patients (62%), coronary heart disease was ruled out by CT angiography without any need for further non-invasive or invasive diagnostics. 8 patients (16%) underwent stress-testing for ischemia. In 11 (22%) patients coronary angiography was recommended, and DSCT findings were confirmed in 10 cases. Only one LCx stenosis was overestimated in DSCT. CONCLUSION: Contrast-enhanced DSCT is a powerful tool in diagnosis of coronary heart disease. 98% of coronary segments could be assessed in diagnostic quality, and at least 90% of haemodynamically significant coronary stenoses were detected.

Insulin-like growth factor-binding protein-3 is associated with the presence and extent of coronary arteriosclerosis

Aging is associated with the progression of arteriosclerosis and the decline of several endocrine functions. We therefore investigated the association of coronary arteriosclerosis with hormones, the serum concentrations of which change during aging. Coronary angiograms of 189 men <70 years old were evaluated by 3 semiquantitative score systems to estimate the extent of focal and diffuse vessel wall alterations. Fasting sera were analyzed for levels of glucose, lipids, thyroid-stimulating hormone, insulin, insulin-like growth factor I (IGF-I), IGF-binding protein-3 (IGFBP-3), dehydroepiandrosterone sulfate (DHEAS), testosterone, and sex hormone-binding globulin (SHBG). After adjustment for age, body mass index, and waist-to-hip ratio, 92 patients with >/=1 stenoses >70% differed from 97 patients without such focal lesions by higher serum levels of glucose, total and LDL cholesterol, and apolipoprotein (apo) B, as well as by lower serum levels of IGFBP-3. Multivariate analyses revealed significant and independent correlations of all 3 coronary scores with LDL cholesterol (or apoB) and IGFBP-3; of 2 coronary scores with age, glucose, and insulin; and of 1 score with IGF-I. No significant correlations existed for waist-to-hip ratio (or body mass index) and DHEAS (or testosterone or SHBG). IGFBP-3 explained 9% to 14% and 3.5% to 10% of the variances of focal and diffuse lesions, respectively. In conclusion, IGFBP-3 and, with much less strength and consistency, insulin and IGF-I, but not markers of hypothyroidism, adrenopause, and andropause, have statistically significant and independent associations with coronary arteriosclerosis in men.

Insulin-like growth factor-binding protein-3 is associated with the presence and extent of coronary arteriosclerosis

Aging is associated with the progression of arteriosclerosis and the decline of several endocrine functions. We therefore investigated the association of coronary arteriosclerosis with hormones, the serum concentrations of which change during aging. Coronary angiograms of 189 men <70 years old were evaluated by 3 semiquantitative score systems to estimate the extent of focal and diffuse vessel wall alterations. Fasting sera were analyzed for levels of glucose, lipids, thyroid-stimulating hormone, insulin, insulin-like growth factor I (IGF-I), IGF-binding protein-3 (IGFBP-3), dehydroepiandrosterone sulfate (DHEAS), testosterone, and sex hormone-binding globulin (SHBG). After adjustment for age, body mass index, and waist-to-hip ratio, 92 patients with >/=1 stenoses >70% differed from 97 patients without such focal lesions by higher serum levels of glucose, total and LDL cholesterol, and apolipoprotein (apo) B, as well as by lower serum levels of IGFBP-3. Multivariate analyses revealed significant and independent correlations of all 3 coronary scores with LDL cholesterol (or apoB) and IGFBP-3; of 2 coronary scores with age, glucose, and insulin; and of 1 score with IGF-I. No significant correlations existed for waist-to-hip ratio (or body mass index) and DHEAS (or testosterone or SHBG). IGFBP-3 explained 9% to 14% and 3.5% to 10% of the variances of focal and diffuse lesions, respectively. In conclusion, IGFBP-3 and, with much less strength and consistency, insulin and IGF-I, but not markers of hypothyroidism, adrenopause, and andropause, have statistically significant and independent associations with coronary arteriosclerosis in men.

Characterization of atherosclerosis in a patient with familial high-density lipoprotein deficiency.

We describe the cardiovascular state of a 60-year-old homozygous patient with familial HDL deficiency (Tangier disease). The patient was examined by coronary angiography and intravascular ultrasound because of chest pain at rest and on exertion. We found a normal left ventricular function, moderately diffuse coronary sclerosis without stenosis and no critical stenosis of peripheral arteries. Intravascular ultrasound revealed the three layer appearance of arterial intima, media and adventitia with normal thickness. No calcified plaques or intimal hyperplasia could be detected apart from a single, discrete atherosclerotic lesion in one iliac artery segment. Concentric non-occlusive atherosclerotic lesions which are readily detectable with intravascular ultrasound were not found. The lack of severe atherosclerosis was remarkable insofar as massive foam cell formation and the virtually complete absence of circulating HDL is characteristic of Tangier disease and has been previously demonstrated in this patient. Our findings suggest that HDL deficiency and foam cell formation in Tangier disease are not necessarily associated with accelerated development of atherosclerosis.

Detection of missense mutations in the genes for lipoprotein lipase and hepatic triglyceride lipase in patients with dyslipidemia undergoing coronary angiography.

Coronary events have a close association with a low HDL/hypertriglyceridemia (LHDL/HTG) phenotype. As enzymes that hydrolyze triglyceride-rich lipoproteins are associated with a modulation of both HDL cholesterol and triglycerides, we have tested the hypothesis that mutations in the genes encoding lipoprotein lipase (LPL) or hepatic lipase (HTGL) may contribute to the formation of coronary atherosclerosis and, thus, of coronary heart disease (CHD). The entire coding and boundary regions of LPL and HTGL genes were analyzed by direct sequencing in 20 patients with both LHDL/HTG and diagnosed CHD. In the LPL gene six different polymorphisms were identified with same frequencies observed in the general population. In the HTGL gene, besides several polymorphisms, we identified three missense mutations: Asn37His, Val73Met, and Ser267Phe. Population screening using allele specific PCR identified Val73Met as a polymorphism while the two others were absent from 100 control individuals. One of the mutations (Ser267Phe) is known to cause HTGL deficiency and is associated with type III hyperlipoproteinemia. Since this dyslipoproteinemia meets the criteria of LHDL/HTG, it is intriguing to speculate that missense mutations in HTGL may play a role in the pathogenesis of this atherogenic phenotype.

Different effects of hypertension, atherosclerosis and hyperlipidaemia on arterial distensibility.

OBJECTIVE: To investigate the different effects of hypertension, hyperlipidaemia and atherosclerosis on the visco-elastic properties of large arteries. DESIGN: Vessel wall properties were determined in patients who had been subjected for the first time to coronary arteriography. Normotensive patients with no coronary disease (n = 15), one-vessel disease (n = 15) or two- or three-vessel disease (n = 15), 15 treated hypertensive patients (mean +/- SEM duration of hypertension 9.6 +/- 1.7 years) with no coronary disease and normocholesterolaemia and 15 healthy controls were matched for blood pressure, age and sex. METHODS: Arterial distension of the common carotid artery was determined by using a multigate Doppler system. The blood pressure curve was recorded by finger plethysmography. RESULTS: The end-diastolic diameter was significantly higher in the hypertensives (P<0.05) but not significantly different in the normotensives compared with the controls. Arterial distensibility was significantly lower in the hypertensive group [(13.3 +/- 0.8) x 10(-3)/kPa] than in the controls [(19.1 +/- 1.5) x 10(-3)/kP; P<0.01), in the group with no coronary disease [(18.8 +/- 1.3) x 10(-3)/kPa; P<0.01] and in those with one-vessel disease [(17.7 +/- 1.4) x 10(-3)/kPa; P<0.05]. Arterial distensibility was not significantly lower in the hypertensives than in the group with two- or three-vessel disease [(15.0 +/- 1.0) x 10(-3)/kPa; NS). No significant correlation was found between cholesterol or lipoprotein(a) levels and arterial distensibility in the normotensive patients. CONCLUSIONS: Hypertension is the predominant factor affecting the visco-elastic properties of large arteries. Arterial compliance is significantly altered only in extensive atherosclerosis.

The relation of interleukin-6, tumor necrosis factor-alpha, IL-2, and IL-2 receptor levels to cellular rejection, allograft dysfunction, and clinical events early after cardiac transplantation.

Immunoregulatory cytokines have been implicated in the pathophysiology of graft dysfunction after heart transplantation (HTx). In 15 consecutive patients undergoing HTx we prospectively determined levels of interleukin-6 (IL-6), tumor-necrosis-factor-alpha (TNF-alpha), interleukin-2 (IL-2), and soluble-interleukin-2-receptor (sIL-2-R) at eight points in time during biopsy and right heart catheterization and within 12 hr of echocardiography during the first three months after HTx. Blood was taken from the pulmonary arterial line. IL-6-levels correlated positively with hemodynamic and echocardiographic parameters of pump dysfunction--namely, pulmonary capillary wedge pressure, pulmonary arterial pressure, right atrial pressure, heart rate--and negatively with isovolumic relaxation time and stroke volume independent of the degree of cellular rejection as classified by the ISHLT criteria. A similar pattern was found for TNF-alpha- and sIL-2-R, while IL-2 correlated negatively with left and right heart filling pressures and positively with fractional shortening. In the three patients who died of sepsis or multiorgan failure within the study period IL-6-, TNF-alpha, and sIL-2-R-levels were elevated and IL-2-levels were suppressed compared with the 12 patients with a stable clinical course. IL-6 and sIL-2-R correlated positively while IL-6 and IL-2 correlated negatively. In this pilot study, a cytokine pattern with elevated levels of IL-6, TNF-alpha, and sIL-2-R as well as suppressed levels of IL-2 in the early period after HTx corresponds to impaired hemodynamics independent of cellular rejection and may indicate an unfavorable prognosis. These cytokines may therefore be useful for monitoring and warrant further study.

T-cell and monocyte subsets, inflammatory molecules, rejection, and hemodynamics early after cardiac transplantation.

BACKGROUND: In the early period after cardiac transplantation, differential diagnosis of graft failure due to rejection, infection, and other causes is important but difficult. METHODS: In 22 consecutive patients undergoing heart transplantation, we prospectively determined levels of interleukin-6 as well as T-cell and monocyte subsets at eight points in time during biopsy and right heart catheterization and within 12 hr of echocardiography during the first 3 months after transplantation. RESULTS: Worse hemodynamic parameters, as characterized by dichotomization according to median values (pulmonary capillary wedge pressure >10 mmHg, mean pulmonary arterial pressure > 18 mmHg, pulmonary vascular resistance > 115 dyn x sec x cm(-5), right atrial pressure > 5 mmHg, cardiac index <3 L/min/m2, early mitral deceleration time < 135 msec, and isovolumic relaxation time <80 msec), were associated with higher levels of interleukin-6, C-reactive protein, polymorphonuclear cells, CD71+/CD14+ monocytes, and IgM levels and, in contrast, with lower levels of immunocompetence markers such as CD3+ T cells, CD4+ T cells, CD8+ T cells, CD3+/CD25+ T cells, CD4+/ CD45RO+ T cells, NK cells, and lower biopsy scores. CONCLUSION: Early after cardiac transplantation, elevated levels of inflammatory cells and soluble inflammatory molecules and lower levels of immunocompetence markers are associated with impaired allograft function in the absence of cellular rejection.

Possible relationship between heat shock protein 70, cardiac hemodynamics, and survival in the early period after heart transplantation.

BACKGROUND: Heat shock proteins (HSPs) are produced by cells in response to a wide variety of stresses. To determine a possible relationship between hemodynamic parameters and HSP 70 in the early postoperative period after heart transplantation, we examined immunohistochemically the inducible HSP 70 (anti-HSP 72) response in human heart biopsies, as well as the effect of myocardial rejection on HSP. METHODS: A total of 105 routinely processed endomyocardial biopsies from 15 consecutive patients who underwent heart transplantation were examined. Analysis of hemodynamic and echocardiographic parameters were performed within 30 min and 12 hr after the biopsies. RESULTS: Immunohistochemically detected inducible HSP 70 was mainly located in the cytoplasm and nucleus/nucleolus of cardiomyocytes. Two specimens additionally showed HSP 70-positive interstitial cells and smooth muscle cells of arteries, whereas lymphocytes were consistently negative. There was a significant relation between the echocardiographically determined increased relaxation time and positive HSP 70 staining (P < 0.011). Patients with elevated right atrial pressure (P < 0.098), as well as those with increased left ventricular end systolic diameter (P < 0.06), showed a trend to higher HSP expression. Three patients who died of sepsis or multiorgan failure showed significantly higher cytoplasmic HSP 70 expression compared with 12 patients with stable clinical course. In case of rejection, significantly more patients showed no HSP expression. CONCLUSION: Although only five patients showed organ rejection, our results suggest an inverse relationship between HSP expression and rejection with the possibility of a role for HSP 70 as a graft marker to assess graft function.

Progressive heterogeneity of myocardial perfusion in heart transplant recipients detected by thallium-201 myocardial SPECT.

UNLABELLED: Progressive graft atherosclerosis is a serious complication in long-term survivors after heart transplantation. Coronary angiography is insensitive with regard to the early and characteristic alterations. We evaluated the progression of these abnormalities and the influence of former rejection episodes. METHODS: Early after transplantation, 43 patients (34 men, mean age 53.7 +/- 10.7 yr) underwent stress and redistribution 201Tl myocardial SPECT after treadmill exercise. Twenty patients were followed-up to the second postoperative year, and 13 patients to the third postoperative year. Thallium-201 distribution and kinetic abnormalities were documented in a scheme enclosing 20 myocardial segments. Additionally, a score was developed that measured the degree of inhomogeneity of 201Tl distribution and the severity of perfusion defects, respectively. RESULTS: Regarding scintigraphy, pathologic results could be found in 40% of segments (redistribution, 25%; reverse redistribution, 30%; persistent defects, 49%). Score values in heart transplant recipients differed significantly from normal controls (p < 0.001) and were comparable to patients with single vessel disease of their native hearts. Thallium-201 inhomogeneity in recipients after treatable rejection episodes did not differ from results in recipients without any biopsy-proven rejection. The follow-up of cardiac transplant patients revealed a significant increase of score values up to the third year after transplantation (p < 0.02), despite reproducible normal angiography. There was no direct correlation between score values and IVUS results, although there was a parallel trend in 10 of 12 follow-ups. CONCLUSION: Despite normal coronary angiography, 201Tl myocardial SPECT frequently revealed pathologic results in heart transplant recipients. Scintigraphic results did not correlate with intimal thickening of epicardial coronary arteries accessible to intravascular ultrasonography in the early phase after transplantation. The presented score of inhomogeneity might reveal progressive disease possibly caused by small vessel alterations.

Isochromosome Xq in Klinefelter syndrome: report of 7 new cases.

In this collaborative study we report on 2 prenatally and 5 postnatally diagnosed cases with a 47,X,i(Xq),Y chromosomal constitution. Excepting tall stature, the 5 adult patients showed all typical manifestations of Klinefelter syndrome. Taken together with previously reported cases, these data suggest that Klinefelter syndrome with isochromosome Xq has a favorable prognosis with normal mental development, and with normal-to-short stature. The prevalence of this Klinefelter variant is calculated to be between 0.3-0.9% in males with X chromosome polysomies.

In vitro correlation of intravascular ultrasound and direct magnification radiography for calcified arterial lesions.

RATIONALE AND OBJECTIVES: Intravascular ultrasound (IVUS) is an adjunct to contrast angiography that gives additional information concerning the morphology of the vascular wall. The authors examined the accuracy of intravascular ultrasound (IVUS) in the evaluation of calcified lesions within the abdominal aorta and the iliac artery. METHODS: Forty-nine human specimens (iliac artery, 26; abdominal aorta, 23) were examined using a 20-MHz 6.0-F ultrasound catheter, followed by magnification radiography of the same specimens using a newly developed microfocus x-ray tube. Magnification radiographs and ultrasound images were divided into identical sectors to analyze the morphology of calcified arteriosclerotic lesions. RESULTS: A total of 644 sectors was analyzed. Sensitivity of intravascular sonography was 70%, specificity 53%. Sensitivity strongly depended on the morphology of the calcified lesions. CONCLUSION: The detection of calcified arteriosclerotic lesions by means of IVUS revealed a sensitivity of 70% in an in vitro study using human specimens. However, the specificity of IVUS was only 53%, which is basically a random chance occurrence.

Long-term left ventricular assist device support: a novel pump rate challenge exercise protocol to monitor native left ventricular function.

A novel, hemodynamically guided exercise protocol with two different left ventricular assist device settings in two long-term recipients is presented. This protocol allows for quantitation of the contribution of the native left ventricle to total cardiac output. It facilitates estimation of the risk associated with device dysfunction, as well as prediction of left ventricular recovery and the potential for weaning.

Selection and management of ventricular assist device patients: the Muenster experience.

BACKGROUND: Because of the growing discrepancy between the availability of donor organs and the number of patients with end-stage heart disease who need heart transplantation, a larger proportion of patients waiting for a suitable donor heart require pre-operative mechanical circulatory assistance. The criteria for the selection and management of these patients as applied at Muenster University Hospital are reviewed. METHODS: The study population consists of 631 patients referred to our center for transplantation between January 1, 1990, and December 31, 1996. Two hundred ninety-seven patients were listed for transplantation and 157 were transplanted. Of 41 patients who underwent implantation of a ventricular assist device (n = 34, Novacor; n = 6, TCI HeartMate; n = 1, Medos), 39 received the device as a bridge to transplantation and 2 as permanent support. For the purpose of the analysis, the study population was divided into 3 groups (elective bridging, urgent bridging, emergency bridging) and compared with heart transplant candidates who did not require mechanical circulatory assistance. RESULTS: Patients who underwent elective or urgent assist-device implantation were younger and had greater hemodynamic compromise than the remainder of patients waiting for heart transplantation, as suggested by a higher functional class and lower mean arterial pressure, cardiac index, serum sodium, and pulmonary artery wedge pressure. Survival of patients who electively underwent implantation of an assist device was better than that of patients who were stable on the waiting list and did not undergo heart transplantation during follow-up. CONCLUSIONS: This finding suggests that earlier implantation of assist devices may facilitate resolution of organ dysfunction before heart transplantation.

Selection and outcome of ventricular assist device patients: the Muenster experience.

BACKGROUND: Because the number of patients on the waiting list for transplantation is increasing and the stagnation in the number of organs donated has led to a more restrictive listing for transplantation, an increased fraction of patients needs to be bridged mechanically. We examined the hypothesis that selection of these patients with regard to urgency status is critical in determining outcome. METHODS: A cohort of 631 patients referred for transplantation to our center between January 1, 1990, and December 31, 1996, was analyzed. Two hundred ninety-seven patients were listed for transplantation and 157 were given transplantation. Forty-one patients had to undergo ventricular assist device implantation (n=34, Novacor; n=6, TCI Heartmate; n=1, Medos), 39 for bridging to transplantation and 2 for permanent support. Initial transplantation evaluation data were analyzed in 3 subgroups (elective bridging, urgent bridging, emergency bridging) and compared with another and with other patients referred for transplantation, specifically those who did not have to be bridged on the waiting list. RESULTS: Patients who underwent elective or urgent assist device bridging were younger and more compromised than the rest of patients accepted on the waiting list (higher functional class, lower mean arterial pressure, lower cardiac index, lower serum sodium, higher pulmonary capillary wedge pressure). In the elective group, overall survival including perioperative mortality rate was better than in the urgent/emergency group and at least as good as in patients who were stable on the waiting list and did not undergo heart transplantation during follow-up. This should prompt cardiologists and cardiac surgeons to consider assist device implantation earlier.

Coronary artery bypass grafting with an expanded polytetrafluoroethylene graft.

BACKGROUND: We report our experience with the Perma-Flow aortocoronary-right heart graft in 15 patients in whom autologous conduits were not available. METHODS: Fifteen patients received 39 coronary anastomoses--10 to left anterior descending coronary artery branches, 15 to circumflex coronary artery branches, and 14 to branches of the right coronary artery. Early angiography was done in 11 patients. RESULTS: One patient died on postoperative day 17 of multiorgan failure. The graft was patent at postmortem examination. Of 30 coronary anastomoses at risk, 24 were patent. Three connections to the left anterior descending system were occluded in patients with an additional internal mammary artery graft to the same coronary system, and three connections to the circumflex system were occluded in patients with a history of major posterior infarction. Three of five distal anastomoses to the right atrial appendage were occluded, whereas all six connections to the superior vena cava were patent. None of the patients had shown recurrent angina at a mean follow-up of 10.9 months (range, 2-39 months). CONCLUSIONS: The synthetic Perma-Flow coronary graft appears to be a safe alternative in patients in whom arterial or venous conduits are not available. Competitive flow may lead to anastomotic occlusions. The appropriate site for the distal arteriovenous fistula seems to be the superior vena cava.

Emergency coronary artery bypass grafting after failed coronary angioplasty: what has changed in a decade?

BACKGROUND: We assessed the impact of patient and procedural characteristics on the outcome after emergency coronary artery bypass grafting (CABG) for failed percutaneous transluminal coronary angioplasty (PTCA) and temporal changes in these factors. METHODS: Patients who underwent PTCA and subsequent emergency CABG were identified from the databases of the Departments of Cardiology and Cardiothoracic Surgery. RESULTS: Two periods of clinical practice were compared. In 1989 to 1993, 2,880 PTCAs were performed, 64 patients underwent emergency CABG (2.3%), and 7 patients died (10.9%). During 1994 to 1998, 46 patients of 3,801 PTCAs underwent emergency CABG (1.2%, p < 0.01), and 7 patients died (15.2%, NS). The average rate of stenting increased from 0.8% to 24% in 1994 to 1998 as well as the frequency of arterial bypass grafts (0% vs 39%). In the latter period, patients were older, were more often females, had more cardiovascular risk factors, a higher Cleveland score (each p < 0.05), and suffered more often from periprocedural myocardial infarctions (p < 0.001) and nonfatal periprocedural complications (p < 0.01). CONCLUSIONS: Although the frequency of emergency CABG after failed PTCA declined, perioperative mortality tended to increase according to an unfavorable shift in patient risk factors and morbidity.