Restenosis and clinical outcome in patients treated with amlodipine after angioplasty: results from the Coronary AngioPlasty Amlodipine REStenosis Study (CAPARES).

OBJECTIVES: Our intent was to investigate the effect of the dihydropyridine calcium channel blocker amlodipine on restenosis and clinical outcome in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Amlodipine has sustained vasodilatory effects and relieves coronary spasm, which may reduce luminal loss and clinical complications after PTCA. METHODS: In a prospective, double-blind design, 635 patients were randomized to 10 mg of amlodipine or placebo. Pretreatment with the study drug started two weeks before PTCA and continued until four months after PTCA. The primary angiographic end point was loss in minimal lumen diameter (MLD) from post-PTCA to follow-up, as assessed by quantitative coronary angiography (QCA). Clinical end points were death, myocardial infarction, coronary artery bypass graft surgery and repeat PTCA (major adverse clinical events). RESULTS: Angioplasty was performed in 585 patients (92.1%); 91 patients (15.6%) had coronary stents implanted. Follow-up angiography suitable for QCA analysis was done in 236 patients in the amlodipine group and 215 patients in the placebo group (per-protocol group). The mean loss in MLD was 0.30 +/- 0.45 mm in the amlodipine group versus 0.29 +/- 0.49 mm in the placebo group (p = 0.84). The need for repeat PTCA was significantly lower in the amlodipine versus the placebo group (10 [3.1%] vs. 23 patients [7.3%], p = 0.02, relative risk ratio [RR]: 0.45, 95% confidence interval [CI]: 0.22 to 0.91), and the composite incidence of clinical events (30 [9.4%] vs. 46 patients (14.5%), p = 0.049, RR: 0.65, CI: 0.43 to 0.99) within the four months follow-up period (intention-to-treat analysis). CONCLUSIONS: Amlodipine therapy starting two weeks before PTCA did not reduce luminal loss, but the incidence of repeat PTCA and the composite major adverse clinical events were significantly reduced during the four-month follow-up period after PTCA with amlodipine as compared with placebo.

Minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass in combination with intraoperative percutaneous transluminal coronary angioplasty for palliative coronary revascularization in a heart transplant recipient.

The use of minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass in combination with intraoperative percutaneous transluminal coronary angioplasty for myocardial revascularization in a heart transplant recipient is reported.

Should the lungs be ventilated during cardiopulmonary bypass? Clinical, hemodynamic, and metabolic changes in patients undergoing elective coronary artery surgery.

No beneficial effects were achieved by ventilating the lungs of a group of 10 patients during total extracorporeal circulation for coronary artery bypass operation. Ventilation of nonperfused lungs, which was suggested to prevent postoperative atelectasis, may even have negative effects. Intrapulmonary shunting increased significantly (p less than 0.05), while the shunt fraction in the nonventilated lungs of another group of 10 patients remained unchanged. There were only minor differences between the two groups with respect to systemic and pulmonary hemodynamic changes.

Intraoperative angiography in minimally invasive direct coronary artery bypass grafting.

Intraoperative angiography in minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass and in hybrid procedures is reported. Twelve procedures were performed in a specially designed surgical-radiologic suite with a cross-disciplinary organization. In 2 patients the anastomosis was successfully revised on the basis of angiographic findings. In 4 of the 12 patients anastomosis of the left internal mammary artery to the left anterior descending coronary artery performed as a minimally invasive direct coronary artery bypass grafting procedure was combined with percutaneous transluminal coronary angioplasty of lesions in other coronary vessels in the same session. Intraoperative angiography allows a reliable diagnosis of an anastomosis or graft failure and prompt and reliable correction, and it allows the combination of minimally invasive direct coronary artery bypass grafting and angioplasty in one session.

Fibro-osseous lesions of the cranio-facial bones.

A brief review of cranio-facial fibro-osseous lesions is given and 15 cases of fibrous dysplasia and ossifying fibroma are presented with clinical, radiological and histomorphological findings. After histological verification of the fibro-osseous nature of the process, 5 lesions were diagnosed on an radiological basis as fibrous dysplasia exhibiting diffuse (blending) margins, while the diagnosis of ossifying fibroma was given to 10 radiologically sharply-demarcated lesions. Both groups of lesions presented the same histomorphological features, although to a varying degree. Spheroidal calcifications, however, were identified in ossifying fibroma only, but not in all of these. Thus, the differential diagnosis of fibrous dysplasia versus ossifying fibroma rests on a radiological criterion after the histopathologist has verified the fibro-osseous nature of a lesion. The observation times varied from 1 1/2 to 34 years. Two cases of fibrous dysplasia and 3 cases of ossifying fibroma recurred. In one case of fibrous dysplasia an osteosarcoma developed 33 years after irradiation. Pain was a common symptom in the present material.

Deviation of the descending aorta associated with enlarged left atrium.

The deviation to the left of the descending aorta associated with enlarged left atrium was analysed in 96 patients with mitral disease confirmed by angiography and cardiac catheterization. The opinion that this finding may be of value in patients below the age of 50 years was supported. In older age groups it is easily confused with the physiologic unfolding of the aorta, when this occurs at the level of the left atrium.

Digital subtraction angiography (DSA) in the evaluation of brain death. A comparison of conventional cerebral angiography with intravenous and intraarterial DSA.

Demonstration that intracranial circulation has ceased is the ultimate proof of brain death. This study was performed to evaluate digital subtraction angiography (DSA) compared with conventional cerebral angiography in the diagnosis of brain death. Intravenous as well as intraarterial DSA was found suitable in the diagnosis of arrested intracranial circulation.

Superior caval vein stenosis due to giant aneurysm of the right coronary artery.

Aneurysms of the coronary arteries may cause angina, myocardial infarction or sudden death due to thrombosis, embolization or rupture. The patient described herein may represent the first reported case of a large coronary artery aneurysm compressing the upper caval vein, and thereby producing a significant inflow gradient. The anatomical details were demonstrated by digital subtraction angiography (DSA). The patient successfully underwent resection of the aneurysm and reconstruction of the coronary artery with a saphenous vein bypass graft.

[Catheter treatment of renal artery stenoses]. / Kateterbehandling av nyrearteriestenoser.

Percutaneous transluminal renal artery angioplasty (PTRA) is an alternative to treatment with drugs and surgery for renovascular hypertension and uremia. The procedure is technically successful in more than 90% of the patients. Renovascular hypertension is cured or improved in nearly 2/3 of the patients. Uremia is cured in 50%, and in another third the kidney function is stabilized. The frequency of restenosis is high, especially for ostial lesions. Therefore, clinical and angiographic follow-up is recommended, so as to redilate when restenosis is present. Introduction of stents probably reduces the frequency of restenosis in the ostial lesions.

[Catheter therapy of coronary disease]. / Kateterbehandling av koronarsykdom.

Percutaneous transluminal coronary angioplasty (PTCA) with balloon catheters is a well established invasive treatment for coronary artery disease. The high frequency of restenosis has promoted the development of new catheters, with different techniques for removing the plaques from the coronary arteries. Until now the rate of restenosis using balloon angioplasty and new atherectomy catheters has not declined. Our experience of these techniques is discussed and compared with the experiences described in the literature. The use of stents seems to be a major step forward, leading to fewer restenoses and emergency bypass operations.

Reproducibility of ischaemic lactate metabolism during atrial pacing in man.

The reproducibility of myocardial ischaemia provoked by atrial pacing was studied in two groups of patients. The heart rate was slowly increased (10 beats per fourth min) until angina in group A, and quickly increased (10 beats per 20 s) in group B. Cardiac venous flow was measured by thermodilution and blood was sampled for metabolic studies at rest and during the maximum obtained heart rate and repeated after 20 min of rest. Ischaemia was defined as a reduction in myocardial lactate extraction ratio by 50% and to a ratio lower than 0.15. Lactate metabolism changed from production (-0.06 +/- 0.05) during the first pacing to extraction (0.05 +/- 0.05) during the second in group A (p less than 0.02). Lactate metabolism was quite reproducible in group B. All the other metabolic and haemodynamic parameters were unchanged in both groups. We conclude that the duration of atrial pacing is important for the reproducibility of pacing-induced myocardial ischaemia.

Failure of combined acetylsalicylic acid and dipyridamole to prevent occlusion of aortocoronary venous bypass graft.

Patients scheduled to receive at least three aortocoronary venous bypass grafts were randomized to active medication or to placebo. The former were given dipyridamole (DP) preoperatively and acetylsalicylic acid (ASA) was added after the operation. For the next 3 months they received DP 75 mg and ASA 325 mg thrice daily. The placebo regimen was identical and the study was conducted with double-blind technique. One patient in each group died. DP-ASA was discontinued in six patients because of gastrointestinal side effects (bleeding peptic ulcer in 2 cases). Angiography after 3 months revealed the patency rate of individual grafts to be 68% in the DP-ASA group and 77% in the placebo group. DP-ASA therefore did not prevent occlusion of aortocoronary venous bypass grafts.

Retrograde internal mammary artery as coronary bypass. A prospective study with postoperative angiographic evaluation.

Although the internal mammary artery (IMA) as a coronary graft offers better long-term patency than the saphenous vein, a factor limiting its use has been the length of the artery's pedicle. In an attempt to overcome this limitation, we evaluated the use of retrograde right IMA in a prospective study. In ten patients scheduled for routine coronary artery bypass surgery, bilateral IMA grafting was used, the left IMA in routine fashion, but the right IMA dissected from the level of the first rib, cut there and placed as an inverted graft. Three months postoperatively the patients were clinically evaluated with stress exercise test (n = 10) and coronary angiography (n = 9). No patient had recurrence of angina. Angiography revealed patency of the retrograde right IMA graft in six of nine patients. On the basis of these data we do not recommend routine use of retrograde IMA.

Pulsatile vs. non-pulsatile flow during cardiopulmonary bypass. A comparison of early postoperative changes.

The aim of the study was to evaluate possible haemodynamic and metabolic effects of pulsatile flow in cardiopulmonary bypass. The subjects were 20 patients undergoing coronary artery bypass grafting. They had no complicating diseases. Ten consecutive patients with pulsatile perfusion were compared with ten consecutive patients with non-pulsatile perfusion. The haemodynamic parameters, chest X-rays, fluid balance and changes in circulating thrombocytes were unaffected by adding pulsatile flow to cardiopulmonary bypass. The arterial-venous oxygen content difference and intrapulmonary shunting were also unaffected. Whole-body oxygen consumption was higher in the pulsatile group immediately after bypass, but subsequently there were no differences. The haemoglobin and haematocrit values were higher in the non-pulsatile group two hours postoperatively, but did not differ in the rest of the observation period. The clinical course was similar in the two groups.

Doppler echocardiography in adults with isolated ventricular septal defect.

Doppler echocardiography and cardiac catheterization were undertaken in 70 consecutive patients, 31-68 years of age (mean 39), who had isolated congenital ventricular septal defects (VSD), 28 of whom had been operated upon. In 50 patients with invasively proven VSD, 37 had a correct Doppler diagnosis of VSD (group 1) and in 13 a false negative result was obtained (group 2); i.e. a sensitivity of 74%. No false positive Doppler diagnosis was made in the 20 patients without evidence of shunt. Left to right ventricular systolic pressure difference (delta P) ranged between 55 and 142 mm Hg, with a mean value of 103 mm Hg in group 1 and 99 mm Hg in group 2. There was good correlation between delta P obtained by continuous wave Doppler and catheterisation in 17 group 1 patients with moderate and large shunts (r = 0.81, P less than 0.001). There was no correlation in the remaining 20 patients in group 1 with small shunts (r = 0.20, P greater than 0.1). Doppler echocardiography in the adult with isolated VSD has good sensitivity and excellent specificity. Doppler prediction of delta P is reasonably correct in patients with moderate and large shunts, but of no value in patients with small shunts.

Restenosis after percutaneous transluminal coronary angioplasty.

Restenosis after percutaneous transluminal coronary angioplasty was demonstrated in 61 (29%) of 210 successfully treated patients. Mostly it occurred within 4 months after treatment and in arteries less than 3 mm in diameter. Careful clinical follow-up is therefore particularly important early after angioplasty of smaller arteries. Redilation can be performed without increased risk of restenosis.

Angiographic and risk factor characteristics of subjects with early onset ischaemic heart disease.

Sixty-six consecutive patients less than 40 years of age with angiographically documented coronary artery disease and coronary heart disease took part in a study aimed at (1) identifying the presence of factors which might explain the premature onset of ischaemic heart disease, and (2) assessing the distribution and severity of the coronary artery lesions. For comparisons we have used a study of risk factors in 1832 men defined as "normals" according to a recent comprehensive examination. The findings show that the typical early onset coronary heart disease case is an overweight, heavily smoking male "blue collar" worker, with high serum levels, a marginally raised blood pressure, and a high prevalence of coronary heart disease among first degree relatives. Coronary angiography showed a preponderance of one vessel disease. In particular, left anterior descending artery lesions were common, which might have contributed to the early manifestation of disease.

Posterior left ventricular aneurysm due to occlusion of the circumflex coronary artery with recurrent ventricular tachycardia. Case report.

A 62-year-old male developed a large posterior left ventricular aneurysm diagnosed 6 months after a sustained myocardial infarction. Coronary angiography revealed a proximal occlusion of the circumflex artery, two 75% stenoses of the right coronary artery and a normal left anterior descending artery. The main clinical indication for surgery was residual bouts of ventricular tachycardia. A successful "mechanical conversion" of this arrhythmia by means of light precordial knocks in the apex region is reported. In this way the patient could be prepared for surgery without using myocardial depressant drugs. The aneurysm was resected, encircling endocardial ventriculotomy was performed and the right coronary artery was grafted. Nine months after the operation the patient is well without the need for antiarrhythmic drugs. The rarity of this condition is stressed and the possible mechanisms of ventricular tachycardia and its treatment in this particular case are discussed.