bluuebunny/crossref_metadata_2025 huggingface dataset:
Ethical and Economic Issues in Interventional Cardiology
Authors: REEDER GUY S.
Published: June 2007

Complex ethical and significant economic issues are encountered in the practice of interventional cardiology. The interventionalist must strive to carefully assess the indications, benefit/risk ratio, and quality of life implications of planned therapy, and communicate this best estimate to the patient in understandable terms that allow informed patient involvement in decisions regarding revascularization strategy. When investigational devices are contemplated, institutionally approved protocols should be utilized by individuals without potential conflict of interest. At the same time, when not in conflict with ethical decisions, economic consequences of device selection must be considered as well.
The Western Washington and Myocardial Infarction Triage and Intervention Trials of Thrombolytic Therapy: 15 Years of Collaboration in the Pacific Northwest
Authors: MAYNARD CHARLES , EVERY NATHAN R. , MARTIN JENNY S. , HALLSTROM ALFRED P. , KENNEDY J. WARD , WEAVER W. DOUGLAS
Published: June 2007

Beginning in 1981, collaborative efforts developed between the University of Washington and community hospitals in Washington, British Columbia, Canada, and later outside the Pacific Northwest, have generated important findings about the treatment and outcome of acute myocardial infarction (AMI). These efforts, collectively known as the Western Washington and Myocardial Infarction Triage and Intervention Project trials, have included randomized trials of thrombolytic drugs, direct antithrombins, platelet receptors, antagonists, and cell adhesion blockers, as well as the formation of registries of consecutive patients admitted to coronary care units with the diagnosis of suspected AMI. Results of these trials have demonstrated that thrombolytic therapy significantly reduces mortality and morbidity from AMI with minimal risk to patients, and that early treatment is associated with improved infarct size and better left ventricular function. The efforts of the next decade should be focused on the further removal of barriers to rapid treatment and to the evaluation of new agents, so that the devastating effects of myocardial infarction are minimized to the fullest extent.
Ten Years Of Stenting: What Next?
Authors: SIGWART ULRICH
Published: June 2007

Endovascular scaffolds have been tried in animals long ago, but it took 70 years to introduce stents into clinical practice. In 1994, two major randomized trials confirmed that stenting after percutaneous transluminal coronary angioplasty (PTCA) does indeed reduce the incidence of restenosis, as well as other events like myocardial infarctions and emergency surgery. Numerous stents are now in use: self‐expanding and balloon‐expandable stents; stainless steel stents; platinum and tantalum stents; flexible and articulated stents; and lately also heparin‐coated stents. New designs with improved fluid dynamics and optimal conformability are now being used. All stents are foreign bodies, and may induce spasm and thrombosis. Meticulous drug treatment was thought to be essential in reducing the incidence of subacute thrombosis, but was associated with a significant number of local bleeding complications. Warfarin has even been suspected of favoring stent thrombosis. An optimal implantation strategy that aims at an absolutely perfect primary result, with no residual narrowing, with absence of dissections, and with complete stent expansion, has dramatically reduced both the complication rate after stenting and the need for heavy anticoagulation. The role of platelet inhibition after stenting is becoming increasingly clear. Ticlopidine in combination with aspirin is presently the recommended strategy. Polymer stents have not yet fulfilled their expectations but hold great promise as a matrix for future drug delivery systems, possibly in combination with metal. Metal stents with adequate structural properties seem to have restenosis rates of some 10%. Radioactive stents (to further reduce intimal hyperplasia) are currently in clinical investigation. In summary, stents have revolutionized the practice of transluminal angioplasty and have secured their place for the future.
In‐Hospital Results of the Wiktor Stent in Acute Myocardial Infarction
Authors: GARCÍA EULOGIO
Published: June 2007

Background: Coronary angioplasty has been established as the preferred method of treatment for patients with acute myocardial infarction when they are admitted to a hospital with skilled interventional cardiologists and personnel well‐trained in cardiac catheterization techniques. Nevertheless, the possibilities of artery reocclusion, recurrent ischemia, and high rates of late restenosis have made some investigators believe that coronary stenting could be a better mechanical reperfusion technique than conventional balloon angioplasty. Methods: We reviewed the in‐hospital results of patients who received a Wiktor coronary stent implant during primary or rescue angioplasty for acute myocardial infarction within 6 hours of either the onset of pain or the recurrence of symptoms after thrombolytic administration. We excluded patients in shock and those whose symptoms were produced by an acute occlusion after an angioplasty procedure. Quantitative coronary analysis of the lesions treated were performed by automatic border detection using the on‐line DCI system by Phillips or off‐line CMS system by Medis. Results: Thirty‐three patients, aged 59 ± 13 years (79% male), received one or more coronary stents (41 stents were implanted) for treatment of acute myocardial infarction during primary angioplasty (30) or rescue angioplasty (3) after the onset of symptoms. Twenty‐nine of the patients were in Killip Class I (patients in shock were excluded). The infarct related artery was the left anterior descending in 19 patients (58%), the right coronary artery in 12 (36%), and the left circumflex in 2 (6%). Twenty‐seven patients (82%) had TIMI 0‐1 flow on the initial angiography. After stent implantation 100% of the patients had TIMI III (85%) or TIMI II (15%) flow. The minimal luminal diameter of the infarct related artery increased from 0.22 ± 0.38 mm before the procedure to 2.99 ± 0.48 mm after stem implantation. Most of the patients (27 [84%]) received antiaggregation therapy‐after the procedure. There was no mortality or reinfarction, although one patient had an embolic stroke. There were no cases of acute or subacute thrombosis of the stent. Conclusion: Use of the Wiktor stent during angioplasty for acute myocardial infarction is followed by immediate angiographic and in‐hospital clinical results comparable to results obtained with other types of stent. This stent is particularly useful in curved lesions and those with an important collateral branch arising from the lesion. If the angiographic result is optimal, the patient can be managed with antiaggregant therapy after stent implantation.
The Comparison of Balloon versus Rotational Angioplasty (COBRA) Study Protocol: A Prospective Randomized Study
Authors: ERBEL RAIMUND , DILL THORSTEN , DIETZ ULRICH , WEBER PETER W. , LIU FENGQI , KÜCHLER ROBERT , HAUDE MICHAEL , RUPPRECHT H‐J , KUCK KARL‐HEINZ , GE JUNBO , HAMM CHRISTIAM W.
Published: June 2007

The Comparison of Balloon versus Rotational Angioplasty (COBRA) study is a prospective, randomized study to compare short‐ and long‐term effects of PTCA and high speed PTCRA (or rotablation) in patients with complex coronary stenoses. Patients with angiographically defined complex coronary stenoses (> 70% diameter reduction) are included in the study. The trial has recruited 501 patients who will have detailed follow‐up for 6 months. The primary end points are: (1) procedural success, defined as angiographically proven residual stenoses < 50% and stenosis reduction of ± 20% in absence of new myocardial infarction, emergency CABG, or death; (2) 6‐month restenosis in the treated segment; and (3) major cardiac events during the follow‐up period. Additionally, improved exercise tolerance will be scored. The final results of the study are expected by late 1997.
Lumps and Bumps: Coronary Artery Aneurysms in Adults
Authors: JAVIER JULIAN J. , CONLEY THOMAS D. , PIERRE MARK St. , TALLEY J. DAVID
Published: June 2007

A 57‐year‐old man was admitted with chest discomfort consistent with myocardial ischemia. The initial ECG showed normal sinus rhythm and an incomplete right bundle branch block, without myocardial ischemia or injury. As a child he was hospitalized for a “rare form” of rheumatic fever. In 1987, he underwent cardiac catheterization revealing coronary artery aneurysms consistent with Kawasaki disease.

Exercise scintigraphy with 99Tc sestamibi showed a reversible defect in the inferior wall. Cardiac catheterization demonstrated multiple coronary artery aneurysms in the right coronary artery (Fig. 1) and proximal left anterior descending coronary artery (Fig. 2). The aneurysms ranged from 4–6 mm in diameter. The patient's medical regimen was optimized and his symptoms improved.
The Total Artificial Heart: From Initial Application to Therapeutic Option
Authors: OLSEN DON B. , LONG JAMES W. , ANDERSON JEFFREY L.
Published: June 2007

Interest in development of mechanical cardiac support has grown out of the realization of the enormous impact of heart failure‐related mortality, the limited potential to provide cardiac transplantation (approximately 2000 patients/year in the USA), and the long waiting period required, even in appropriately selected patients. Both left ventricular assist devices (LVADs) and total artificial hearts (TAHs) have been developed to assist in addressing these needs. This review focuses on TAH development. The first bridging TAH was implanted in 1969, and the first permanent device in 1982 with a patient survival of 112 days. Since that time, evolution of device design and manufacture, patient selection, and ancillary therapies have occurred. Worldwide clinical application now spans 27 years and includes experience with TAH implantation in 311 patients, with eight different pneumatically driven devices implanted either as permanent devices (N = 5) or as temporary, bridging therapy to transplantation (N = 306), with all but four implanted after 1984. Utah‐developed TAHs represent the largest source of this experience (N = 287). In the earlier (Symbion manufactured) TAH series (N = 204, 1985–1992), 42% of implanted patients and 59% of transplanted patients were discharged alive from the hospital, and average support time was 24 days. In the current (Cardio West manufactured) series (N = 78, 1993–1996), 67% of implanted patients and 94% of transplanted patients were discharged alive, and average support time is 30 days. Of transplanted and discharged patients, 98% remain alive. With improvements in device design and manufacture, as well as anticoagulant regimens, the incidence of stroke with long‐term deficits has decreased from 3 out of 7 in 1984‐1985 to 1 out of 61 in 1988, with no permanent deficits since then. Infection rates have also decreased. Only one implanted patient died of TAH mechanical failure (an early experience). Based on this evolving experience, use of the TAH as a bridge to transplantation in selected patients who are not appropriate for an LVAD has become a viable current therapeutic option. Further TAH development and application is anticipated.
Antiplatelet Versus Warfarin Therapy: Platelet, Neutrophil, and Thrombus Deposition for Intracoronary Stents in a Porcine Model
Authors: TANGUAY JEAN‐FRANÇOIS , CROWLEY JAMES J. , KRUSE KEVIN R. , ARMSTRONG BRIAN A. , SANTOS RENATO M. , ZIDAR JAMES P. , VIRMANI RENU , PHILLIPS HARRY R. , STACK RICHARD S.
Published: June 2007

Antiplatelet therapy may offer an advantage over warfarin in reducing adverse clinical events after intracoronary stem implantation. The mechanism of this effect has not been elucidated but platelet adhesion may play a predominant role in the process of subacute stent thrombosis. This study compared the effect on platelet, neutrophil, and thrombus deposition of three different anticoagulation regimens (aspirin/warfarin vs aspirin/ticlopidine vs aspirin alone) after intracoronary stenting in juvenile swine. Thirty stents were deployed in 15 juvenile farm swine randomized to one of 3 anticoagulation protocols: aspirin 325 mg/day; aspirin 325 mg/day and ticlopidine 500 mg/day; aspirin 325 mg/day and warfarin 0.1 mg/kg/day. Autologous platelets were labeled using 111Indium‐oxime and a slotted tube metal stent was deployed using a high pressure balloon. Platelet deposition in the stented segment was determined at 24 hours. Each segment was analyzed by light microscopy to document an injury score; mean and maximum thrombus deposition per strut were measured; and neutrophils were counted on each metal strut and in the vessel wall. Platelet deposition at 24 hours was significantly higher in the aspirin/warfarin group (3.69 ± 1.16 ± 108 plts/cm2) than in the aspirin/ticlopidine (1.74 ± 0.45 ± 108 plts/cm2, P = 0.0009) or aspirin (2.42 ± 2.13 ± 108 plts/cm2, P = 0.03) groups. There was no significant difference between the aspirin and aspirin/ticlopidine groups (P = 0.9). Mean thrombus area per strut was significantly greater in the aspirin/warfarin group (0.027 ± 0.006 mm2) compared to the aspirin/ticlopidine group (0.017 ± 0.002 mm2, P = 0.002). The majority of the thrombus (79%) but minority of neutrophils (24%) were found on the stent struts. In this coronary stent model, warfarin given with aspirin was associated with greater thrombogenicity and more platelet deposition than either aspirin/ticlopidine or aspirin alone.
Infrarenal Aortic Stenosis: Percutaneous Stent Therapy
Authors: WHITE CHRISTOPHER J. , EL‐EISAWY REDA
Published: June 2007

Percutaneous therapy of distal abdominal aortic occlusive disease is an extension of the strategy for treating iliac artery occlusive lesions. The use of stents for these lesions offers the advantage of increased primary success and the potential for improved long‐term patency. We present an illustrative case of primary stent therapy for a distal aorta occlusive lesion and describe the assessment of these patients and the technique of infrarenal aortic stent placement. Percutaneous stent therapy of these lesions offers an attractive alternative to surgical therapy in these patients.
Recanalization of Totally Occluded Saphenous Vein Bypass Grafts With Rheolytic‐Thrombectomy Device AngioJet® Catheter
Authors: LIU FENGQI , HAUDE MICHAEL , GE JUNBO , EICK BEATE , BAUMGART DIETRICH , ERBEL RAIMUND
Published: June 2007

We report a preliminary case of successful recanalization of a saphenous vein graft using a novel thrombectomy device AngioJet® catheter. The case demonstrates that the AngioJet catheter is a simple and safe tool for the clinical application. The device may play a useful role in the treatment of thrombotic lesions.
Successful Percutaneous Balloon Valvuloplasty for Combined Congenital Tricuspid and Pulmonary Stenosis
Authors: AZHARI NAWAL , AL FADEL FADLEY , OMAR GALAL
Published: June 2007

Percutaneous balloon valvuloplasty was successfully performed in a 13‐month‐old symptomatic infant with congenital tricuspid and pulmonic valve stenosis. Both valves were dilated in the same setting, resulting in a significant hemodynamic and clinical improvement.
Multimodality Neuromonitoring for Neurocardiology
Authors: EDMONDS HARVEY L. , SINGER IGOR , SEHIC AIDA , STRICKLAND TED J.
Published: June 2007

Neurophysiologic monitoring, including quantitative EEG, transcranial Doppler (TCD) ultrasound and transcranial near‐infrared spectroscopy (NIRS), can be of diagnostic value in neurocardiology—the study of dysfunctional brain‐heart relationships. A new multivariate EEG technique bispectral analysis, enables the cardiologist to objectively and precisely document transient episodes of syncope and seizure. TCD permits precise determination of the nature and extent of cerebral hemodynamic irregularities, while NIRS detects frontal lobe imbalance in the delivery and consumption of oxygen. These powerful new neurophysiologic tools, coupled with traditional systemic hemodynamic and electrocardiographic measures, will undoubtedly improve the diagnostic yield in the complex determination of the causes of syncope and cardiac‐based confusional states.
Development and Pathophysiological Basis of Thrombolytic Therapy in Acute Myocardial Infarction Part II. 1977‐1980 The Pathogenetic Role of Thrombus Is Established by the Goettingen Pilot Studies of Mechanical Interventions and Intracoronary Thrombolysis in Acute Myocardial Infarction
Authors: RENTROP K. PETER
Published: June 2007

Between 1977 and 1980, our group performed immediate coronary angiography in 158 patients admitted with acute myocardial infarction (MI) at the University of Goettinger, Germany. From June 1978 to May 1979, our pioneering study of mechanical transcatheter recanalization of acute total coronary artery occlusions using guidewires and tapered catheters was performed. Restoration of antegrade flow in 7 of 13 patients was associated with an improvement in left ventricular function not seen in historical controls. From June 1979 to December 1980, the pathogenetic role of thrombus and spasm in acute coronary syndromes was explored in our pioneering study of intracoronary streptokinase infusion. Following injection of nitroglycerin, streptokinase was selectively infused at a rate of 2000 U/minute for 50–95 minutes. Only four of the initial 22 infarct patients showed improvement of antegrade flow following intracoronary nitroglycerin alone. Reopening of the completely obstructed vessel or increase in lumen diameter at the site of subtotal occlusion occurred in 22 of 29 infarct patients within 15–90 minutes of streptokinase infusion but in none of the five patients with unstable angina. Chest pain was alleviated and left ventricular function was improved significantly after successful lysis. The first presentation of both our mechanical and pharmacological interventions in acute MI to a large international audience at the annual American Heart Association meeting in 1979 convinced clinicians of the etiologic role of fibrin‐rich coronary thrombus in acute MI. The demonstration of rapid restoration of antegrade flow initiated a worldwide renaissance in the application of thrombolytic therapy and paved the way for primary angioplasty in acute MI.
Historical Prospective: Therapeutic Catheterization Procedures in Congenital Heart Disease
Authors: MULLINS CHARLES E.
Published: June 2007

The development of pediatric and congenital therapeutic (“interventional”) catheterization procedures is traced from the earliest attempts to the current procedures. Therapeutic cardiac catheterization procedures for pediatric and congenital heart disease have grown from a dream to a reality during only the last three decades. Although some of the technology has come from the adult interventions and has paralleled the development of adult catheter interventions, most of the therapeutic procedures for congenital lesions were developed by a dedicated and persistent group of pediatric cardiologists and originated in the pediatric cardiac catheterization laboratories. Many of the common congenital lesions, which three decades ago required cardiac surgery for treatment, now, as standard accepted therapy, are managed in the catheterization laboratory. The most successful advances have been in the opening of stenotic valves, opening and fixing stenotic vessels with intravascular stents, and, at the opposite extreme, the closure of PDAs, secundum ASDs, some VSDs, and numerous miscellaneous abnormal communications. Although many of these therapies are now the standard of care, all of the catheter therapies in pediatric and congenital lesions are in the infancy of their development and will undergo many improvements and refinements in the future.
Balloon Aortic Valvuloplasty
Authors: RAO P. SYAMASUNDAR
Published: June 2007

Since the description by Lababidi in 1983 of balloon aortic valvuloplasty, it has been used extensively by several groups of workers for relief of valvar aortic stenosis of moderate to severe degree. The indications for the procedure are peak‐to‐peak gradients ≥ 50 mmHg with symptoms or ECG changes or a gradient of ≥ 70 mmHg irrespective of the symptoms and ECG changes. One or more balloon catheters are placed across the aortic valve, over an extra‐stiff guidewire and balloon inflated, producing aortic valvuloplasty. The recommended balloon: annulus ratio is 0.8:1.0. Immediate reduction of peak‐to‐peak gradient along with a fall of left ventricular peak systolic and end‐diastolic pressures occurs. Rarely, significant aortic insufficiency, particularly in the neonate, may develop. At intermediate‐term follow‐up, catheter‐measured peak‐to‐peak gradients and Doppler‐measured peak instantaneous gradients remain low for the group as a whole. However, nearly one‐quarter of the patients may develop restenosis, defined as peak‐to‐peak gradient ≥ 50 mmHg. The restenosis is successfully treated with surgical or repeat balloon valvotomy. Predictors of restenosis were age ≤ 3 years and an immediate postvalvuloplasty aortic valve gradient ≥ 30 mmHg. Comparison with surgical results is difficult, but overall, the balloon therapy appears to carry less morbidity. Long‐term follow‐up data are scanty. The limited data suggest low Doppler peak instantaneous gradients, minimal additional restenosis beyond what was observed at intermediate‐term follow‐up, and progression of aortic insufficiency in nearly one‐quarter of patients. Event‐free rates are 76% and 60%, respectively, at 5 and 10 years following initial balloon valvuloplasty. Based on immediate and intermediate‐term follow‐up data, balloon aortic valvuloplasty appears to produce reasonably good results, avoiding/postponing the need for surgical intervention. The late follow‐up data are of some concern in that significant aortic insufficiency with left ventricular dilatation may develop, and some require surgical intervention. Prospective studies on larger groups of children and careful comparison with long‐term follow‐up surgical data may be necessary to make a definitive recommendation that balloon aortic valvuloplasty is the therapeutic procedure of choice.
New Thrombolytics, Adjunctive Therapies, and Mechanical Interventions for Acute Ischemic Syndromes: A Current Perspective
Authors: HANNA GEORGE P. , SMALLING RICHARD W.
Published: June 2007

Significant advances occurred in the management of acute coronary syndromes over the past two decades that have resulted in > 25% reduction in mortality from myocardial infarction (MI).1 The incorporation of early thrombolysis and promptly recanalizing the occluded coronary artery receive the major credit along with improvements in intensive coronary care units (CCUs), chest pain centers, and activation of advanced emergency medical services (EMS) for prehospital treatment and resuscitation. However, acute MI (AMI) and its complications remain the leading causes of death and disability in the western world. In the past few years, aggressive interventions such as angioplasty, stents, and intra‐aortic balloon pumping (IABP)for managing acute coronary syndromes have received significant attention. However, controversy regarding their usefulness in this setting remains. In this review article, we will address some of the pros and cons of such interventions, as well as potential roles of newer thrombolytics and adjunctive therapies.
Pathogenesis of Atherosclerosis: The Alternative Hypothesis
Authors: BHAKDI SUCHARIT
Published: June 2007

The concept that oxidation is the major single event underlying the transformation of LDL to a proinflammatory molecule dominates the world literature. An alternative hypothesis on the pathogenesis of atherosclerosis will be presented here. We have found that nonoxidative, enzymatic modification of LDL with ubiquitous enzymes also transforms the molecule to an atherogenic moiety. Enzymatically altered LDL (E‐LDL) shares major properties in common with lipoproteins that have been isolated from atherosclerotic lesions. It activates complement and is recognized by a scavenger receptor on human macrophages, thus inducing foam cell formation. Uptake of E‐LDL is accompanied by induction of MCP−1 synthesis and secretion. In contrast, E‐LDL does not stimulate IL‐1 or TNF‐production and is only a weak inducer of IL‐6. Monoclonal antibodies were produced that recognize neoepitopes on E‐LDL, but that do not react with native or oxidized LDL. With the use of these antibodies, extensive deposition of E‐LDL in very early atherosclerotic lesions was demonstrated. Activated complement components colocalized with E‐LDL, corroborating the concept that subendothelially deposited LDL is enzymatically transformed to a complement activator. The relevance of unhalted complement activation was revealed by the finding that C6‐deftciency markedly protected against development of diet‐induced atherosclerosis in rabbits. Thus, our hypothesis departs from mainstream atherosclerosis research and derives from the recognition that extracellular exposition of free cholesterol by itself confers proinflammatory properties onto LDL. The degrading enzymes probably are present in the extracellular matrix, so the only requirement for atherogenesis to occur is the deposition of large amounts of LDL. Oxidative processes or infections probably play only minor roles, and reduction of LDL plasma levels will predictably represent the single most important prophylactic measure against development and progression of atherosclerosis.
Mitral Valve Repair for Isolated Mitral Valve Regurgitation: A Plea for Early Operation
Authors: PERIER PATRICK , STUMPF JÜRGEN , GÖTZ CHRISTIAN , LAKEW FATOUM , SCHNEIDER ANDREAS , CLAUSNIZER BERND , HACKER ROBERT
Published: June 2007

Although mitral valve repair is a recognized method to surgically treat mitral valve regurgitation, the ideal timing of the operation still is controversial. The goal of this study was to study the long‐term results of mitral valve repair focusing on symptomatic versus nonsymptomatic patients. From October 1988 to June 1994, 262 patients (mean age = 57.4) with isolated mitral regurgitation underwent mitral valve repair. Seventy‐nine patients (group I) were nonsymptomatic (NYHA Class I or II) and 184 (group II) were severely symptomatic (NYHA III or IV). The surgical techniques have been mainly those described by Alain Carpentier. All patients but three had an annuloplasty with a Carpentier ring. Mean follow‐up was 4.02 ± 0.1 years and total follow‐up, 972 patient‐years. There was one operative death (0.4%). Postoperative Doppler echocardiography showed satisfactory mitral valve function in 97% of the patients and two cases of systolic anterior motion (1%). At 7 years, actuarial survival was 80%± 9%, 95%± 5%, 75%± 11% for the total group, group I, and group II, respectively. At 7 years, freedom from thromboembolic or bleeding complications and reoperation was 96%± 4%, 93%± 8%, and 94%± 3%, respectively. Mitral valve repair for isolated mitral valve regurgitation provides satisfactory survival at 7 years. The long‐term survival is better when patients are operated at an early stage when they are still nonsymptomatic.
New Trends in Coronary Revascularization: Neoangiogenesis by Human Growth Factors
Authors: SCHUMACHER BERND , HANNEKUM ANDREAS , PECHER PETER
Published: June 2007

This article is a report of our clinical experience with the human growth factor FGF as applied to the ischemic human myocardium. After the completion of extensive preliminary animal experiments, the growth factor FGF, obtained from genetically manipulated Escherichia coli bacteria and highly purified, was introduced into aortocoronary bypass surgery as an additional therapeutic agent. A double‐blind study was carried out on 40 patients with coronary heart disease, separated into “growth factor” and control groups, each containing 20 members. All patients were treated for coronary three‐vessel vascular disease, in each case with an IMA bypass for the LAD and single venous bypasses for the RCX and or RCA. To bridge over additional peripheral stenoses in the LAD or one of its branches, human growth factor FGF was injected into the myocardium of those in the growth factor group. Twelve weeks later, the IMA bypasses were selectively demonstrated by intraarterial DSA. These angiographs were then quantitatively evaluated. In all patients of the growth factor group, the formation of new vessels could be demonstrated in the region where FGF had been administered in a manner strictly reminiscent of our experimental results. A capillary net sprouting from the coronary artery and making further connection with this vessel could be demonstrated, and the computer‐supported evaluation of the angiographs showed a significant increase in the blood supply of the region of the myocardium injected. The use of FGF may be the appropriate treatment for patients with peripheral stenosis or diffuse coronary arteriosclerosis who cannot be treated surgically. However, large randomized studies are required to confirm these results.
Risk Assessment for Coronary Interventions
Authors: SCHOFER JOACHIM
Published: June 2007

Risk factors associated with a poor acute outcome of coronary interventions changed significantly as a result of the development of interventional techniques and adjunct pharmacological therapies. In the 1980s morphological parameters as classified by the modified AHA/ACC score were predictive of MACE. With advanced experience and technological improvements in the early 1990s only some lesion parameters retained their predictive power for balloon angioplasty. In the era of new devices some of the lesion parameters (bifurcational lesions, calcification) remained associated with a worse acute outcome, but procedure‐related parameters (e.g., length of stented segment, remaining dissection) had more impact on the outcome. Some clinical parameters like age, presence of an acute coronary syndrome, and impaired left ventricular function are still predictive of a worse outcome. The impact of thrombocyte activation, which is an essential feature of the acute coronary syndrome, may be modified by application of GP IIb/IIIa inhibitors. Because of the different study designs, reported MACE rates among recently published studies differ significantly. A generalizable scoring system for risk assessment, which takes into account the different and conflicting study results, does not appear to be imminent.
Update on Glycoprotein IIb/IIIa Blockade in Endovascular Interventions
Authors: LE KHOI M.
Published: June 2007

Platelet aggregation plays a central role in the ischemic complications of percutaneous coronary interventions (PCI) and the acute coronary syndromes (ACS). Although aspirin and heparin have been effective at decreasing adverse events in these settings, the perceived need for more potent inhibition of platelet aggregation has led to targeting of the platelet surface membrane glycoprotein IIb/IIIa (GP IIb/IIIa) receptor. Several agents have been developed; four: abciximab, tirofiban, eptifibatide, and lamifiban have been tested in clinical trials. Overall, the positive findings of these studies have supported the hypothesis that enhanced platelet blockade leads to improved clinical outcomes in the settings of PCI and ACS. In this article, an overview of the various GP IIb/IIIa receptor inhibitors is presented. The clinical trials of these agents as adjunctive therapy for patients undergoing PCI and in treatment of acute myocardial infarction are reviewed. Practical considerations relating to clinical efficacy, drug safety, and economic issues are discussed.
Update on Interventions in Saphenous Vein Grafts
Authors: SHUBROOKS SAMUEL J.
Published: June 2007

Interventions in saphenous vein grafts present some of the most challenging problems in preventing acute complications and limiting restenosis. Available options include repeat bypass surgery, balloon angioplasty, directional atherectomy, transluminal extraction atherectomy, rotational atherectomy, laser angioplasty, and stenting. Stenting appears to provide the best acute and long‐term results. Debulking with directional atherectomy prior to stenting may be helpful but its role is unproven. With any device, it is essential to attain the lowest possible residual stenosis with the least amount of manipulation. Complications with vein graft interventions are most commonly related to distal embolization, which occurs most frequently in older vein grafts with diffuse disease, large plaque volume or thrombus, or those with total occlusion. Use of thrombolytics, glycoprotein Ilb/IIIa receptor inhibitors, and thrombectomy devices may be helpful when thrombus is present. Calcium channel blockers may be beneficial when embolization of plaque debris results in slow flow or no‐flow during interventions.
Update on Intravascular Radiation
Authors: KENT KENNETH M.
Published: June 2007

After two decades of experiences with endovascular interventions, with new devices, laser angioplasty and stents, the initial procedural success rate improved, the complications decreased and a broader range of lesion subsets could be successfully treated. However, the angiographic restenosis rate remained the same in the 30% to 40% of patients undergoing balloon angioplasty and 15% to 20% in patients undergoing stenting of simple, focal lesions. Many modalities of treatment, including radiation therapy, were explored to decrease these high restenotic rates. Preclinical studies on animal models did support the role of radiation. The first human experience was reported in 1997. Since then many randomized trials have begun to study the efficacy and effectiveness of different radioactive sources and methods of delivery. The dawn of an new exciting era has begun.
Transcatheter Closure of Atrial Communications Using the Amplatzer™ Septal Occluder
Authors: HIJAZI ZIYAD M. , CAO QI‐LING , PATEL HITENDRA , RHODES JONATHAN
Published: June 2007

Certain types of atrial septal defects (ASDs) are amenable for transcatheter closure using various investigational devices. The use of the clamshell or buttoned devices is accompanied with a high incidence of residual shunt. The experience of ASD closure using the Amplatzer™ Septal Occluder (ASO) is limited. Therefore, the purpose of this article is to discuss the protocol of closure and report on the acute results using this device. Nineteen patients (17 ASD/2 fenestrated Fontan [FF]) underwent an attempt at catheter closure of their defects at a median age of 13.3 years (range 5.5–67.4 years) and a median weight of 49 kg (range 18–94 kg) using the ASO. The median ASD diameter measured by transesophageal echocardiography (TEE) was 12 mm (range 6–23.8 mm), and the median defect balloon stretched diameter was 17 mm (range 6–31 mm). All ASD patients had right atrial and ventricular volume overload with a mean ± SD Qp/Qs of 2.4 ± 0.9. A 7 to 8Fr catheter was used for delivery of the device in all patients. The device was placed correctly in all but one patient. There were immediate and complete closures (C) in 13 of 18 patients; 3 patients had trivial residual shunts (TS), and 2 patients had small residual shunts (SS). In the two patients with FF, oxygen saturation improved from 85% to 95% and 88% to 96%, respectively. One patient received two devices for two separate defects. The median fluoroscopy time was 15.5 minutes (range 7.4–33.4 minutes), and the median total procedural time was 78 minutes (range 52–180 minutes). There was one episode of device embolization in one patient. The device was successfully retrieved and 2 months later a second closure was performed successfully. No other complications were encountered during or after the procedure. Follow‐up was performed using transthoracic echocardiography (TTE) at 1 day and 1 month and by TEE at 3 months. At day 1, there was C of the defect in 15 of 19 patients and 4 had TS; 18 patients completed 1‐month follow‐up, 16 of 18 had C and 2 patients had TS. Eleven patients completed 3‐month follow‐up, all with C. So far there have been no episodes of endocarditis, thromboembolism, or wire fracture. We conclude that the use of the new ASO is safe and effective in complete closure of atrial communications up to 23.8 mm in diameter.
The Duct‐Occlud Device for Closure of Patent Ductus Arteriosus
Authors: MOORE JOHN W. , BOOSFELD CHRISTOPH
Published: June 2007

The Duct‐Occlud device is a coil‐type device designed to occlude small‐to‐moderate patent ductus arteriosus. The design of the device, its delivery system, and the implant procedure are described, and the experimental and clinical experiences accumulated utilizing the device for occlusion of patent ductus arteriosus are reviewed.
Possis Angiojet Rapid Thrombectomy System: A New Device for the Definitive Treatment of Thrombotic Coronary Lesions
Authors: YUN DOUGLAS , MOONEY JODI , MOONEY MICHAEL R.
Published: June 2007

The incidence of thrombotic lesions is relatively common, and is associated with increased risk and complications. The optimal approach to the percutaneous treatment of these high risk lesions remains unclear. The Possis Angiojet Rapid Thrombectomy System is a new device designed to remove intravascular thrombus by rheolytic thrombectomy. This article describes the use of the Possis Angiojet on a patient with peri‐infarct angina and refractory thrombus in the left anterior descending coronary artery.
Influence of Balloon Angioplasty on Heart Rate Variability in Patients with Coronary Artery Disease
Authors: KEELEY ELLEN C. , LISOWSKY TARAS , O'NEILL WILLIAM W. , MADDENS MICHAEL E.
Published: June 2007

We assessed the influence of elective balloon angioplasty on heart rate variability (HRV) in patients with coronary artery disease. In 62 patients (41 men and 21 women, aged 33 to 69), two 6‐minute electrocardiographic recordings were performed 2 hours apart. Patients were divided into three groups: group A (26 patients) underwent balloon angioplasty; group B (14 patients) underwent coronary angiography alone, and group C (22 patients) served as controls. There was a statistically significant decrease in time and frequency domain measurements in group A patients after successful balloon angioplasty (P < 0.05). The logarithm of the high frequency decreased in group B patients after coronary angiography alone (P < 0.05). HRV did not change in group C. There was no correlation with lesion location. We conclude that in patients with coronary arterial disease, successful balloon angioplasty is associated with an immediate decrease in HRV in time and frequency domains regardless of the artery involved. Coronary angiography alone is associated with an early decrease in the logarithm of the high frequency domain measurement of HRV. These changes may be due to procedure‐related factors, patient characteristics, and microvascular derangements. A delayed improvement in HRV after balloon angioplasty is not addressed by the present study and warrants further evaluation.
Complete Myocardial Revascularization by Single Session Triple Vessel Percutaneous Coronary Angioplasty and Provisional Stenting
Authors: WACINSKI PIOTR , URBAN PHILIP , CHATELAIN PASCAL , BACCHIOCCHI‐SUILEN CAROLINE , DE OLIVAL JOSE RAMOS , DORSAZ PIERRE‐ANDRÉ
Published: June 2007

Background: Although availability of stents has made percutaneous transluminal coronary angioplasty (PTCA) safer, single vessel angioplasty still represents 90% of procedures performed today. We report our initial experience with single session triple vessel angioplasty, using stents as needed to improve suboptimal balloon results. Patients: Fourteen patients (12 men, 85%), aged 67 ± 19 years were treated. All had triple vessel disease and angina. Mean left ventricular ejection fraction was 61%± 8%. Results: PTCA was attempted in all three coronaries or one of their major branches during the same procedure. Seventeen target lesions were in the left anterior descending coronary artery, 2 in a diagonal branch, 11 in the left circumflex, 2 in a marginal branch, 13 in the right coronary artery, 3 in the posterior descending, and 1 a saphenous vein graft. PTCA of 3.5 ± 0.7 sites/procedure was attempted. The success rate was 13 (93%) of 14 patients and 47 (96%) of 49 lesions. Thirty‐four (69%) lesions were treated by implantation of one or several stents, and 10 (71%) of 14 patients received at least one stent. Hospital stay duration was 4 ± 2 days. One patient required repeat PTCA to treat subacute stent thrombosis 2 days after the procedure (creatine kinase [CK] peak < 2 times upper limit of normal). There were no in‐hospital deaths, Q‐wave infarction, or need for coronary artery bypass grafting (CABC). After a median follow‐up period of 24 months (range 3–102), one (7%) patient had died of a noncardiac cause, three (21 %) had required repeat PTCA for restenosis in previously dilated lesions, and none had suffered a myocardial infarction. At follow‐up, the median angina class was I (range I‐II). Conclusion: For selected patients with three vessel disease, complete revascularization by single session PTCA and provisional stenting as needed is feasible, and is associated with a low rate of short‐ and long‐term complications when successfully performed.
Will Noninvasive Techniques Replace Coronary Angiography?
Authors: HOFMANN MANFRED
Published: June 2007

Electron beam computed tomography (EBCT) and magnetic resonance imaging (MRI) represent modern noninvasive imaging technologies. MRI in particular has improved diagnosis of many extracardiac diseases. It is claimed that these technologies are superior to the established technique of coronary angiography (CA) for diagnosis of coronary artery disease (CAD) because they are easily repeatable, eliminating the risk of an invasive procedure, and potentially cost saving. Both EBCT and MRI have produced excellent images of proximal coronary arteries. However, their imaging precision is far from that of CA, especially for distal artery segments and the left circumflex and right coronary arteries. An improved image quality probably will be achieved in the future. However, for the next several years CA is essential for diagnosis of CAD and planning of therapy. In selected patients, MRI will provide additional information to angiographic and echocardiographic data (e.g., for assessment of coronary flow, myocardial viability, and morphology of extracardiac vessels). For reasons of cost containment, in many patients with CAD the simultaneous procedure of diagnostic CA and therapeutic angioplasty seems more reasonable than the additional expensive performance of EBCT and MRI.
Saphenous Vein Graft Intervention
Authors: CORDERO‐YORDAN HERBERT , LOPEZ ALEJANDRO N. , HEUSER RICHARD R.
Published: June 2007

Surgical revascularization enjoys tremendous technical advances and offers low mortality despite its invasive nature. The management of patients with recurrent angina after CABG presents a difficult problem. The risk of repeat CABG is two‐ to fourfold higher than initial CABG. In view of these problems, PTCA is a feasible alternative that prevents reoperation in a select group of patients. A high restenosis rate and poor long‐term clinical outcome offset the good immediate results with PTCA of SVGs. Stenting offers the same procedural success rate with the added benefit of a lower restenosis rate and thus better short‐ and intermediate‐term outcomes. Further randomized trials and long‐term studies are needed to clearly define the benefit of stenting in vein grafts.
Diabetes and Multiple Stents Independently Double the Risk of Short‐term Revascularization
Authors: GAXIOLA EFRAIN , VLIETSTRA RONALD E. , BRENNER ALAN S. , BROWNE KEVIN F. , EBERSOLE DOUGLAS G. , ROMAN LYDIA , KERENSKY RICHARD A.
Published: June 2007

Several studies show worse outcome for diabetic patients after percutaneous transluminal coronary angioplasty (PTCA). There are relatively few studies evaluating outcome in the modern era of coronary stenting. We compared the incidence of death, myocardial infarction (MI), and repeat target lesion revascularization (RTLR) by PTCA or coronary artery bypass grafting (CABG) over a 6‐month follow‐up in 110 diabetic and 400 nondiabetic patients receiving Palmaz‐Schatz stents. All patients received aspirin/ticlopidine and stents were deployed using high‐pressure inflations. Seventy‐five (68.2%) diabetic patients and 272 (68%) nondiabetic patients had single stents, while 35 (31.8%) diabetic and 128 (32%) nondiabetic patients had multiple stents (≥ 2stents in the same vessel). The success rate and acute major complications were not significantly different between diabetic and nondiabetic patients. There was also no significant difference in death, MI, and repeat PTCA between these two groups. Diabetic patients underwent CABG more frequently than nondiabetic patients (12.7% vs 3.2%, respectively, P =0.001) and diabetic patients also had RTLR more frequently than nondiabetic patients (25.5% vs 12.8%, respectively, P = 0.002) during 6‐month follow‐up. Multivariate analysis showed that diabetes and multiple stents independently contributed to the 6‐month RTLR rate. Coronary stenting in diabetic patients can be carried out with a high success rate and low incidence of acute major complications. The presence of diabetes mellitus and multiple stent placement significantly increase the incidence of repeat target lesion revascularization.
Percutaneous Mitral Commissurotomy in Acute Pulmonary Edema
Authors: AOUAD AÏCHA , BENNANI RAJAE , GHANNAM RACHID , BENSOUDA ADIL , SRAIRI JAMAL EDDINE , MESBAHI REDOUANE , EL HAITEM NAÏMA , BENOMAR MOHAMED
Published: June 2007

From January 1994 to July 1998, percutaneous mitral commissurotomy was performed in 520 patients. Of these patients, 7 (4 men and 3 women aged 31 ± 5.6 years) were dilated in an emergency situation of intractable pulmonary edema caused by severe mitral stenosis. Three patients required mechanical ventilatory support. Percutaneous mitral commissurotomy was performed with the Inoue balloon. The dilatation of the valve was undertaken even though the echocardiographic score of the valve was high. Percutaneous mitral commissurotomy resulted in an increase in the mitral valve area from 0.72 ± 0.18 cm2 to 1.95 ± 0.18 cm2 (P = 0.011) with a concomitant reduction in pulmonary artery systolic pressure from 82.5 ± 16.4 mmHg to 46.7 ± 11.6 mmHg (P = 0.018). One patient died (he had two cardiac arrests before the dilatation). During follow‐up (mean 18 months), one patient presented with a restenosis, one an aggravation of mitral insuflciency grade, and four were in NYHA functional Class II. Thus, percutaneous mitral commissurotomy can be considered as a treatment of choice in patients with intractable pulmonary edema caused by severe mitral stenosis.
Role of Epicardial Mapping in Catheter Ablation of Postmyocardial Infarction Ventricular Tachycardia
Authors: SANTONI‐RUGIU FRANCESCO , GOMES J. ANTHONY , MEHTA DAVENDRA
Published: June 2007

The role of epicardial mapping for radiofrequency (RF) catheter ablation of postmyocardial infarction monomorphic ventricular tachycardia (VT) is still under investigation. We present two septuagenarian patients with a history of myocardial infarction, poor left ventricular function, and drug‐refractory monomorphic VT who were treated with RF catheter ablation. The first patient had a history of myocardial infarction, left ventricular aneurysm, and mitral valve replacement complicated by recurrent drug refractory VT and congestive heart failure. The second patient had ischemic cardiomyopathy and VT and was implanted with a cardioverter defibrillator and subsequently suffered repeated episodes of VT refractory to multiple antiarrhythmic drugs. In both patients, coronary sinus mapping was performed with a multipolar catheter as endocardial mapping did not reveal satisfactory sites for ablation. Epicardial catheter mapping provided stable electrograms and identification of areas of slow conduction during VT. RF lesions guided by epicardial mapping resulted in successful ablation of VT and no recurrence at long‐term follow‐up. This report emphasizes the potential usefulness of coronary sinus mapping as an adjuvant to endocardial mapping to guide VT ablation.