[Midterm results of coronary bypass surgery exclusively with arterial revascularization]. / Resultados a medio plazo de la cirugía coronaria con el uso exclusivo de injertos arteriales.

INTRODUCTION AND OBJECTIVES: In recent years, the exclusive use of arterial grafts in coronary surgery has been the surgical option to achieve maximum survival and minimum recurrence of coronary events. The aim of this study was to analyze the surgical results and follow up of this approach. PATIENTS AND METHODS: Over a period of six and a half years, 87 patients underwent coronary surgery using arterial grafts alone for revascularization. The mean age of the patients was 62 +/- 1 years with 78 men and 9 women; 22 patients (25%) were clinically unstable. The number of vessels affected per patient was 1.83 +/- 0.1, and the number of patients with one, two and three affected vessels, were 38 (44%), 26 (30%) and 23 (26%), respectively. The mean ejection fraction was 63 +/- 1.6. Emergency surgery was carried out in 13 cases (16%). RESULTS: A total of 1.9 +/- 0.1 grafts were implanted per patient and complete revascularization was achieved in 65 cases (75%). The left mammary artery was used in 87 cases (100%), the right mammary artery in 31 (35.6%) and the radial artery in 20 cases (23%). Hospital mortality was 1.1% (one case). During the postoperative period, 3 patients (3.4%) presented myocardial infarction, 12 (13.8%) atrial fibrillation and there were 3 cases of sternal dehiscence.A total of 86 patients (98.9%) were followed over a mean period of 24.5 +/- 0.5 months. Survival, angina-free period and period free of any coronary event at 5 years were 97 +/- 0.05%, 89 +/- 0.1% and 87 +/- 0.1% respectively (mean +/- standard error, CI 95%). On multivariate analysis, the presence of peripheral vascular disease (p < 0.015) and the development of low cardiac output (p < 0.04) or atrial fibrillation (p < 0.04) during the postoperative period were predictive factors for the appearance of coronary events during follow-up. CONCLUSIONS: Surgery exclusively with arterial grafts achieves good medium term results in relation to survival and time free of coronary events.

[Anomalous origin of the right coronary artery from the left sinus of Valsalva. Apropos of 2 cases]. / Origen anómalo de la arteria coronaria derecha del seno de Valsalva izquierdo. A propósito de dos casos.

Anomalous origin of right coronary artery from the left sinus of Valsalva is a uncommon congenital anomaly which is difficult to demonstrate angiographically. For many years pathologists classified it as a minor anomaly of no clinical significance. It has only recently been associated with significant manifestations of myocardial ischemia. These manifestations have included acute myocardial infarction, angina pectoris, syncope, ventricular tachycardia and fibrillation, and sudden death. Two patients with this anomaly are reported. One patient had angina pectoris in the absence of significant atheromatous coronary lesions. In the second patient the aberrant origin of the right coronary artery was associated to aortic valve disease. The possible physiopathology mechanisms responsible for manifestations of myocardial ischemia in patients with this anomaly are analyzed.

[Prognostic significance of silent ischemia in the exercise test in patients with coronary disease]. / Significado pronóstico de la isquemia silente durante la prueba de esfuerzo en pacientes con enfermedad coronaria.

To evaluate the prognostic significance of silent ischemia during exercise testing, 152 consecutive patients (143 males, 9 females) with a mean SD of 55 +/- 7 years (age range 32-73) who underwent exercise testing and coronary arteriography within 3 months were studied. All patients had the following characteristics: 1) a positive electrocardiographic exercise test response; 2) significant coronary artery disease on the arteriography; 3) uninterrupted clinical follow-up for a minimum of 6 months. The 152 patients were divided in 2 groups: group I: 56 patients (37%) with ischemic ST-segment depression during exercise testing without angina (silent ischemia); group II: 96 patients (63%) with ischemic ST-segment depression and angina (symptomatic ischemia). Patients in group I and group II showed similar time to ST-segment depression (3.6 +/- 1.5 min vs 3.2 +/- 1.4 min; p = NS), maximal ST-segment depression and peak heart rate-systolic pressure product (21,151 +/- 7,124 vs 20,456 +/- 6,024; p = NS). Exercise duration was longer in group I than in group II (5.6 +/- 2.1 min vs 4.8 +/- 1.5 min; p less than 0.001). The extent of coronary artery disease defined by the number of significant narrowed coronary vessels, left ventricular end diastolic pressure and ejection fraction were similar in the 2 groups. Sixty six patients who underwent coronary bypass surgery were not included in the analysis. The remaining 86 patients (40 in group I and 46 in group II) were medically treated. The mean follow-up period was 43,5 +/- 25 months (range 6-101).2+ myocardial ischemia during exercise testing.

[Initial results and 6 month clinical follow-up after implantation of a silicon carbide coated coronary stent]. / Resultados iniciales y seguimiento clínico a 6 meses tras el implante de un stent coronario recubierto de carburo de silicio.

INTRODUCTION AND OBJECTIVES: To present the initial Spanish experience with the Tenax coronary stent, a laser sculpted from high-precision 316L stainless steel coated with hydrogen rich amorphous silicon carbide that reduces thrombogenecity and improves biocompatibility. PATIENTS AND METHODS: From July 1998 to July 1999, 206 patients (62 +/- 5 years) underwent implantation of 231 Tenax stents in 9 centers as the only revascularization procedure. The most frequent clinical indication was unstable angina (66%), and most of the lesions were complex (class B2 and C). The target vessels were the left anterior descending (51%) and right coronary arteries (36%). The ejection fraction was < 0.5 in 19% cases. RESULTS: Revascularization was complete in 70%, elective in 80%, and the implantation was direct in 25% of the cases. The procedure was successful in all the lesions, reducing stenosis from 62 +/- 16 to 16 +/- 10% and increasing the minimal luminal diameter from 0.81 +/- 0.40 to 2.61 +/- 0.59 mm. The TIMI flow was reduced in 30%, but normalized after the stent in all but one case. The incidence of cardiac events was minimal: 1 acute thrombosis (0.5%) resolved by a new angioplasty and 1 non-Q myocardial infarction (0.5%). At the 6-month clinical follow-up 10% of the patients presented complaints of angina greater than class II, and a new angioplasty was carried out in 1.9% of these cases. CONCLUSION: Clinical and angiographic data suggest that the hydrogenated silicon carbide coating of the Tenax coronary stent may indeed play a beneficial role in patient outcome, and should therefore be evaluated by prospective clinical trials.

Prinzmetal's angina:reflex cardiovascular response during episode of pain.

Previous angiographic studies have shown that coronary spasm occurs in association with the variant angina described by Prinzmetal, confirming his original hypothesis. In this work we recorded the heart rate changes and the incidence of arrhythmias during variant angina. The patients were divided into two groups: anterior, with electrocardiographic signs of anterior ischaemia, and inferior, with changes in the inferior leads. There was a significant increase of heart rate during pain in anterior myocardial ischaemia and a significant decrease when the ischaemia was inferior. The incidence of ectopic arrhythmias during pain was significantly greater in patients with anterior ischaemia, but there was a high incidence of atrioventricular block in patients with inferior ischaemia. We suggest that these findings can be explained by different responses of the automatic nervous system to anterior and inferior acute myocardial ischaemia.

Coronary arterial stenosis and subclavian steal in Takayasu's arteritis.

This report describes a young boy with previous myocardial infarction and hypertension. Demonstration of coronary arterial ostial stenosis and a variant of subclavian steal was documented by selective arteriography. Surgical resolution of the most important stenosis is descending aorta, permitted effective control of hypertension. It is considered that one could reach this arteritis through different etiologies, tuberculosis having a preponderant place, and that it is important in all cases to carry out coronary arteriography.