Sirolimus, Tacrolimus and Zotarolimus eluting stents to treat bifurcated lesions: a 7-month clinical outcome comparison.

AIM: Drug eluting stents (DES) have been shown to reduce restenosis compared with bare metal stents in bifurcated lesions. The aim of this study was to evaluate the long-term clinical outcomes of patients with bifurcated lesions treated by 3 different DES. METHODS: Consecutive patients with symptomatic coronary artery disease on one bifurcated lesion with SB>2.25 mm (on visual estimation) undergoing at the Department of Cardiology of the Catholic University of Rome, Italy were screened. Patients treated with Sirolimus-eluting stent (Cypher Select; SES Group), Tacrolimus-eluting stent (Taxus-Libertè; TA Group) and Zotarolimus-eluting stent (Endeavor Driver; ZOT Group) were enrolled in the study. Clinical and angiographic characteristics of all patients were prospectively recorded. Major adverse clinical events (MACE), including death, acute myocardial infarction (MI) or target lesion revascularization (TVR) by either percutaneous coronary intervention (PCI) or coronary surgery were recorded during the follow-up. Incidence of definite or probable stent thrombosis was calculated according to the ARC criteria. RESULTS: Two hundred and forty-one consecutive patients were enrolled (89 Group CY, 98 Group TA and 54 Group EN). Length of follow-up was 235+/-60 days. Baseline clinical and angiographic characteristic were similar across the groups. The adopted technique for stent implantation was provisional stenting (73.4%), T-stenting technique (7%), crush (7%) and V-stenting (2.6%). The rate of patients finally treated with two stents was similar among groups. The cumulative rate of MACE (9% SES, 12% TA, 11% ZOT: P=0.7) and of TVR (2% SES, 9% TA, 7% ZOT) was similar among groups. No definite stent thrombosis was observed during follow-up, while 1 probable stent thrombosis was observed in TA group. CONCLUSION: The clinical outcome of bifurcated lesions using DES and mainly a technique of single stent implantation is good. In the present observational study, clinical adverse events did not differ in patients with bifurcated lesions treated by Cypher, Taxus or Endeavor stent implantation.

Low incidence of serotonin-induced occlusive coronary artery spasm in patients with recent myocardial infarction.

Intracoronary infusion of serotonin has been reported to induce varying degrees of coronary vasoconstriction in different coronary syndromes, but it has never been studied in patients after myocardial infarction. In patients with recent myocardial infarction, we found a low incidence (11%) of serotonin-induced occlusive spasm only in the infarct-related artery (IRA), and a significantly higher vasoconstriction in the distal segment of the IRA than in the same segment of the non-IRA.

Ventricular arrhythmia induced by programmed ventricular stimulation after acute myocardial infarction.

The prevalence, characteristics and clinical significance of ventricular electrical instability with programmed ventricular stimulation was studied in 50 hemodynamically stable patients 17 to 40 days after acute myocardial infarction (AMI) using double extrastimuli at 2- and 10-mA intensity and from 2 right ventricular sites. Ventricular electrical instability was defined as induction of 10 or more consecutive intraventricular reentrant beats. Of 50 patients, 23 (46%) had ventricular electrical instability (10 of these had sustained ventricular tachycardia [VT] induced). No significant differences were observed between patients with and without ventricular electrical instability with respect to age, site of AMI, coronary prognostic index, maximal level of CK, number of narrowed coronary arteries and presence of severe wall motion abnormalities. During a mean follow-up of 11.2 months no patient died suddenly. During repeated Holter recordings patients with ventricular electrical instability had a higher incidence of nonsustained VT than did patients without ventricular electrical instability.

Tricuspid regurgitation due to sinus of Valsalva-right heart fistula diagnosed by two-dimensional echocardiography.

The case of a 31-year-old woman with severe right heart failure in the course of bacterial endocarditis and systolic and diastolic murmur at the third left intercostal space is described. Two-dimensional echocardiography showed a vegetation moving from the noncoronary aortic sinus of Valsalva to the right atrium, encroaching upon the septal leaflet of the tricuspid valve. An acquired fistula was confirmed by aortography and surgery. This is an unusual case of tricuspid regurgitation due to acquired aortic sinus of Valsalva-right heart fistula diagnosed by two-dimensional echocardiography.

Midterm endothelial function and remodeling of radial artery grafts anastomosed to the aorta.

BACKGROUND: The purpose of this study was to elucidate the midterm endothelium-dependent vasodilatory capacity of radial artery grafts anastomosed to the aorta, as well as their morphometric evolution with the time. METHODS: Five years after surgery we evaluated the response of aorta-anastomosed radial artery grafts to the endovascular infusion of acetylcholine in 11 of the first 61 patients operated on at our institution, and we compared it to the response with that of internal thoracic artery grafts. Moreover, the first 20 patients who had a perfect radial artery graft on angiography at 1 year were restudied at 5 years and subjected to a comparative analysis of the diameters of the radial artery graft and the grafted coronary arteries. RESULTS: At midterm angiography, dilation of the 2 types of grafts was similar in response to acetylcholine administration (radial artery, from 2.61 +/- 0.39 to 2. 90 +/- 0.34 mm; internal thoracic artery, from 2.68 +/- 0.21 to 2.93 +/- 0.27 mm; P =.01 for both). The diameters of aorta-anastomosed radial artery grafts and grafted coronary arteries increased between both 1 and 5 years according to angiographic studies (radial artery grafts, from 2.08 +/- 0.45 to 2.54 +/- 0.53 mm; grafted coronary arteries, from 1.92 +/- 0.47 to 2.18 +/- 0.41 mm; P <.001 for both), but the increase was greater for the radial artery grafts (P <.001). CONCLUSIONS: Aorta-anastomosed radial artery grafts maintain an appreciable capacity for endothelium-dependent vasodilatation 5 years after implantation and undergo a progressive increase in luminal diameter with time. These observations contradict the presumed tendency for progressive fibrous intimal hyperplasia to develop in radial artery grafts.

Reversible left anterior descending artery spasm, prolonged cardiac arrest and left main thrombosis during a PTCA attempt of the circumflex artery.

The authors report a case of percutaneous transluminal coronary angioplasty of the circumflex artery complicated by occlusion of the non-diseased left anterior descending artery by spasm. During advanced cardiac life support, required for the subsequent cardiac arrest, intra-coronary nitrates and calcium antagonists were administered. After 45 minutes, the spasm resolved, but N probably as a result of prolonged blood stasis N a thrombus appeared in the left main artery. While attempting to stent the left main, the thrombus was mechanically dislodged, leaving the epicardial coronary tree free, with a good flow.

EuroSCORE as predictor of in-hospital mortality after percutaneous coronary intervention.

OBJECTIVE: To date, no common risk stratification system is available to predict the risk of surgical or percutaneous myocardial revascularisation in patients with coronary artery disease (CAD). Thus, we sought to assess the European System for Cardiac Operative Risk Evaluation (EuroSCORE) validity to predict in-hospital mortality after percutaneous coronary intervention (PCI). DESIGN, SETTING AND PARTICIPANTS: EuroSCORE was prospectively and systematically assessed in 1173 consecutive patients undergoing PCI in a high-volume single centre between April 2005 and October 2006. MAIN OUTCOME MEASURE: The receiver-operating characteristics (ROC) curve was used to describe performance and accuracy of the EuroSCORE risk model for the prediction of in-hospital mortality after PCI. RESULTS: The EuroSCORE model demonstrated an overall relation between EuroSCORE rank and the incidence of in-hospital mortality, showing consistency in predicting patient risk across many subgroups and levels of global risk. At multivariable logistic regression analysis the EuroSCORE value was an independent in-hospital mortality predictor (p = 0.002) together with left main disease (p = 0.005), procedural urgency (p = 0.001), ACC/AHA C type lesion (p = 0.02) and PCI failure (p = 0.01). The area under the ROC curve for the EuroSCORE system was 0.91 (95% CI 0.86 to 0.97), indicating a good ability of the model to discriminate patients at risk of dying during the index hospitalisation. CONCLUSION: The EuroSCORE risk model, already extensively validated for the prediction of early mortality following open-heart surgery, can also be efficiently utilised in the setting of PCI. The introduction of the EuroSCORE assessment in patients with documented CAD may help to improve the revascularisation strategy decision-making process.

[Effect of potassium chloride on myocardial stimulation threshold and correlated electrophysiologic parameters (author's transl)]. / Effetti del cloruro di potassio sulla soglia di stimolazione miocardica e sui parametri elettrofisiologici correlati. Studio diretto nell'uomo.

The influence of KCl on different electrophysiologic parameters and myocardial stimulation threshold (MST) are considered in 9 patients with cardiac pacemaker. Reduction of MST during the diastolic period and the supernormal phase of excitability (SNP), depression of automaticity and slight bradycardia have been observed. The Authors, on the basis of kaliemia values and electrophysiologic parameters, emphasize the improvement of myocardial responsiveness when kaliemia does not exceed 6.5 mEq/l. The electrophysiologic effects of KCl are compared with those obtained in vitro on the transmembrane potential. Therapeutic effects for the treatment of arrhythmias and exit block in patients with cardiac pacemakers are considered.

Anomalous coronary arteries: a report of 2 cases of single coronary artery.

One patient with chronic exertional angina, not significant electrocardiographic signs of myocardial ischemia at exercise stress test and recent onset of angina at rest underwent coronary arteriography. A second one with known severe aortic stenosis underwent cardiac catheterization and coronary arteriography because of effort chest pain and syncope. A single coronary artery originating respectively from the right and from the left sinus of Valsalva but without significant coronary stenosis was detected in both patients. This entity is a quite uncommon finding of relevant interest if surgical treatment is required and good prognosis if not associated with additional cardiac anomalies.

Indoramin as second step therapy in the management of benign essential hypertension.

An open study was carried out to assess the efficacy of indoramin used as second step therapy in 30 patients with moderate to severe hypertension who had failed to respond adequately to monotherapy with a thiazide or beta-blocker. After a 1-week washout period, patients started treatment with 25 mg indoramin twice daily plus hydrochlorothiazide (25 mg twice daily) or propranolol (40 mg once daily). Indoramin dosage was subsequently adjusted in 25 mg steps (to maximum 150 mg daily), if necessary, at follow-up control visits every 14 days. Analysis of the results from the 22 patients who completed the 75-day study period showed that there were progressive, statistically significant reductions in systolic and diastolic blood pressure (supine and erect) to clinically acceptable levels. Heart rate also decreased significantly and this was more evident in the 7 patients treated with the combination of indoramin, thiazide plus beta-blocker. No patient had orthostatic hypotension and few side-effects were reported, although 7 patients withdrew for this reason.

[The hemodynamic effects of nifedipine in congestive cardiomyopathy (author's transl)]. / Effetti emodinamici della nifedipina nella cardiomiopatia congestizia.

The Authors present the haemodynamic effects of nifedipina (Adalat-Bayer) in nine patients with congestive cardiomyopathy. Heart rate (HR), systemic vascular resistances (SVR) and mean aortic blood pressure (MABP) were significantly modified in all nine patients following the administration of the drug. Six of them showed an increase of cardiac index (CI) and a decrease of myocardial oxygen consumption (MVO2); three of them presented a decrease of CI and an increase of MVO2. This discrepancy can be due to the different percentage of increase and to the maximal of valves of HR in the two groups. Nifedipina can be useful in the treatment of congestive cardiomyopathy with elevated STR (afterload) and peripheral hypoperfusion (more than pulmonary congestion).

Ticlopidine and aspirin fail to suppress the increased platelet aggregability that follows percutaneous coronary interventions.

Previous studies indicate that percutaneous transluminal coronary angioplasty (PTCA) is associated with platelet activation. It is not well-established whether enhanced platelet aggregability after PTCA is prevented by the association of ticlopidine with aspirin. The aim of this study was to evaluate whole blood platelet aggregability before and after elective PTCA in patients with chronic stable angina receiving ticlopidine and aspirin. We studied 16 patients referred for elective PTCA, treated for > or = 72 hours with oral aspirin and ticlopidine (group 1), and 10 patients referred for diagnostic coronary angiography, treated with oral aspirin alone (group 2). An intravenous bolus of heparin was administered at the start of PTCA. In both groups, platelet aggregability was assessed at baseline and 24 hours after the procedure, using the PFA 100(R) system. This method measures the time required for flowing whole blood to occlude a collagen and adenosine diphosphate (ADP)-coated ring, shorter times indicating greater aggregability. In both groups, platelet aggregability after the procedure was significantly increased compared with baseline: 104+/-30 seconds before versus 88+/-24 seconds at 24 hours in group 1 (p=0.03) and 84+/-16 seconds before versus 69+/-14 seconds at 24 hours in group 2 (p=0.004). Group 1 patients, compared with group 2, showed a trend toward reduced aggregability at baseline (p=0.06) and significantly lower aggregability 24 hours after the procedure (p=0.03). Ticlopidine and aspirin reduce whole-blood platelet aggregability compared with aspirin alone but fail to suppress the increased aggregability that occurs 24 hours after PTCA.

[Remodelling of the radial artery graft 5 years after aortocoronary bypass intervention]. / Rimodellamento dei graft in arteria radiale a cinque anni dall'intervento di bypass aortocoronarico.

BACKGROUND: The radial artery (RA) is being employed as coronary artery bypass graft with good results, but when it is proximally anastomosed to the ascending aorta, undergoes substantial hemodynamic changes which could lead to significant graft intimal hyperplasia. The aim of this study was to investigate the evolution of RA graft morphology over time. METHODS: We studied 20 patients with a perfectly patent RA graft at both 1 and 5 year angiography after coronary artery bypass graft. RESULTS: Both RA graft and grafted coronary artery diameters, assessed by quantitative coronary angiography, significantly increased at 5 years, in comparison to 1 year angiography (2.08 +/- 0.45 vs 2.54 +/- 0.53 mm, +22%, p < 0.001 and 1.92 +/- 0.47 vs 2.18 +/- 0.41 mm, +13.3%, p < 0.001, respectively). CONCLUSIONS: Hemodynamic changes following RA employment for coronary artery bypass graft stimulate a remodeling of RA graft itself and of the grafted coronary arteries. The progressive increase of diameters observed in RA grafts strongly argues against the development of flow-limiting graft intimal hyperplasia when RA is proximally anastomosed to the ascending aorta. Moreover, grafted coronary artery dilation suggests that hemorrheologic changes following coronary artery bypass graft could play a major role in the development of RA remodeling over time.

Color Doppler study of mitral regurgitation during percutaneous transluminal coronary angioplasty.

Mitral regurgitation (MR) was evaluated by color Doppler echocardiography during percutaneous transluminal coronary angioplasty (PTCA) in 28 patients with one-vessel artery disease (left anterior descending artery in 11, right coronary artery in 8, and circumflex artery in 9) and normal left ventricular function. In all three groups, left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) decreased significantly during artery occlusion in comparison with baseline values (no differences among various groups). Anterior and inferior akinesia/dyskinesia was observed in all patients during left anterior descending and right coronary artery occlusion, respectively. Lateral akinesia/dyskinesia was induced by occlusion of the circumflex artery in six patients (all with proximal lesions [p < 0.05 vs the other two groups]) and the right coronary artery in one. Only the six patients with circumflex artery occlusion showed PTCA-related MR (> 2+ in two). LVEF and WMSI were similar during artery occlusion in patients with and without MR. Neither mitral leaflet prolapse nor anulus dilation occurred during PTCA in any of the patients. Our data show that during brief occlusion of the proximal circumflex artery, functional MR (usually mild) frequently occurs in relation to specific lateral akinesia/dyskinesia.