Opposing effects of endothelin-1 on C-type natriuretic peptide actions in rat cardiomyocytes

C-type natriuretic peptide (CNP) and Endothelin-1 are paracrine peptides with opposing vascular and mitogenic actions. In cardiac myocytes, CNP reduced contractility and induced accumulation of cyclic guanosine monophosphate (cGMP). Endothelin-1 caused an increase in contractile amplitude, abolished the negative inotropic effect of CNP, reduced the negative inotropic effect of a membrane permeable cGMP, and inhibited cGMP accumulation induced by CNP. We conclude that endothelin-1 abolishes the negative inotropic effect of CNP. This effect may be mediated by inhibition of the negative inotropic actions of cGMP as well as by reduction of cGMP levels.

Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia

OBJECTIVES

The goal of this study was to investigate the nature of the association between silent ischemia and postoperative myocardial infarction (PMI).

BACKGROUND

Silent ischemia predicts cardiac morbidity and mortality in both ambulatory and postoperative patients. Whether silent stress-induced ischemia is merely a marker of extensive coronary artery disease or has a closer association with infarction has not been determined.

METHODS

In 185 consecutive patients undergoing vascular surgery, we correlated ischemia duration, as detected on a continuous 12-lead ST-trend monitoring during the period 48 h to 72 h after surgery, with cardiac troponin-I (cTn-I) measured in the first three postoperative days and with postoperative cardiac outcome. Postoperative myocardial infarction was defined as cTn-I >3.1 ng/ml accompanied by either typical symptoms or new ischemic electrocardiogram (ECG) findings.

RESULTS

During 11,132 patient-hours of monitoring, 38 patients (20.5%) had 66 transient ischemic events, all but one denoted by ST-segment depression. Twelve patients (6.5%) sustained PMI; one of those patients died. All infarctions were non-Q-wave and were detected by a rise in cTn-I during or immediately after prolonged, ST depression-type ischemia. The average duration ofischemia in patients with PMI was 226+/-164 min (range: 29 to 625), compared with 38+/-26 min (p = 0.0000) in 26 patients with ischemia but not infarction. Peak cTn-I strongly correlated with the longest, as well as cumulative, ischemia duration (r = 0.83 and r = 0.78, respectively). Ischemic ECG changes were completely reversible in all but one patient who had persistent new T wave inversion. All ischemic events culminating in PMI were preceded by an increase in heart rate (delta heart rate = 32+/-15 beats/min), and most (67%) of them began at the end of surgery and emergence from anesthesia.

CONCLUSIONS

Prolonged, ST depression-type ischemia progresses to MI and is strongly associated with the majority of cardiac complications after vascular surgery.

C-type natriuretic peptide has a negative inotropic effect on cardiac myocytes

C-type natriuretic peptide (CNP) has vasodilatory and antimitogenic actions, but its role in the control of cardiac function is unclear. We studied the effect of CNP on cultured, beating neonatal rat cardiac myocytes. CNP caused a significant reduction in the amplitude of contraction and a significant accumulation of intracellular cyclic GMP. The effect of a membrane permeable cyclic GMP on cell contraction was similar to that of CNP. CNP caused no change in Ca2+ transients. Blockade of natriuretic peptide receptors abolished the effects of CNP on contraction and accumulation of intracellular cyclic GMP. Blockade of cyclic GMP-dependent protein kinase abolished the effect of CNP on myocyte contraction. We conclude that CNP has a negative inotropic effect on neonatal rat cardiac myocytes. The effect of CNP is mediated via natriuretic peptide receptor(s) causing elevation of intracellular cyclic GMP which possibly activates protein kinase and causes attenuation of myofilament sensitivity to Ca2+.

Cytotoxic T lymphocytes are activated following myocardial infarction and can recognize and kill healthy myocytes in vitro

The damage of myocardial infarction (MI) is often progressive. A possible mechanism for subsequent myocardial damage and heart failure after MI is immune response against cardiac self-antigens. The purpose of our study was to test the hypothesis that cytotoxic T lymphocytes are activated following acute MI and may have a role in producing further myocardial damage. Rats were allocated into three experimental groups: acute MI, Sham MI and non-operated control. One, two and three weeks after surgery, lymphocytes were obtained from rat spleens and incubated with neonatal cardiac myocytes. Lymphocyte proliferation was assessed by a thymidine incorporation assay and calculated as proliferation index (PI). Myocyte destruction was measured by a crystal-violet staining assay and expressed as percentage of cell destruction. Proliferation index was significantly higher among lymphocytes obtained from MI animals (44. 3+/-5.8 and 44.9+/-5.1, at 2 and 3 weeks after MI, respectively) than sham MI (29.3+/-5.3, 27.1+/-4.7) (P<0.05) or control animals (17.1+/-2.5, 16.2+/-2.8) (P=0.03). Cytotoxic activity of the MI lymphocytes against the cultured cardiomyocytes was significantly higher 2 and 3 weeks after MI, (36.4+/-7.3%, 69.3+/-4.9%) compared to sham MI (17.9+/-3.14%, 36.6+/-5.3%) (P<0.001) and control animals respectively (13.3+/-5.4%, 17.4+/-6.1%) (P<0.001). The cytotoxic activity against healthy cardiomyocytes was myocyte-specific, induced by CD8 lymphocytes and major-histocompatibility complex (MHC) restricted. Cytotoxic T lymphocytes (CD8) are activated following MI and can recognize and kill normal cardiomyocytes in vitro. The newly described pathophysiological insights may provide novel oportunities to prevent death of non-ischemic cardiomyocytes and heart failure following myocardial infarction.

Unusual presentation of familial Mediterranean fever: role of genetic diagnosis

OBJECTIVE

To describe the role of molecular analysis in the diagnosis of an unusual presentation of familial Mediterranean fever (FMF).

CASE REPORT

Two patients presenting with prolonged fever without signs and symptoms of serositis are described. FMF was diagnosed by genetic analysis, which disclosed that both patients were homozygous for the M694V mutation of the Mediterranean fever (MEFV) gene.

CONCLUSION

Molecular analysis of FMF should complement the investigation of patients with fever of unknown origin. This test enables a definite diagnosis of the disease and may promote the diagnosis and treatment of patients with an unusual or incomplete clinical picture of FMF.

Changes in cardiac mechanics with heat acclimation: adrenergic signaling and SR-Ca regulatory proteins

The involvement of adrenergic signaling and sarcoplasmic calcium regulatory proteins in the development of heat acclimation-induced adaptations in cardiac mechanics was studied in heat-acclimated (34 degrees C) rats for 2, 5, and 30 days (AC(2), AC(5), and AC(30), respectively). Control (C) rats were held at 24 +/- 1 degrees C. Systolic pressure (LVP) and velocities of contraction (dP/dt/P) and relaxation (-dP/dt/P) were measured using a Langendorff system. For adrenergic signaling, beta-adrenoreceptor (AR) density and affinity (Scatchard plots) and cardiac inotropic response to norepinephrine (10(-7) mM, +/- 10(-6) mM propranolol) were measured. For the regulatory proteins, steady-state levels of Ca(2+)-ATPase and phospholamban (PLB) mRNAs and the encoded proteins Ca(2+)-ATPase [sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA)] and PLB were measured using semiquantitative RT-PCR and Western immunoblotting, respectively. Both short (STHA; AC(2) and AC(5))- and long-term heat acclimation (LTHA; AC(30)) enhanced LVP. However, dP/dt. P and -dP/dt. P in STHA hearts resembled that of the controls, whereas on LTHA, both parameters decreased (P < 0.05), implying decreased velocity of contraction and relaxation. beta-AR density remained unchanged with their affinity markedly decreased (P < 0.05). AR responsiveness, however, diminished in AC(2) but was markedly enhanced on LTHA. During STHA, PLB and sarcoplasmic reticulum Ca(2+)-ATPase transcripts were upregulated with no change in the encoded proteins except for SERCA downregulation on AC(5), leading to an increased PLB/SERCA ratio (P < 0.05). This mismatched preacclimation lusitropic state on STHA and increased PLB/SERCA ratio was evident (P < 0.05) due to downregulation of SERCA and upregulation of PLB. Our data fit a biphasic acclimation model in which desensitized adrenergic signaling is dominant during STHA, whereas on LTHA, the contractile machinery is influenced by altered expression of the calcium regulatory proteins leading to both augmented adrenergic inotropic response (via PLB elevation) and decreased velocity of relaxation. The sustained low thyroxin measured on LTHA causally associates with this response.

Acute myocardical infarction due to delirium tremens

A 36-year-old patient with normal-appearing coronary arteries suffered an acute Q-wave myocardial infarction during acute alcohol withdrawal and delirium tremens. Sympathetic hyperactivity with coronary spasm and increased platelet reactivity are probably the underlying mechanisms.

Long-term outcome of patients with very long stents for treatment of diffuse coronary disease

OBJECTIVES

The study sought to determine the 6-month clinical outcome of patients who underwent implantation of very long coronary stents to treat diffuse disease and/or long dissections and to compare the findings with those reported in the literature for patients who underwent implantation of multiple short coronary stents.

BACKGROUND

New designs of flexible stents enable the implantation of long stents rather than multiple short, older design stents. The initial experience is very promising but the long-term outcome has not been described yet.

METHODS

Fifty-seven consecutive patients in whom 67 long stents (>/=30 mm) were successfully deployed were included in this study. Six-month clinical and angiographic follow-up was prospectively collected. Patients with recurrent angina underwent coronary angiography without further testing. Patients who remained asymptomatic at the 6-month follow-up visit underwent positron emission tomographic imaging, and those with results suggestive of ischemia underwent coronary angiography. A combined study end point was defined as death, myocardial infarction, and the need for target vessel revascularization.

RESULTS

Only 1 patient (2%) reached a study end point at hospital discharge. An additional 20 patients (total 21 patients [37%]) reached an end point by 6 months. The outcome was not influenced by the clinical presentation (stable or unstable angina) or by the indication for stenting (elective or emergency). Predictors for adverse outcome were multiple stents per narrowing (63% vs 29%, P <. 04), and stents smaller than 3.5 mm (49% vs 22%). Narrowing and stent length were not predictive of a study end point in narrowings that were successfully treated by a single long stent.

CONCLUSIONS

Elective stenting provides an effective solution for patients with diffuse coronary disease provided that a single long stent (usually <40 mm) can cover the full length of the narrowing. The results are better when vessels larger than 3 mm are treated. Compared with multiple short stents, implantation of a single long stent is probably at least as effective, and the procedure is quicker and cheaper and thus should be the preferred approach.

A 42-year-old man with recurrent myocardial infarction and normal appearing coronary arteries

We report the occurrence of a coronary mural thrombus and recurrent myocardial infarction in a patient with normal-appearing epicardial coronary arteries and small-vessel coronary artery disease. The current case emphasizes the importance of permanent medical treatment with anti-platelet and vasodilators in patients with small-vessel coronary artery disease.

Heat acclimation induces changes in cardiac mechanical performance: the role of thyroid hormone

The involvement of reduced thyroxine level in the emergence of heat acclimation-induced negative lusitropic effect was examined. Experiments were carried out on 1) control rat hearts maintained at 24 +/- 1 degreesC (C); 2) rat hearts acclimated at 34 degreesC for 1 mo (AC); 3) AC-euthyroid rat hearts, via administration of thyroxine in the drinking water (AT); and 4) hypothyroid rat hearts, maintained at 24 +/- 1 degreesC, via administration of thiouracil in the drinking water (CP). Systolic pressure and velocities of contraction (dP/dt. P) and relaxation (-dP/dt. P) were measured using the Langendorff perfusion system. The steady-state levels of Ca2+-ATPase and phospholamban mRNAs and the expression of the encoded proteins Ca2+-ATPase (SERCA) and phospholamban (PLB) were measured, using semi-quantitative RT-PCR and Western immunoblotting, respectively. Rat thyroxine levels were measured using RIA. Heat acclimation, which brought about a reduced thyroxine level, led to downregulation of Ca2+-ATPase mRNA expression and translation and upregulation of phospholamban mRNA and PLB. Consequently, the PLB-to-SERCA ratio (PLB/SERCA) of the AC hearts showed a significant increase. These changes, as well as the greater pressure generation and the reduced dP/dt. P and -dP/dt. P observed in AC hearts were blunted in the AT hearts. Our data suggest that sustained heat acclimation-induced low thyroxine level has a decisive effect on the contractile machinery of the AC heart. Elevated PLB/SERCA apparently explains the negative lusitropic effect observed in these hearts.

Highly selective sigma receptor ligands elevate inositol 1,4,5-trisphosphate production in rat cardiac myocytes

Exposure of cardiac myocytes from adult rat ventricles to the highly selective, high affinity sigma receptor ligands 1S,2 R-cis-N-[2-(3,4-dichlorophenyl)ethyl]-N-methyl-2-(1-pyrrolidinyl)-cycloh exylamine (BD-737) (0.1-100 nM) and N-[2-(3,4-dichlorophenyl)ethyl]-N,N',N'-trimethylethylenediamine (BD-1047) (0.01-10 nM), caused potentiation of electrically-evoked amplitudes of contraction and Ca2+ transients, while exposure to 100 nM BD-1047 caused attenuation of these amplitudes. In addition, BD-737 (1-100 nM) and BD-1047 (10-100 nM) caused an increase in the incidence of spontaneous twitches. These effects were inhibited when the incubation with BD-737 was done in the presence of the phospholipase C inhibitor, neomycin, or after pre-incubation with thapsigargin or caffeine which deplete the sarcoplasmic reticulum Ca2+ stores. Inositol 1,4,5-trisphosphate (IP3) production in cardiac myocytes was determined by the IP3 binding protein assay. Both substances caused an increase in the intracellular concentration of IP3. BD-737 caused a rapid transient increase to 3.2-fold in 1 min and stabilization at 2.1-fold of control thereafter. BD-1047 caused a gradual increase reaching 4.4-fold after 5 min. The results suggest that the effects of these sigma receptor ligands on contractility and spontaneous contractions are mediated by activation of phospholipase C and elevation of intracellular IP3 level.

Coronary arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia--a case report

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) disease is characterized by cutaneous, mucosal, and visceral vascular anomalies. Two patients were previously described with coronary artery aneurysms (ectasia) associated with this disease. This report describes a patient with Osler-Weber-Rendu disease in whom multiple coronary arteriovenous malformations were identified during coronary angiography. The patient presented with anginal chest pain resulting from severe anemia. Upper gastrointestinal endoscopy revealed multiple angiodysplastic lesions throughout the esophagus and stomach.

New indicator for stent covering area

A small gap between stent struts is essential to support the vessel wall, prevent elastic recoil, and prevent intimal flaps from prolpasing into the lumen. We defined Gap Index as the ratio of strut width divided by the percent of the vessel wall area covered by the stent metal, and proved mathematically that this index relates inversely to the total length of stent struts (or coil), and directly related to stent cell size. Twenty-four (12 tubular and 12 coil) stents from 17 manufacturers were analyzed. Strut width in the tubular and coil groups was 354.1 +/- 276.0 and 955.9 +/- 553.9 microm, respectively (P < 0.001). The relative metallic surface area (RMS) in the tubular and coil groups for 3 mm stent diameter was 16.0 +/- 4.6 and 10.6 +/- 3.7%, respectively (P < 0.005). Great variations in Gap Index were found amongst different stents, with up to 100-fold. Gap Index in the tubular and coil groups for 3 mm stent diameter was 24.4 +/- 21.7 and 105.8 +/- 97.5 units, respectively (P = 0.001). Thus, coil stents have a smaller relative metallic surface area despite increased strut width. This is the result of reduced total strut length and fewer and larger cells, as represented by a higher Gap Index. This information may be useful for new stents designs.

Pituitary apoplexy as a first manifestation of pituitary adenomas following intensive thrombolytic and antithrombotic therapy

Apoplexy of a previously asymptomatic pituitary macroadenoma may occur in the setting of intensive thrombolytic, antithrombotic, or anticoagulant therapy for acute myocardial infarction. Classic clinical findings may initially be nonspecific and a high index of suspicion is therefore required for early diagnosis.

Long-term angiographic follow-up of coronary balloon angioplasty in patients with diabetes mellitus: a clue to the explanation of the results of the BARI study. Balloon Angioplasty Revascularization Investigation

OBJECTIVES

We sought to compare the angiographic outcome of diabetic patients (treated with insulin or oral hypoglycemic agents) after successful coronary angioplasty with that in nondiabetic patients. The analysis included the outcome of the dilated (restenosis) and nondilated narrowings (disease progression).

BACKGROUND

Recent data have confirmed that diabetes mellitus is an important risk factor for long-term adverse events. These adverse events are more common after balloon angioplasty than after bypass surgery (Bypass Angioplasty Revascularization Investigation [BARI]).

METHODS

We examined retrospectively 353 coronary angiograms of 248 patients (55 diabetic, 193 nondiabetic) who were referred for diagnostic angiography >1 month after successful angioplasty (1.4 +/- 0.6 [mean +/- SD] repeat angiograms/patient). Restenosis and disease progression/regression were compared between groups by means of quantitative angiography.

RESULTS

Baseline clinical and angiographic characteristics were similar in both groups. There was a nonsignificant trend for a higher restenosis rate of dilated narrowings in diabetic patients. There were no significant changes between diabetic and nondiabetic patients in the rates of progression and regression of narrowings that were not dilated during the initial angioplasty. The main difference was in the rate of appearance of new narrowings: There was a 22% increase in the number of narrowings on the follow-up angiogram in diabetic patients (38 new, 174 preexisting narrowings) compared with 12% (86 new, 734 preexisting narrowings) in nondiabetic patients (p < 0.004). Diabetes mellitus and the performance of angioplasty in the artery had an additive risk for development of new narrowings, which were identified in 15 (16.9%) of 89 arteries with and 16 (13.2%) of 121 without angioplasty in diabetic patients and in 42 (12.7%) of 331 arteries with and 38 (7.3%) of 518 without angioplasty in nondiabetic patients (p = 0.009).

CONCLUSIONS

The combination of diabetes mellitus and an artery that was instrumented during balloon angioplasty is additive and increases the risk of formation of new narrowing in that artery. This finding may explain the high adverse event rates observed in diabetic patients in the angioplasty arm of the BARI study, most of whom had angioplasty performed in at least two arteries.

Initial experience with long coronary stents: the changing practice of coronary angioplasty

The initial experience with the use of long coronary stents (> 30 mm in length) was analyzed retrospectively. Sixty-seven stents were deployed in 58 narrowings in 57 patients (34 AVE Microstents, 16 Nir stents, four Gianturco-Roubin II stents, and 13 Wallstents). Stents were implanted in 22 patients with unstable angina, 34 patients with stable angina, and one patient during direct angioplasty for acute myocardial infarction. Eighteen additional short stents were implanted to cover the entire length of the lesions so that an average of one and a half stents were deployed per patient. The length of the narrowings before stenting was 40 +/- 20 mm and the length of the stented segments was 45 +/- 20 mm. Stents were deployed for "bailout" in 23 narrowings, to improve suboptimal results of balloon angioplasty in 18 narrowings, and electively in 17 narrowings. Twenty of the 67 long stents were deployed in saphenous vein grafts. The success rate of stent implantation was 100%. One patient had a rupture of a saphenous vein graft after deployment of two long stents, with tamponade treated by emergency surgery. One patient had chest pain 18 hours after stent deployment; by the time he arrived at the catheterization laboratory the pain had subsided and the angiogram revealed a patent artery with normal flow. There were no other major complications during the hospital course and 1-month follow-up. We conclude that long coronary stents can be deployed successfully in native coronary arteries and vein grafts. They are useful for elective implantation and extremely helpful in bailout situations. The immediate results are excellent, but long-term outcome is awaited.

Chronic heat improves mechanical and metabolic response of trained rat heart on ischemia and reperfusion

Cardiac mechanics and metabolic performance were studied in isolated perfused hearts of rats subjected to a combined chronic stress of heat acclimation and swimming training (EXAC) or swimming training alone (EX). Diastolic (DP) and systolic pressures (SP), coronary flow (CF), and oxygen consumption were measured during normoperfusion (80 mmHg), and the appearance of ischemic contracture (IC), DP, and SP were measured during progressive graded ischemia, total ischemia (TI), and reperfusion insults. ATP, phosphocreatine, and intracellular pH were measured during TI and reperfusion with 31P nuclear magnetic resonance spectroscopy. During normoperfusion, SP and cardiac efficiency (derived from rate-pressure product-oxygen consumption relationships) were the highest in the 2-mo EXAC hearts (P < 0.0001). During progressive graded ischemia, the development of IC (percentage of total hearts) was similar in both EXAC and EX hearts; the only significant difference was confined to the 1- vs. 2-mo groups. The onset of IC was delayed in the EXAC hearts and, on reperfusion, recovery, particularly of DP, was significantly improved in the latter. After TI, EXAC hearts retained 30% of the ATP pool and there was a delayed decline in intracellular pH. On reperfusion, these hearts also displayed improved ATP and phosphocreatine recovery, the 2-mo EXAC heart demonstrating significantly faster high-energy phosphate salvage, improved diastolic function, and pulse pressure recovery. The data attest to the beneficial effects of heat acclimation on cardiac mechanics of trained rats during normoperfusion and cardiac protection on ischemia and reperfusion. Possibly, energy sparing, lesser acidosis, and shorter duration of IC on ischemia and improved energy salvage on reperfusion contribute synergistically to this potent beneficial effect.

Angiographic deterioration of target coronary artery narrowing as a result of percutaneous balloon angioplasty

We evaluated the long-term angiographic outcome of balloon angioplasty by comparing original and follow-up target coronary narrowing. Rather than using restenosis to determine outcome, as in most angioplasty studies, we took an unusual approach and analyzed outcome in terms that are commonly used in progression and regression studies after medical interventions. Quantitative angiographic measurements were undertaken in 315 narrowings with an initial diameter stenosis <90% before and after angioplasty and at follow-up. Angiographic deterioration (>10% increase in follow-up diameter stenosis) was identified in 44 (14%) narrowings. Angiographic deterioration was not influenced by age, sex, risk factors, lipid profile, or the indication for angioplasty. Deterioration was also not predicted by the severity, length, or the location of the narrowing. The deteriorating narrowings had a higher recoil after dilatation compared with narrowings with angiographic improvement (21% +/- 31% vs 12% +/- 17%, p = 0.006); the residual stenosis after angioplasty was therefore higher. The late loss was also significantly increased compared with narrowings with angiographic improvement (65% +/- 26% vs 8% +/- 24%, p < 0.001). We conclude that the incidence of angiographic deterioration of coronary disease as a result of restenosis is uncommon but not negligible. Interventional cardiologists should resist the temptation to dilate mild, silent coronary narrowings because the procedure might have an unfavorable angiographic (and probably clinical) effect.

Distinct components of morphine effects on cardiac myocytes are mediated by the kappa and delta opioid receptors

Morphine exerts direct effects on cultured cardiac myocytes from neonatal rats. These effects are mediated via the delta and the kappa opioid receptors, as mu opioid receptors are not present in neonatal cardiomyocyte cultures. Binding parameters to the delta and kappa opioid receptors were determined in membrane preparations from these cultures by heterologous competition to [3H]diprenorphine binding, with [D-Pen2, D-Pen5]-enkephalin (DPDPE) and trans-(dl)-3, 4-dichloro-N-methyl-N-[2-(1-pyrrolidinyl)-cyclohexyl]-benzeneacetamide methanesulfonate (U-50,488H) as specific displacers respectively. To define the components of morphine effects mediated via activation of either the delta or the kappa opioid receptor alone, cardiac myocytes were exposed to morphine in the presence of specific antagonists to the kappa or delta opioid receptor respectively. Activation of the kappa opioid receptors by morphine caused a transient increase in Ca2+ influx, leading to increase in amplitudes of [Ca2+]i transients and contraction, with no change in the intracellular pH. Activation of the delta opioid receptors alone by morphine caused a decrease in the amplitude of contraction. This decrease was mediated by a decrease in the intracellular pH leading to reduced responsiveness of the myofilaments to Ca2+. There was no change in Ca2+ influx and in the amplitude of [Ca2+]i transients. The effects mediated through the delta opioid but not through the kappa opioid receptors were pertussis toxin sensitive, indicating coupling of the delta opioid receptors to pertussis toxin sensitive GTP-binding proteins. The overall effects of morphine on the neonatal cardiac myocytes were the sum of the effects exerted by morphine when it activated each of the opioid receptors alone.

Left ventricular free wall rupture as the presenting manifestation of acute myocardial infarction in diabetic patients

We present 5 diabetic patients with acute myocardial infarction in whom left ventricular free wall rupture was the presenting manifestation. Echocardiography may be indicated in diabetic patients with acute myocardial infarction and in shock, prior to thrombolysis.

Experience with the AVE Micro stent in native coronary arteries

Experience with implantation of 62 AVE Micro stents is described. Stents were quickly and successfully deployed in 62 of 63 attempts (98.4%), in tortuous coronary vessels, through proximally deployed stents, and under conditions of hemodynamic instability. It is therefore a very attractive choice to treat difficult anatomy during urgent situations.

Age- and gender-related differences in success, major and minor complication rates and the duration of hospitalization after percutaneous transluminal coronary angioplasty

This report describes the effect of age and gender on the results of balloon angioplasty using current technique and indications. A consecutive group of 2,067 patients who underwent angioplasty at a single institution after 1990 is described. Angioplastic success was 92.2% and similar among men and women and the various age groups. Sixteen patients (0.8%) died, and mortality among women was significantly higher (1.4 vs. 0.6%, p < 0.001). There were no age or gender differences in the rate of Q-wave myocardial infarction and the need for coronary artery bypass. Minor complications such as groin complications (10.5% women, 5.0% men; p < 0.001) and infections (6.4% women, 3.7% men; p < 0.05) were more common in women, and as a result the duration of hospitalization after angioplasty was longer. The length of hospitalization after angioplasty was longer with advanced age, mainly as a result of higher groin complications (p < 0.001), infections (p < 0.01) and renal failure (p < 0.05). We conclude that using current indications and technique, angioplasty can be performed safely with a high success rate. Mortality is higher among women. The length of hospitalization after angioplasty is longer in women and, at advanced age, due to higher rate of minor complications.