bluuebunny/crossref_metadata_2025 huggingface dataset:
History of Pacing in Hypertrophic Cardiomyopathy
Authors: DODINOT BERNARD , SADOUL NICOLAS , CHILLOU CHRISTIAN DE. , ALIOT ETIENNE
Published: June 2007

The history of pacing in hypertrophic obstructive cardiomyopathy (HOCM) begins in 1964 and ends in the early 1990s when several well‐documented articles confirmed that pacing the apex of the right ventricle could be considered as an effective primary therapy of severe, drug resistant HOCM. The first pacemaker implantation was reported in a patient with HOCM who developed a complete AV block. The efficacy of right ventricular (RV) pacing on the gradient was enhanced, but the concept of pacing in the absence of conduction abnormalities was not suggested. In 1967, Hassenstein was the first to demonstrate that right apex ventricular pacing in HOCM with intact AV conduction induced gradient reduction. He subsequently performed the first hemodynamic implantation several years later. The largest series confirming the undoubted efficacy of pacing in HOCM were reported by Jeanrenaud in Switzerland and Fananapazir in the USA in the early 1990s.
Percutaneous Transluminal Coronary Angioplasty Using 6 Fr Guiding Catheters: A Matched Study with 8 Fr Guiding Catheters
Authors: BEDOSSA MARC , LE BRETON HERVÉ , ZAKI AMR , LECLERCQ CHRISTOPHE , FOULGOC JEAN‐LUC , BORIES JEAN , PONY JEAN‐CLAUDE
Published: June 2007

Coronary angioplasty using 6 Fr guiding catheters has been described. This study was based on matching a prospective 105 coronary angioplasty procedures performed using 6 Fr guiding catheters (group I) with 100 other prospectively collected procedures performed through 8 Fr catheters (group II). Procedural variables such as quantity of contrast injected, total duration of the angioplasty, and vessel opacification were collected, as well as the success rate and local vascular complications. The two groups were identical regarding the baseline clinical and angiographic characteristics (age, sex, clinical indication, type of the lesion, and the size of the artery attempted). Success rate was similar between both groups (94.2% and 95% for groups I and II, respectively). Cross‐over from 6 Fr to 8 Fr system was needed in two cases (one for inadequate back‐up support, the other for a long dissection and inadequate vessel opacification). The use of 6 Fr guiding catheters was possible in such acute situations as myocardial infarction or scent delivery for coronary dissections. The quantity of contrast injected through the 6 Fr catheters (164 ± 74 mL) was significantly less than through the 8 Fr ones (217 ± 92 mL; P ± 0.01). On the other hand, the mean duration of the procedure was slightly longer using the 6 Fr system (40 ± 18 min vs 34.4 ± 18 min for groups I and II, respectively; P < 0.02). There was no difference between the two groups regarding the local vascular complications. This study demonstrates the feasibility of PTCA using 6 Fr guiding catheters in a variety of clinical indications, with a smaller quantity of contrast than in the 8 Fr ones, but a slightly longer duration. The other potential advantages of 6 Fr guiding catheters (lower rate of local complications, less blood loss) have not been proven in this study. (J Interven Cardiol 1996;9:373–379)
Dilatation of Coronary Artery Bifurcation Stenosis Using the Original Palmaz‐Schatz Stent
Authors: KURBAAN A.S. , SIGWART ULRICH
Published: June 2007

Stenosis of a coronary artery bifurcation is a difficult interventional problem. The principle problem is the risk of damaging the ostium of one vessel while dilating the other. The “kissing” balloon technique and progress in stent technology have made available a number of approaches. The gap opposite the articulation bridge of the Palmaz‐Schatz 153 stent can be used to gain access to an important vessel at a bifurcation. We report a case with significant stenosis involving the left main stem extending to the ostia of anterior descending and circumflex arteries. A stent was inserted into the left main stem and circumflex ostium, and through the gap the left anterior descending artery ostium was successfully dilated by battoon angioplasty.
Intervention in Hypertrophic Obstructive Cardiomyopathy
Authors: SUTTON RICHARD , SPANODIMOS STAVROS
Published: June 2007

This article reviews the present status of intervention in hypertrophic obstructive cardiomyopathy. Interventions include pacing, which is best administered by VDD mode with sufficiently short atrioventricular delay as to assure ventricular capture. Occasionally, this may require the addition of atrioiventricular (AV) junctional ablation in order to achieve 100% ventricular capture. This approach alters the left ventricular (LV) contraction sequence, thereby reducing the left ventricular outflow obstruction. VVI pacing is inadequate because of the necessity for atrial contribution to the hypertrophied ventricle. This contribution may he ineffective even with VDD pacing, without the benefit of AV junctional ablation, because of late activation of the left atrium. Ablation of the left bundle branch may also achieve altered contraction sequence of the LV, but experience with this technique is very limited. Two different methods of reduction of the interventricular septum have been proposed. The first is transaortic laser, which has not gained wide acceptance, and the second is a new and promising method that appears to be less traumatic. This is alcohol delivery to the first septal branch of the left anterior descending coronary artery by an angioplasty technique. Surgical approaches include septal myomectomy directly to reduce the obstruction and mitral valve replacement to eliminate the part played in the obstruction by the anterior cusp of the valve. In conclusion, younger patients, even those who are asymptomatic, should be considered for surgical myomectomy, there being little place now for mitral valve replacement. In older patients, pacing and septal chemoablation offer the greatest promise, but their places are not yet fully established. (J Interven Cardiol 1996; 9:399–403)
“Fork” Stenting for Bifurcational Lesion
Authors: ODA HIROTAKA , ITO EIICHI , MIIDA TSUTOMU , TOEDA TETSUROU , HIGUMA NORIO
Published: June 2007

Based on the experience of our in vitro examination to assess the stents for a safe and effective angioplasty through the struts, a Palmaz‐Schatz stent was implanted easily and completely from the left main trunk to the left anterior descending coronary artery through the struts of a Wiktor stent implanted from the left main trunk to the circumflex artery in two cases.
Treatment of a Left Internal Mammary Graft Ostium Stenosis Using a Palmaz‐Schatz Stent with Intravascular Ultrasound Guidance and Reduced Anticoagulation
Authors: GUARNERI ERMINIA M. , RUSSO ROBERT J. , ZALMAN FRANKLIN , MORRIS NANCY B. , TEIRSTEIN PAUL S.
Published: June 2007

A 62‐year‐old man sustained an anterior wall myocardial infarction 7 years following coronary artery bypass graft surgery. The patient underwent successful placement of a Palmaz‐Schatz stent within the ostium of the left internal mammary artery utilizing ultrasound guidance and was discharged in 24 hours with reduced anticoagulation.
Local Delivery of Antithrombotic Drug Inhibits Neointimal Hyperplasia Following Arterial Injury
Authors: TOMARU TAKANOBU , YOSHIMURA ASHIO , AOKI NAOTO , OMATA MASAO , GESCHWIND HERBERT J. , UCHIDA YASUMI
Published: June 2007

The efficacy of local delivery of antithrombotic drugs on neointimal hyperplasia was investigated in 41 rabbits. One side of a rabbit iliac artery was injured by a balloon catheter as a control‐injured artery. Another side of the iliac artery was also injured, and followed by local delivery of the antithrombotic drug (argatroban: 0.05 mg/kg; heparin 25 U/kg; or batroxobin 1 U/kg + heparin 25 U/kg). One hour after the balloon injury, angioscopy demonstrated occlusive or mural thrombus in all the controls, but few in the local drug‐delivery arteries. Four weeks after balloon injury, angiographic percent stenosis in the locally drug‐delivered arteries was 8%± 2% in the argatroban group (n = 7. P < 0.001 vs control side; 67%± 33%), 25%± 19% in the heparin group (n = 5, P < 0.005 vs control 66%± 14%), and 5%± 5% in the batroxobin group (n = 7, P < 0.01 vs control 59%± 39%). The activated partial thromboplastin time and fibrinogen did not change significantly. The PDGF‐B chain was prominent at the neointimal layer in all the controls, but less so in the locally drug‐delivered arteries. Thus, local delivery of antithrombotic drugs can inhibit neointimal hyperplasia after balloon injury by reducing thrombus related growth stimulation.
Primary Intracoronary Stenting of Unprotected Left Main Coronary Artery Stenosis in Two Patients with No Contraindication to Surgery: Immediate and Follow‐Up Results
Authors: KONING RENÉ , CRIBIER ALAIN , ELTCHANINOFF HÉLÈNE , TRON CHRISTOPHE , LETAC BRICE
Published: June 2007

Although successful stenting has been reported on protected left main coronary artery or unprotected left main in patients with prohibitive surgical risks or in bail‐out situations, no case of left main primary stent implantation in patients without surgical contraindication has yet been reported. We report immediate and late clinical and angiographic results in two patients (57 and 38‐year‐old men) who had unprotected left main coronary disease, with isolated stenosis on a large and long left main trunk, ideally suitable for stenting. We believe that stenting could change the matter of the contraindication of balloon angioplasty in left main coronary disease. However, further studies with a large number of patients and long‐term follow‐up are necessary to determine whether this approach will constitute a valuable alternative to surgery in the future.
The New ACS Multilink Coronary Stent: Single Center Experience in 103 Consecutive Patients With and Without Oral Anticoagulation
Authors: CLAGUE JONATHAN R. , KURBAAN ARVINDER S. , KELLY PAUL A. , DENNE LIN , DAVIES SIMON W. , RICKARDS ANTHONY F. , SIGWART ULRICH
Published: June 2007

Background

Since the introduction of this stent, anticoagulant regimens have changed from an aggressive protocol (aspirin, heparin, and warfarin) to a simplifed regimen (aspirin and ticlopidine). In this study our experience with this stent is reviewed, and acute and chronic outcomes with the two anticoagulant protocols are compared. All patients undergoing ACS Multilink stent implantation between July 1993 and June 1996 were included. The clinical and angiographic characteristics were documented and outcomes recorded. The two anticoagulant groups were compared: 103 patients (94 males, age range 41–80 years, mean 59) received 124 stents: 68% had Canadian Cardiac Society (CCS) grade III or IV angina prior to the procedure; and 73% underwent bail‐out stenting. High pressure inflations (> 14 a) were used in 40% of cases. Eighty‐four (85%) received aspirin and ticlopidine only. The initial success rate was 99%. Two patients underwent emergency surgery. There were no deaths and no cases of subacute stent thrombosis. Clinical follow‐up is available on 66 patients (mean 190 days). Of these, 56 patients (54%) are in CCS grade 0 or 1. One patient has required surgical revascularization. There is one case of documented restenosis within the stented segment.
Progress in Interventional Cardiology
Authors: Talley J. David , Smith Eugene S.
Published: June 2007

This issue of News & Views will focus on events reported prior to and during the 46th Annual Scientific Session of the American College of Cardiology, March 16‐19, 1997, in Anaheim, CA, USA. Topics to be discussed include the results of recently completed clinical trials involving plasminogen activators used in the treatment of acute myocardial infarction (MI), glycoprotein (GP) IIb/IIIa inhibitors used in the treatment of unstable angina pectoris and non‐Q wave MI, an update on the treatment of MI complicated by cardiogenic shock, and optimal diagnostic strategies for patients who have sustained a non‐Q wave MI.
The Short‐ and Long‐Term Outcome of Left Internal Mammary Artery Angioplasty
Authors: DEVLIN GERARD , SCHWARTZ LEONARD , DROUIN KATHY , LIMA VALTER C. , MARQUIS JEAN FRANCOIS.
Published: June 2007

Failure of internal mammary artery (IMA) bypass grafts is uncommon. However, as their use continues to increase, this complication will be encountered more frequently by interventional cardiologists. The purpose of this article is to describe the short‐ and long‐term outcome of patients undergoing IMA angioplasty through a retrospective review of patients undergoing internal mammary angioplasty at two centers from January 1988 to June 1995. Percutaneous recanalization was attempted on 82 lesions either within an IMA or in the ongoing native left anterior descending artery during 74 procedures in 67 patients. The mean time from bypass surgery was 23 months. The lesion success rate was 84%. Dissection of the IMA occurred in 18% of procedures and was the most common cause for procedural failure and unfavorable outcome. Long‐term follow‐up was available in 82% of patients at a mean follow‐up of 45 months postprocedure. Clinical events occurred in 23 patients (34%) with 4 deaths (1 of which occurred during the initial hospitalization and after emergency bypass surgery), 2 repeat coronary bypass operations, and 17 patients with repeat coronary angioplasties. Despite the high repeat revascularization rate, 80% of patients were asymptomatic or had only infrequent angina at follow‐up. We conclude that angioplasty of or through an IMA bypass graft can be performed with a satisfactory procedural success rate and long‐term symptomatic benefit.
Mechanical Circulatory Support: Candidate Selection, Benefits, and Potential Complications
Authors: KFOURY ABDALLAH G. , ANDERSON JEFFREY L. , TAYLOR DAVID O.
Published: June 2007

Advanced heart failure remains a deadly disease despite recent medical and surgical advances in its therapy. Heart transplantation is still considered the best long‐term therapeutic option for patients with end‐stage heart failure, but its use is severely limited by donor availability. While various treatment modalities as alternatives to cardiac transplantation continue to be investigated, mechanical circulatory support has proven to be succesful when used as a bridge to transplantation. Its success in this mission will likely make it a front‐runner among future permanent therapeutic options for terminal heart failure. Candidate selection, benefits, and potential complications of mechanical circulatory support are reviewed in this article.
Part II: Endovascular Therapy: A Cardiovascular Surgeon's Experience
Authors: DIETHRICH EDWARD B.
Published: June 2007

Dr. Dorros: Our next speaker has evolved from a cardiovascular surgeon doing vascular surgery to a cardiovascular surgeon performing endovascular therapy of bifurcation disease. We have asked Dr. Diethrich from the Arizona Heart Institute to give us a cardiovascular surgeon's perspective.
Left Ventricular Perforation During Percutaneous Balloon Mitral Valvuloplasty With Emergency Surgery
Authors: EL HAITEM NAIMA , AOUAD AICHA , BENNANI RAJAE , ALAMI MOHAMED , FELLAT NADIA , HAJJI LEILA , SRAIRI JAMAL‐EDDINE , MESBAHI REDOUANE , ABIR‐KHALIL SAADIA , BENLAMINE SAMIR , ABDELALI SALIMA , GHANNAM RACHID , BENOMAR MOHAMED
Published: June 2007

Two cases of left ventricular (LV) perforation by balloon catheter following successful balloon mitral valvuloplasty are presented. The first patient was dilated first with a single straight‐tip balloon catheter and after with a double balloon catheter. The second patient underwent a valvuloplasty with a double balloon catheter only. The subsequent tamponade was treated by immediate aspiration but without hemodynamic improvement. Both patients required emergency surgery with surgical repair of the LV apex, and both of them could be weaned. Both patients are well 18 months after the procedure. We discuss the mechanism of this serious complication and technical considerations to prevent it.
The Indian Experience of Percutaneous Transvenous Mitral Commissurotomy: Comparison of the Triple Lumen (Inoue) and Double Lumen (Accura) Variable Sized Single Balloon With Regard to Procedural Outcome and Cost Savings
Authors: NANJAPPA MANJUNATH CHOLENAHALLY , DORROS GERALD , HEMANNA SETTY SRINIVASA KIKKERI , KANTH PATIL CHANDRA , VENKAT VENKATESH HUCHAPPA , NINGE GOWDA CHICKKALINGA GOWDA , SWAMY NARAYANA , THIPPA REDDY YAVAGAL SURESH , BYRAPPA KUMAR , BHAVI SADHA BHOOPAL TONDE
Published: June 2007

The efficacy, safety, and cost of percutaneous mitral commissurotomy (PTMC), using variable volume dependent sized catheters, compared a triple lumen (Inoue) with a double lumen (Accura) catheter. PTMC was performed using Accura balloons in 400 patients and Inoue balloons in 512 patients. The group demographics, increase in mitral valve area, and incidence of significant complications were similar. The catheters were similar with respect to maneuverability and procedure (fluoroscopy) time. The Accura balloons could be reutilized statistically more often (6.3 ± 1.4 for Accura and 5.2 ± 0.8 for Inoue, P < 0.05). Accura balloons were more cost‐effective, with 6.3 usages lowering the per procedural catheter cost to $214.00, while the Inoue balloons, with 5.2 usages, had a final catheter cost of $395.00. The potential savings would have been $155,340.00 if Accura balloons were utilized. Conclusions: Accura and Inoue mitral valvuloplasty balloons were comparable with regard to efficacy and safety, but the Accura balloon was significantly less costly and is therefore more suitable for use in India and other nations where resources are limited.
Advances in Dual Chamber Implantable Cardioverter/Defibrillators
Authors: ELLIOTT LYNN , GILKERSON JIM
Published: June 2007

We describe the past, present, and possible future of implantable dual chamber defibrillators and take a quick look at the history of implantable cardioverter defibrillators (ICDs) to provide the background for this article. Four of the current generation dual chamber ICDs and the merits and issues surrounding these devices are compared. We then take a look at the future directions for dual chamber ICDs and discuss the research, technologies, algorithms, and issues that will drive the future of dual chamber ICDs.
The Role of Antiarrhythmic Drugs in Patients With Implanted Cardioverter Defibrillators
Authors: LÉVY SAMUEL
Published: June 2007

A significant percentage (40%‐70%) of patients with implantable cardioverter defibrillators (ICDs) receive adjunctive antiarrhythmic drug therapy, although this percentage is presently decreasing. The most common aims of drug therapy in ICD patients are to reduce the number of ventricular arrhythmic events triggering the device, to prolong ventricular tachycardia cycle length and to increase efficacy of antitachycardia pacing, to treat combined supraventricular tachycardias and avoid inappropriate shocks, and to decrease defibrillation energy requirements. However, some antiarrhythmic agents may increase the defibrillation threshold (DFT) and/or the pacing thresholds, may slow the tachycardia below the limit for rate detection, and may cause proarrhythmia. Amiodarone is particularly useful in patients with arrhythmia storm but may increase DFTs in some patients. Follow‐up and appropriate device programming of patients with ICDs is particularly necessary in patients with combined antiarrhythmic drug therapy.
AVID and Beyond: Lessons Learned
Authors: CANNOM DAVID S.
Published: June 2007

The implantable cardioverter defibrillator (ICD) has been approved by the Food and Drug Administration (FDA) since 1985 and is widely used in practice. Until recently, however, the efficacy of the ICD has depended on a large published series of retrospective studies analyzing ventricular tachycardia and fibrillation patients. The recently published Antiarrhythmics Versus Implantable Defibrillator (AVID) trial is the first prospective randomized trial to show clearly that the ICD is more effective than drug therapy (amiodarone or sotalol) in patients who have survived an out‐of‐hospital cardiac arrest or have syncopal or hemodynamically significant ventricular tachycardia. The survival advantages probably hold true only for patients with an ejection fraction under 35% who have either coronary disease or other forms of cardiomyopathy. The survival advantage in this trial—which was halted prematurely because of the results noted—was short‐lived (2.8 months) and expensive. The results of this trial will clearly define the role of the ICD in everyday clinical practice and will be of invaluable benefit to patients, physicians, and insurers alike. The results of the AVID trial, as well as other postevent and pre‐event trials, are summarized in this article. A number of sub studies have already resulted from the AVID study and are also presented.
Prophylactic Trials With Implantable Cardioverter Defibrillators: MADIT and Beyond
Authors: NISAM SEAH , SINGER IGOR
Published: June 2007

Numerous studies have proven the efficacy of the ICD in prolonging life, both in patients with previous history of ventricular tachyarrhythmias and in patients such as in MADIT, without such arrhythmias, but at a high risk of VT or VF. Nevertheless, this therapy has had relatively small impact on reducing the overall problem of sudden cardiac death, simply because the populations treated using currently accepted indications make up a tiny portion of at‐risk patients. There are numerous studies aiming to further clarify which patients can benefit from ICDs for primary prevention. One of these, CABG‐Patch, has finished, with a neutral result. The only certain implication is that patients destined for CABG surgery and having no further specific arrhythmia risk markers should not receive ICDs. Other studies have recently begun, and it will be several years before their results are known. The proven efficacy of the ICD for therapy of VT and VF has, in fact, introduced new feasibility and ethical considerations in designing future clinical trials.
Development and Pathophysiological Basis of Thrombolytic Therapy in Acute Myocardial Infarction Part I. 1912–1977 The Controversy Over the Pathogenetic Role of Thrombus in Acute Myocardial Infarction
Authors: RENTROP K. PETER
Published: June 2007

Although acute myocardial infarction (MI) was among the indications of Fletcher's 1959 safety study of thrombolytic therapy, this indication was not pursued in subsequent U.S. trials. The 1977 FDA approval of thrombolytic therapy did not include acute MI. The view that coronary thrombus, due to rupture of the underlying plaque and frequently associated with dissecting hemorrhage from the lumen into the plaque causes MI, had lost its dominance. Branwood had concluded that coronary thrombosis was not the cause but the consequence of MI, occurring in a minority of patients. Paterson had ascribed plaque hemorrhage to rupture of capillaries within the plaque. Autopsy studies in the mid‐1960s provided fresh evidence that coronary thrombi were common in acute MI and that intimal fissuring caused both intraluminal thrombosis and plaque hemorrhage. Despite this, Robert's view that plaque fissures were artifacts resulting from sectioning arteries, and that coronary thrombosis resulted from a prolonged low output state associated with large infarcts, prevailed. Meanwhile, European investigators continued to explore thrombolysis in acute MI, although they believed that the lysis time for a coronary thrombus exceeded the time limit of myocardial tolerance of anoxia. They hoped to improve collateral flow and microcirculation by lysing microthrombi in capillaries and venules within and around the infarct zone. The reduction in blood viscosity associated with fibrinolytic therapy was expected to further improve collateral flow and to decrease myocardial oxygen demand by reducing afterload. The discussion about the pathogenesis of acute MI was limited by the inherent selection bias of autopsy studies and a paucity of in vivo angiographic data.
Balloon Atrial Septostomy: The Oldest Pediatric Interventional Procedure
Authors: PATEL HITENDRA T. , CAO QI‐LING , HIJAZI ZIYAD M.
Published: June 2007

Balloon atrial septostomy (BAS) remains an important interventional procedure in the palliation of certain forms of congenital heart disease (CHD), Currently, there are four Food and Drug Administration approved catheters (The Miller catheter, the Rashkind catheter, the Fogarty catheter, and the NuMED septostomy catheter) being used for this procedure. The incidence of complications using these catheters ranges from 0%–11%. The purpose of this article is to discuss the available data using these catheters and to report our own experience using the new NuMED catheter. Sixteen patients with CHD (transposition of the great vessels in 14, hypoplastic left heart in one, and one patient with double outlet right ventricle and mitral atresia) underwent BAS using the new NuMED catheter. Twelve patients were < 24‐hours old, 3 < 1‐week old, and one patient was 72‐days old at the time of the procedure. The mean ± SD weight was 3.4 ± 0.6 kg. The aortic saturation increased from 75%± 19% to 90%± 5% (P = 0.002), and the mean v‐wave gradient between the left and right atrium decreased from 5.4 ± 3.7 to 1.6 ± 2.6 mmHg (P < 0.001); the mean v‐wave gradient decreased from 5.9 ± 3.3 to 1.6 ± 2.6 mmHg (P < 0.001), and the mean gradient decreased from 3.9 ± 2.4 to 0.5 ± 1.1 mmHg (P < 0.001). The diameter of the atrial communication increased from 2 ± 1.1 to 6.5 ± 1.1 mm (P < 0.001). The only complication encountered was an episode of atrial flutter in one patient, which responded to cardioversion. We conclude that BAS using this new catheter is safe and effective.
Peripheral Pulmonary Artery Stenosis: Acute and Mid‐term Results of High Pressure Balloon Angioplasty
Authors: ETTINGER LEIGH M. , HIJAZI ZIYAD M. , GEGGEL ROBERT L. , SUPRAN STACEY E. , CAO QI‐LING , SCHMID CHRISTOPHER H.
Published: June 2007

Surgical angioplasty for branch pulmonary arterial stenosis (BPAS) is associated with a low success rate and a high mortality rate. The success rate of balloon angioplasty using low pressure balloon catheters is about 60%. Little data are available on the success rate using high‐pressure balloon (HPB) catheters. Therefore, our goal is to report the procedural and mid‐term success rates using HPB catheters for the treatment of BPAS and those factors associated with success. 38 patients (25 boys/13 girls) with BPAS underwent at least one attempt (48 procedures) of balloon angioplasty using HPB catheters. Their median age was 1.1 years (range, 0.1–22.1 year), and their median weight was 9.6 kg (range, 3.7–61 kg). Thirty patients (79%) had BPAS following surgical intervention for their cardiac defects (mostly post tetralogy of Fallot), and eight (21%) patients had the BPAS associated with Williams syndrome (2 patients), Alagille syndrome (one patient), unoperated tetralogy of Fallot (one patient), and congenital BPAS (4 patients). Twenty‐six procedures involved the left pulmonary artery (LPA), and 22 procedures involved the right pulmonary artery (RPA). The overall acute success rate was 56% (27 of 48 vessels). The mean ± SD of the gradient across the stenotic segment decreased from 37 ± 20 to 23 ± 20 mmHg (P < 0.001), and the diameter of the narrowest segment improved from 3.5 ± 1.6 to 5.7 ± 2.5 mm (P < 0.001). The median RV/AO pressure ratio decreased from 0.64 to 0.52 (P = 0.009). The median ratio of balloon size to the diameter of the narrowest segment was 2.67 (range, 1.3–7.8). Lesion location (RPA) was associated with higher acute success rate (P = 0.03), but not with mid‐term outcome. Acute (P = 0.006) and mid‐term (P = 0.04) success were related to balloon diameter to vessel diameter ratio. At mid‐term follow‐up (median interval 2.5 years), 16 vessels (33%) were widely patent. Complications included perforation of a small branch pulmonary artery in one patient, resulting in hemoptysis with complete recovery. One patient developed pulmonary artery hypertension; two patients developed an aneurysm of the dilated segment; one patient developed femoral vein thrombosis; and one patient had a paradoxical embolus associated with a cerbrovascular accident. There were no procedure‐related deaths. We conclude that BPAS is challenging to treat. The use of HPB angioplasty may avoid surgery or the permanence of stem implantation and should be the first intervention for this condition in the pediatric patient. Other interventions should be reserved for refractory stenosis.
Interventional Catheterization in Kawasaki Disease
Authors: KATO HIROHISA , ISHII MASAHIRO , AKAGI TEIJI , ETO GENZYU , IEMURA MOTOHUMI , TSUTSUMI TAKAHIRO , UENO TAKAFUMI
Published: June 2007

The experiences of catheter interventional treatment in Kawasaki disease are quite limited. In this article, we report our experiences of catheter intervention. We performed the percutaneous transluminal coronary revascularization (PTCR) in 18 cases, the percutaneous transluminal coronary angioplasty (PTCA) in 12, the stent implantation in 7, and the percutaneous transluminal coronary rotational ablation (PTCRA) in 7, which resulted in success in 55.5%, 75%, 100%, and 100%, respectively. In this article, we discuss the indications and methods for coronary artery lesions of long‐term Kawasaki disease. PTCR is useful for treatment of acute myocardial infarction and for prevention of massive thrombus formation, particularly within 2 years from the onset of Kawasaki disease. PTCA is effective in many instances, particularly in patients without severe calcification of the coronary artery. However, neoaneurysm had developed in a certain number of the patients. Stent implantation is more preferable than PTCA, because it may potentially prevent neoaneurysmal formation and restenosis. Rotational ablation is effective for the stiff stenotic lesions with severe calcification, particularly for ring calcification, which frequently develops in the long‐term Kawasaki disease patients. The intravascular ultrasound is very useful in evaluating the tissue characterization of the coronary artery and to select the treatment strategy, and to evaluate the catheter interventional treatment.
The Transcatheter Management of the Neonate and Infant with Pulmonary Atresia and Intact Ventricular Septum
Authors: CHEATHAM JOHN P.
Published: June 2007

The optimal management of the neonate and infant with pulmonary atresia (PA) and intact ventricular septum (IVS) remains controversial. The ultimate aim of any treatment algorithm is to achieve a four‐chambered, biventricular, completely separated circulation. In 1991, transcatheter perforation of the atretic membrane followed by successful balloon valvuloplasty was reported using a laser‐assisted guidewire in the United Kingdom and the stiff end of a guidewire in the United States. The following year, a radiofrequency (RF) guidewire was successfully used, while stenting of the ductus arteriosus to maintain adequate pulmonary blood was also reported. Most recently, a steerable 5 Fr RF catheter was used to “burn” the atretic membrane. From a series of 15 publications, a total of 69 neonates underwent attempted pulmonary valve perforation: 17 laser guidewire, 28 RF guidewire, 25 stiff end guidewire, and 1 steerable RF catheter. Successful perforation by technique was: 82.4% laser, 88.5% RF, 68% stiff end, and 100% steerable RF. The accumulative success rate was 79.7%, mortality 4.3%, major complication 18%, and need for additional pulmonary blood 48%. Follow‐up thus far has been encouraging. The technique of transcatheter perforation of the atretic pulmonary valve membrane is demanding and not without risk, but in experienced hands can be successful nearly 90% of the time using the RF guidewire. RF energy is commonly used for other cardiac problems and has inherent cost and availability advantages over laser energy. Since nearly 50% of the neonates still require additional pulmonary blood flow, the interventionalist must be capable and ready to stent the PDA, or send to surgery. The neonate with right ventricular (RV) dominant coronary circulation remains a high risk group. However, careful cardiac catheterization with temporary transcatheter RV decompression may lead to a better understanding of this complex physiology.
Pathogenesis of Acute Ischemic Coronary Syndromes
Authors: TALLEY J. DAVID
Published: June 2007

Understanding of the pathogenesis of acute ischemic coronary syndromes has lead to the development of novel diagnostic and therapeutic modalities offering the possibility of improved clinical outcomes. This article details the importance of the vulnerable atherosclerotic plaque, invlammaiton and plaque rupture and thronbosis in the development of the clinical manifestations of an acute ischemic coronary syndrome.
Mitral Balloon Valvuloplasty as an Outpatient Procedure Using Inoue Balloon Technique
Authors: SIVANANDAM VASUDEVAN , FAWZY MOHAMMED EID , MIMISH LAYTH A. , NIAZI KUSHROW , KINSARA ABDUL HALIM , KHAN BASHIR A. , HALEES ZOHAIR AL
Published: June 2007

Objective: To evaluate the safety and feasibility of mitral balloon valvuloplasty (MBV) as an outpatient procedure. Background: MBV is usually done as an inpatient procedure, requiring 3–4 days of hospital admission. Only one report is available about MBV as a day case procedure in the English literature. Methods: Between October 1994 and December 1996, 128 patients underwent MBV using an Inoue balloon. Of those, 31 patients (Group I) had the procedure as outpatients and 97 patients (Group II) as inpatients. Their mean age in Group I was 29 ± 9 years and in Group II 32 ± 10 years (P < 0.3). Atrial fibrillation was present in 4 patients in Group I and in 13 patients in Group II (P < 0.99). Results: Hemodynamic study revealed that mitral valve area increased from 0.9 ± 0.2 to 1.9 ± 0.5 cm2* in Group I and from 0.8 ± 0.2 to 1.7 ± 0.5 cm2* in Group II, Left atrial pressure decreased from 24 ± 5 to 15 ±6 mm Hg* in Group I and 24 ± 6 to 16 ± 5 mmHg in Group II.* Mitral valve gradient decreased from 15 + 5 to 5 + 2 mmHg in Group I and 15 + 5 to 6 + 3 mmHg in Group II* (*P < 0.001). Patients in Group I stayed in the Preadmission Unit for a mean period of 9.5 ± 2.5 hours. Patients in Group II stayed for a mean of 2.5 days in the hospital. Severe mitral regurgitation developed in one patient in each Group and needed semiurgent mitral valve replacement without sequela. No death, convulsions, or thromboembolism were encountered, and three patients in both Groups developed minor hematoma and needed no additional treatment. Conclusion: MBV as an outpatient procedure is feasible and safe and could significantly decrease the cost of medical care.
Buttoned Device Closure of the Atrial Septal Defect
Authors: RAO P. SYAMASUNDAR , SIDERIS ELEFTHERIOS B.
Published: June 2007

Whereas surgical closure of atrial septal defects (ASDs) is safe and effective, it carries significant morbidity and expense; therefore, nonsurgical, transcatheter methods have been developed. A variety of transcatheter implantable devices have been investigated; in this article, the buttoned device will be reviewed. Clinical trials with the buttoned device began in 1989, and the device, based on experience with device implantation, has been modified, and currently a fourth‐generation device with two radiopaque spring buttons is in use and is generally implanted by an over‐the‐wire technique. Now nearly 1,000 devices have been implanted. In the initial generations of the device, while the effectiveness of occlusion was good, the unbuttoning rate was high, in the range of 7%. With the modification of the device, the unbuttoning rate has fallen to nearly 1%. During follow‐up of the initial 180 implantations, up to 7 years, there was need for surgical or catheter reintervention in approximately 8% of patients. Progressive decrease in the residual shunts occurred without any other major complication. Further modification of the device, such as inverted buttoned device to occlude interatrial right‐to‐left shunts and centering buttoned device to close large ASDs with poor septal rims, have been undertaken with good results. The device has also been successfully used to close the patent foramen ovalia/small ASDs to prevent recurrence of strokes presumably secondary to paradoxical embolism. Several new devices have recently emerged, and clinical trials have begun. The preliminary results with these devices are similar to the preliminary observations with the Clamshell and buttoned devices. Experience in a larger number of patients and longer duration of follow‐up is necessary for comparison with similar data accumulated with the buttoned device. To date, the buttoned device has the largest experience and longest follow‐up, and current data suggest safety and efficacy of the buttoned device in closing ASDs.
Intracoronary Radiation Post PTCA Prevents Late Arterial Constriction
Authors: WAKSMAN RON , CONDADO JOSE A. , SAUCEDO JORGE F. , LANSKY ALEXANDERA J. , POPMA JEFF J. , KLEIN J. LARRY , CROCKER IAN R. , WILLIAMS DAVID O. , KING SPENCER B.
Published: June 2007

Vascular constriction post PTCA is a major component in the mechanism of restenosis following intervention. Ionizing radiation demonstrated reduction of neointima formation after injury in animal models and lowered the restenosis rates in pilot clinical studies. To determine the effect of intracoronary radiation therapy on vascular remodeling, angiograms from two radiation trials were analyzed by QCA methods. Patients in these trials had de novo lesions and were treated with balloon angioplasty followed by either beta or gamma radiation. All patients were studied angiographically at 6 months; patients with total occlusion at the treated artery were excluded from the analysis. In the gamma trial, 192‐Iridium was utilized in 14 patients (15 lesions) with doses between 20‐25 Gy. In the beta trial, 90‐Sr/Y was utilized in 17 patients (17 lesions) with doses between 12‐16 Gy. The QCA analysis from these studies demonstrated negative late loss and late loss index at six months for patients from the beta (‐0.02 ± 0.3) and the gamma (‐0.19 ± 0. 3) study. The effect of positive remodeling was maintained at 24 months, ‐0.16 ± 0.4 in the gamma group. Larger MLD at follow‐up compared to the immediate post MLD were demonstrated in 50% of the patients from both studies. Thus, intracoronary radiation resulted in lower late loss and late loss index rates than previously reported following balloon angioplasty alone suggesting a positive vascular remodeling effect of intracoronary radiation.
Surgical Repair of Femoral Artery Puncture Sites
Authors: FINK OLIVER , VALESKY ANTON
Published: June 2007

The incidence of arterial puncture site complications after transfemoral catheterization is mainly dependent on patient related and procedure related factors. Color flow duplex sonography is the method of choice for detection of the arterial injuries and a possibility for noninvasive ultrasound guided compression therapy of pseudoaneurysms. In our own experience we describe the vascular surgical treatment of 172 patients with 159 pseudoaneurysms (26 combined with AV fistula), 10 arterial dissections and thrombosis, 3 dislocated and lost intravascular materials. Indications for vascular surgical treatment are failure of compression therapy to pseudoaneurysms and arteriovenous fistulas, pain with progressive enlargement of the pseudoaneurysm, arterial dissections and thrombosis with limb ischemia, and anticoagulation. Surgical repair requires a differential vascular corrective treatment.
The Restoration of Coronary Blood Flow in Acute Myocardial Infarction
Authors: TIMMIS GERALD C. , TIMMIS STEVEN B.H.
Published: June 2007

When an acute coronary syndrome degenerates into a myocardial infarction the centerpiece of therapy is the normalization of myocardial blood flow to the extent that it can be achieved in the shortest interval possible after the onset of symptoms. A variety of strategies including mechanical intervention have been used to achieve this goal, but the benchmark therapy to which all other therapeutic alternatives must be compared involves the use of thrombolytic agents. However, given the availability of catheter laboratories and interventional expertise, mechanical reperfusion appears to be at least as good and probably better than thrombolytic therapy. Because of the universal access to thrombolytic therapy, certain clinical issues must be underscored. More important than pursuing the ideal thrombolytic agent is the administration of thrombolytic therapy at the earliest possible juncture after the onset of symptoms heralding myocardial infarction. Adjunctive therapy includes aspirin and intravenous heparin. Altering platelet activity by glycoprotein IIb/IIIa receptor blockers holds enormous promise for thrombolytic therapy and PTCA, but as yet enjoys limited availability on a global scale.
Update on Percutaneous Intervention in Left Main Artery Stenosis
Authors: Park Seung‐Jung
Published: June 2007

Advances in percutaneous intervention make it possible to expand the use of angioplasty to multiple and complex coronary artery lesions. Unfortunately, unprotected left main coronary artery (LMCA) stenosis has been regarded as a contraindication of percutaneous intervention because of its potential risk of early cardiac death and poor late clinical outcomes. However, LMCA stenosis is an attractive target for percutaneous intervention because of its larger caliber, short lesion length, and lack of tortuosity. Recently, stenting of unprotected LMCA stenoses has been reported with promising results in carefully selected patients. It now can be considered as a therapeutic option of unprotected LMCA stenoses in selected centers. This article summarizes the current status, technical considerations, and future directions of percutaneous intervention in the treatment of unprotected LMCA stenoses.
Update on Percutaneous Management of Chronic Total Occlusion
Authors: NOBUYOSHI MASAKIYO , SHIZUTA SATOSHI
Published: June 2007

Management of chronic total occlusions (CTOs) remains a challenge for interventional cardiologists. Despite advances in the design of angioplasty hardware and increased operator experience, percutaneous angioplasty of CTO still is associated with a relatively low primary success rate compared with non‐CTO. Although the stent has dramatically improved initial and long‐term outcome, the incidence of restenosis and reocclusion continues to be high in patients with excessive lesion length and/or small vessel size. Adjunctive pharmacotherapy, such as platelet glycoprotein IIb/IIIa receptor antagonist, may play an important role in the prevention of early reocclusion as well as late restenosis. Similarly, radiation therapy may be useful in the prevention/treatment of in‐stent restenosis. Although observational data have shown a poor long‐term survival in patients with CTO, convincing prospective or randomized data are lacking. Future investigations will need to focus on the long‐term outcome of patients with CTO referred for angioplasty compared with CABG or medical therapy.
Update on Coronary Intervention Through the Radial Approach
Authors: SAITO SHIGERU
Published: June 2007

Transradial coronary intervention can result in similar procedural and clinical outcomes compared to those of transfemoral coronary intervention with lower access site complications. Continuing improvements in intracoronary stents and other interventional devices will facilitate further the coronary interventions by the transradial approach.
Development and Pathophysiological Basis of Thrombolytic Therapy in Acute Myocardial Infarction: Part IV
Authors: RENTROP K. PETER
Published: June 2007

Acute and day 10 to 14 recanalization rates with intracoronary thrombolytic and/or spasmolytic therapy were determined in the First Mt. Sinai‐N.Y.U. Reperfusion Trial (1984). Recanalization of total occlusion was accelerated by intracoronary streptokinase, the first proven potentially beneficial effect of thrombolytic therapy. Intravenous administration of thrombolytic agents, including t‐PA, was less effective in accelerating recanalization than intracoronary streptokinase as assessed by 90‐minute rates of TIMI‐III flow. In clinical practice the greater ease of intravenous administration outweighed this disadvantage, but intracoronary administration was uniquely suited to analyze the pathophysiological principles of reperfusion therapy. The first randomized trial (n = 533) to establish the benefits of early reperfusion, the Netherlands Randomized Trial, achieved infarct vessel patency in 85% of patients within 200 minutes of symptom onset by administering intracoronary streptokinase alone or following a rapid intravenous infusion of streptokinase. Ejection fraction improved significantly and mortality at 28 days was reduced (6% vs 12%). The ISIS‐2 Trial (1988) showed mortality reduction with intravenous thrombolytic therapy up to 24 hours after infarct onset, but did not explain the benefit of late reperfusion. In the Second Mt. Sinai‐N.Y.U. Reperfusion Trial (1989; n = 393), intracoronary streptokinase administered 4 to 14 hours after infarct onset increased thallium uptake. Streptokinase improved ejection fraction in patients with collateralized total occlusion but not in those with noncollateralized total occlusion. Preintervention antegrade flow was associated with ejection fraction improvement regardless of treatment assignment. We concluded that thrombolytic therapy after > 4 hours of infarction salvages myocardium in patients with collateralized total coronary artery occlusion. Total coronary occlusion was associated with collateral flow in 33% at acute angiography, but in 90% at day 10 to 14 angiography, indicating a second phase of collateral growth. An angioplasty model was developed to assess appearance and disappearance of collateral flow immediately after controlled coronary occlusion and reflow in humans. Using this model we demonstrated limitation of ischemia by collateral recruitment prospectively.
Design and Objectives of the Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) Study
Authors: O'NEILL WILLIAM W. , SERRUYS PATRICK , KNUDTSON MERRILL , VAN ES GERRIT‐ANN , TIMMIS GERALD C. , VAN DER ZWAAN COEN , KLEIMAN JAY , BARKER KERRY , DREILING ROGER , HUBBARD RICHARD , ALEXANDER JOHN , ANDERS ROBERT
Published: June 2007

Clinical trials have demonstrated the efficacy of glycoprotein (GP) IIb/IIIa antagonists in preventing the thrombotic end points of death, myocardial infarction, and urgent revascularization when they are administered at the time of percutaneous coronary revascularization (PTCR). It has been postulated that prolongation of receptor blockade beyond acute intervention would extend the clinical benefit of these agents. The Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) study was a multicenter, international, randomized placebo‐controlled trial of the oral GP IIb/IIIa antagonist Xemilofiban administered prior to and after PTCR. The study was designed to assess the efficacy and safety of continuing oral xemilofiban for 6 months to prevent these primary thrombotic end points. More than 7,200 patients were randomized in 29 countries to receive placebo or one of two doses of xemilofiban. Stenting was performed at the discretion of the operator. All patients received aspirin and periprocedural heparin; all stented patients received continuous xemilofiban, or ticlopidine for 2–4 weeks followed by xemilofiban‐placebo. Most patients were also evaluated 1 month after conclusion of the study drug treatment. Clinical data from up to 6 months of drug treatment and 1 month posttreatment were used to evaluate the acute and long‐term efficacy and safety of xemilofiban. Secondary end points included the need for any revascularization, repeat hospitalization for unstable angina, and nonhemorrhagic stroke. The cumulative incidence of bleeding events and effects of xemilofiban in stented and nonstented patients were evaluated. The efficacy of continuing xemilofiban and aspirin therapy as the sole antithrombotic medications following stent deployment was assessed against a ticlopidine and aspirin control group. The incremental clinical benefit of long‐term receptor blockade over acute receptor antagonism was evaluated.