Percutaneous transluminal coronary angioplasty of one major coronary artery when the contralateral vessel is occluded.

OBJECTIVES: In 193 patients we evaluated the safety and efficacy of angioplasty of a critical stenosis of the right coronary artery (52 patients) or the left anterior descending coronary artery (141 patients), with the contralateral coronary artery occluded and the circumflex artery being without significant stenosis. BACKGROUND: Attempted angioplasty of either the left anterior descending or the dominant right coronary artery when the contralateral vessel is occluded may trigger overwhelming left ventricular dysfunction or hemodynamic collapse, or both. METHODS: Immediate and late outcome (33 +/- 18 months) in the study group were compared with outcome in 214 patients who had angioplasty in both the left anterior descending and right coronary arteries and in 194 patients who had coronary artery surgery and were matched for number and location of significant lesions, ejection fraction, age, gender and study period. RESULTS: Left ventricular function was normal (38%) or mildly (34%), moderately (22%) or severely (6%) compromised. There were 11 (5.7%) emergency and 5 (2.6%) elective coronary artery operations, 3 (1.6%) myocardial infarctions and 1 in-hospital death in the study group. After discharge there were 25 (13.1%) elective coronary operations, 7 (3.7%) myocardial infarctions and 9 (4.7%) deaths in the study group. The incidence of death and myocardial infarction was similar in all groups, with 80% power to detect a 7% difference in adverse events. The study group had more elective surgery before and after discharge than did the surgical control group (p = 0.02). CONCLUSIONS: Dilating one major vessel when the contralateral vessel is occluded appears to be as safe as coronary surgery or two-vessel angioplasty. Incomplete revascularization in study group patients did not impair survival or increase myocardial infarction compared with the angioplasty and surgical control groups.

Repeat coronary angioplasty as treatment for restenosis.

Repeat coronary angioplasty has become the standard approach to a first restenosis. However, the long-term outcome of such a strategy is not well defined. In the present study, 465 patients (mean age 58 years [range 27 to 79], 53% with multivessel disease) underwent a second angioplasty procedure at the same site. The procedure was successful in 96.8% with a 1.5% rate of in-hospital bypass surgery, a 0.9% incidence rate of myocardial infarction and no procedural deaths. Four hundred sixty-three patients (99.6%) were followed up for a mean of 40.5 months. Forty-nine patients (10.6%) underwent a third angioplasty procedure at the same site, 55 (11.8%) had coronary bypass surgery and 33 (7.1%) underwent angioplasty at a different site. During follow-up, 12 patients (2.6%) sustained a myocardial infarction and 21 (4.5%) died including 13 (2.8%) with cardiac death. Of the 442 surviving patients, 88% experienced sustained functional improvement and 78% were free of angina. The actuarial 5-year cardiac survival rate was 96% and the rate of freedom from cardiac death and myocardial infarction was 92%. For the subgroup of 49 patients who had a third angioplasty procedure at the same site, the success rate was 93.9% with a 2% incidence rate of myocardial infarction. There were no in-hospital deaths or coronary artery bypass operations. The mean follow-up interval for this subgroup was 30.5 months with a 22.4% cross-over rate to coronary bypass surgery, a 4.1% incidence rate of myocardial infarction and a 2% cardiac mortality rate. At last follow-up, 89% of patients had sustained functional improvement and 76% were free of angina. The combined angiographic and clinical restenosis rate was 48%. Repeat angioplasty as treatment for restenosis is an effective approach associated with a high success rate, low incidence of procedural complications, and sustained functional improvement in combination with an acceptable rate of bypass surgery. However, there is a trend toward diminished angioplasty efficacy after a second restenosis. Thus, decisions for further revascularization should be made after careful review of available options.

[Percutaneous mitral valvuloplasty using balloon catheterization. Immediate results in 80 cases]. / Valvuloplastia percutânea mitral por balão. Resultados imediatos de 80 casos.

In our first 80 attempts of percutaneous double balloon mitral valvuloplasty (BMV) 77 procedures have been successful. The mean patients age was 44 +/- 17 years, there were 16 men; 12 patients had previously been operated, 29 patients had important valvular deterioration (calcifications, thickening or unpliability) or of subvalvar system. For technical failure BMV was performed with only one balloon in 8 patients. BMV resulted in significant improvement in haemodynamic values: the mean capillary pressure fell from 22 +/- 6 to 12 +/- 5 mmHg (p less than 0.001), the mean mitral gradient from 15 +/- 6 to 5 +/- 3 mmHg (p less than 0.001). Cardiac index remained unchanged. The hemodynamic valve area, by Gorlin formula, increased from 1.09 +/- 0.29 to 2.19 +/- 0.72 cm2 (p less than 0.001). Doppler and echocardiography data were similar to haemodynamic data. Mitral valve area obtained with BMV was equivalent to the area usually obtained in closed mitral commissurotomy. There were 3 tamponades. The first, in a patient to whom BMV was not successful. For the 2 others, surgically evacuated, intracavitary pressures were measured after surgical pericardial drain. BMV was of little efficacy in one patient who died 3 days thoracotomy. The three tamponades were caused by straight tip balloon left ventricle perforation. There was no tamponade with pigtail tip catheter balloon. Mitral valve regurgitation was never increased more than 1 + Interatrial septal defect with QP/QS greater than or equal to 1.5 and less than 2 was present in 5 patients. BMV may be a useful alternative to surgery with low incidence of complication. Mitral valve area increase is similar with both treatment.

Balloon inflation following injection of contrast material through the distal lumen of the USCI balloon catheter.

We report on four patients in whom we observed inflation of the balloon following injection of contrast material into the distal lumen during percutaneous transluminal coronary angioplasty. This is a rare technical problem. However, inadvertent balloon inflation may cause transient occlusion of the proximal coronary artery and in one case was associated with acute occlusion of a vessel that had been dilated. Management involves prompt deflation of the balloon.

Coronary stenting in the elderly: longitudinal results in a wide spectrum of patients treated with a new and more practical approach.

One hundred-twelve intracoronary stents (83 Palmaz-Schatz, 25 biliary, and 4 Gianturco-Roubin) were placed in 87 (51.7% male) patients aged > or = 70 years (70-93; mean 76.1) during a 1-year period. All stents were deployed using high-pressure inflation (mean 17.4 +/- 2 atm) without intravascular ultrasound. All patients received antiplatelet therapy with aspirin and ticlopidine. Seven patients additionally received warfarin at the physician's discretion. No patient was excluded from analysis regardless of presentation (40% acute myocardial infarction and 12.6% bailout) or complication. There were four deaths and two target vessel reinterventions in-hospital. One reintervention (a bailout) developed a non-Q-wave myocardial infarction. Bleeding, vascular complications, and length of stay were all greater for the warfarin group. The event-free survival rate was 83.9%, at an average of 8.6 months follow-up. A wide range of elderly patients can thus undergo stenting without intravascular ultrasound, usually without warfarin, yielding results comparable to those with more standard therapy in select populations.

Digital subtraction fluoroscopy: a new method of detecting coronary calcifications with improved sensitivity for the prediction of coronary disease.

The association between calcification of the coronary arteries and coronary artery narrowing is well established. However, fluoroscopic visualization of coronary calcifications has been insufficiently sensitive to be useful as a screening test. Since digitization of radiographic images permits the subtraction of noncardiac structures from moving cardiac structures, such subtraction might increase the sensitivity of coronary fluoroscopy. To determine whether coronary calcifications were better visualized with digital subtraction fluoroscopy than with conventional fluoroscopy, we taped diseased human coronary arteries to a pulsating water balloon inside the thorax of a dog cadaver and studied this model with both fluoroscopic techniques. Calcific atherosclerotic plaques were more easily identified with digital subtraction fluoroscopy than with conventional fluoroscopy. We tested the method clinically by submitting 191 subjects without history or electrocardiographic evidence of previous myocardial infarction who were referred for coronary arteriography to both fluoroscopic studies. For at least one, at least two, and three calcified coronary arteries, digital fluoroscopy was more sensitive (92%, 66%, and 40%) than conventional fluoroscopy (63%, 21%, and 2%) (all p less than .001) for the prediction of significant coronary obstructions (greater than 50%). Although digital fluoroscopy was less specific than conventional fluoroscopy (digital: 65%, 89%, and 97%; conventional: 81%, 98%, and 100%) (all but last, p less than .01), receiver operating curve analysis revealed a significantly larger area under the curve, indicating higher accuracy for the digital technique (p = .03). Digital subtraction fluoroscopy was more accurate in younger than in older patients.(ABSTRACT TRUNCATED AT 250 WORDS)