Steroid-eluting stents in patients with acute coronary syndromes. Angiographic results of DESIRE: Dexamethasone-Eluting Stent Italian REgistry

BACKGROUND

Steroids have known powerful anti-inflammatory effects. This study was designed to assess the possible antiproliferative action of the Dexamet(R)dexamethasone-loaded stent.

METHODS

This was a prospective, controlled registry performed in 20 Italian centers that enrolled 332 patients with acute coronary syndromes (ACS) treated according to an early-invasive approach with the implantation of 420 dexamethasone-eluting stents in 387 coronary lesions. Six of the enrolling centers participated in the angiographic substudy: elective 6-month follow-up angiography was performed in 140/151 patients (92.7%). Quantitative coronary analysis (QCA) was performed at a centralized core laboratory on 156 lesions treated with the Dexamet stent.

RESULTS

One hundred forty patients (156 lesions) underwent elective QCA. Patients presented with either unstable angina (80%) or Non-ST-elevation myocardial infarction (20%); 70 patients (50%) had ST-T segment changes, 81 (58%) had troponin elevation and 31 (22.1%) were diabetic. One hundred twenty-five patients had a single lesion, 117 of which were treated with a single stent, while 8 received multiple stents. Mean lesion and stent lengths were 11.94 +/- 6.30 and 17.30 +/- 6.08 mm, respectively. In-segment binary restenosis (percent [%] diameter stenosis >/= 50%) was 34.3% per patient (48/140), or 33.3% per lesion (52/156); the mean late lumen loss was 0.95 +/- 0.64 mm in-stent and 1.02 +/- 0.59 mm in-segment. At multivariate analysis, baseline minimum luminal diameter (MLD) (MLD - odds ratio [OR] = 0.18; 95% confidence interval [CI] = 0.04-0.72; p = 0.01) and lesion length (OR = 1.12; 95% CI = 1.04-1.2; p < 0.01) were independent predictors of 6-months binary restenosis

CONCLUSIONS

This is the first large, multicenter analysis of the angiographic outcome obtained with Dexamet. Our results do not support any effective antiproliferative action of this device implanted in patients with ACS.

Abciximab in elderly with acute coronary syndrome invasively treated: effect on outcome

Older age is an independent predictor of mortality after percutaneous coronary intervention (PCI) in patients with Non-ST elevation Acute Coronary Syndrome (ACS). GPIIb/IIIa inhibitors are proved to improve outcome in high risk patients, but conflicting data are available about the effects of these inhibitors in elderly. Accordingly, we studied a consecutive population of elderly patients undergoing PCI for Non-ST elevation ACS. A total of 500 patients were divided in: GPI group (247 pts; mean age 77+/-1.9 years) treated by stenting plus abciximab and, no GPI group (253 pts; mean age 77+/-2.4 years) treated by stenting alone. Propensity analysis was used to account for the nonrandomized use of GPIIb/IIIa inhibitors. During hospitalization, incidence of death was similar among groups (3.2% vs 4.6%) without difference regarding incidence of major (1.6% vs 1.1%) and minor bleedings (4% vs 3%). At long-term follow-up the rate of death was significantly lower in GPI group (4.5% vs 12.3%; p=0.002) as well as the rate of acute myocardial infarction (2.8% vs 11.1%; p=0.0001), and pre-PCI (5.7% vs 13.4%; p=0.003). Cox regression analysis identified abciximab use as an independent predictor of lower long-term major adverse cardiac event (MACE) after adjustment for propensity score (Exp (B) 0.620, 95%CI 0.394-0.976, p=0.039). Our results suggest that addition of abciximab to stenting improves outcome in elderly patients with Non-ST elevation ACS, leading to an absolute benefit for reduction of death and MACE, with an acceptable rate of major and minor bleedings.

Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial

BACKGROUND

Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be done within 90 min. However, the best subsequent management of patients after thrombolytic therapy remains unclear. To assess the best management, we randomised patients with STEMI treated by thrombolysis and abciximab at a non-interventional hospital to immediate transfer for PCI, or to standard medical therapy with transfer for rescue angioplasty.

METHODS

600 patients aged 75 years or younger with one or more high-risk features (extensive ST-segment elevation, new-onset left bundle branch block, previous myocardial infarction, Killip class >2, or left ventricular ejection fraction < or =35%) in hospitals in France, Italy, and Poland were treated with half-dose reteplase, abciximab, heparin, and aspirin, and randomly assigned to immediate transfer to the nearest interventional centre for PCI, or to management in the local hospital with transfer only in case of persistent ST-segment elevation or clinical deterioration. The primary outcome was a composite of death, reinfarction, or refractory ischaemia at 30 days, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number 00220571.

FINDINGS

Of the 299 patients assigned to immediate PCI, 289 (97.0%) underwent angiography, and 255 (85.6%) received PCI. Rescue PCI was done in 91 patients (30.3%) in the standard care/rescue PCI group. The primary outcome occurred in 13 patients (4.4%) in the immediate PCI group compared with 32 (10.7%) in the standard care/rescue PCI group (hazard ratio 0.40; 95% CI 0.21-0.76, log rank p=0.004). Major bleeding was seen in ten patients in the immediate group and seven in the standard care/rescue group (3.4%vs 2.3%, p=0.47). Strokes occurred in two patients in the immediate group and four in the standard care/rescue group (0.7%vs 1.3%, p=0.50).

INTERPRETATION

Immediate transfer for PCI improves outcome in high-risk patients with STEMI treated at a non-interventional centre with half-dose reteplase and abciximab.

Endothelial alpha1-adrenoceptors regulate neo-angiogenesis

BACKGROUND AND PURPOSE

Intact endothelium plays a pivotal role in post-ischaemic angiogenesis. It is a phenomenon finely tuned by activation and inhibition of several endothelial receptors. The presence of alpha(1)-adrenoceptors on the endothelium suggests that these receptors may participate in regenerative phenomena by regulating the responses of endothelial cells involved in neo-angiogenesis.

EXPERIMENTAL APPROACH

We evaluated the expression of the subtypes of the alpha(1)-adrenoceptor in isolated endothelial cells harvested from Wistar-Kyoto (WKY) rats. We explored the possibility these alpha(1)-adrenoceptors may influence the pro-angiogenic phenotype of endothelial cells in vitro. In vivo, we used a model of hindlimb ischaemia in WKY rats, to assess the effects of alpha(1) adrenoceptor agonist or antagonist on angiogenesis in the ischaemic hindlimb by laser Doppler blood flow measurements, digital angiographies, hindlimb perfusion with dyed beads and histological evaluation.

KEY RESULTS

In vitro, pharmacological antagonism of alpha(1)-adrenoceptors in endothelial cells from WKY rats by doxazosin enhanced, while stimulation of these adrenoceptors with phenylephrine, inhibited endothelial cell proliferation and DNA synthesis, ERK and retinoblastoma protein (Rb) phosphorylation, cell migration and tubule formation. In vivo, we found increased alpha(1)-adrenoceptor density in the ischaemic hindlimb, compared to non-ischaemic hindlimb, suggesting an enhanced alpha(1)-adrenoceptor tone in the ischaemic tissue. Treatment with doxazosin (0.06 mg kg(-1) day(-1) for 14 days) did not alter systemic blood pressure but enhanced neo-angiogenesis in the ischaemic hindlimb, as measured by all our assays.

CONCLUSIONS

Our findings support the hypothesis that the alpha(1)-adrenoceptors in endothelial cells provide a negative regulation of angiogenesis.

Rheolytic Thrombectomy during Percutaneous Coronary Intervention Improves Long-Term Outcome in High-Risk Patients with Acute Myocardial Infarction

OBJECTIVES

Aim of the present study was to compare the immediate and long-term effects of AngioJet rheolytic thrombectomy performed in the setting of a percutaneous coronary angioplasty (PTCA) with those of conventional PTCA in patients with acute myocardial infarction (AMI) and angiographic evidence of high intracoronary thrombus burden.

BACKGROUND

Plaque rupture, with subsequent exposure to the flowing bloodstream of high thrombotic materials often leads to intravascular thrombosis, representing the main pathophysiological event of acute coronary syndromes. PTCA is the first-choice treatment for these patients in hospitals with cardiac catheterization facilities. However, distal embolization of thrombotic material, fibrin, and other fragments from atherosclerotic plaques might lead to procedural failure.

METHODS

Immediate and 1-year follow-up results of a group of 30 consecutive patients, presenting with AMI and angiographic evidence of high thrombus burden, who underwent rheolytic thrombectomy and PTCA were compared with those of 30 consecutive patients with similar clinical presentation, risk profile, and angiographic picture, and treated with standard PTCA procedure.

RESULTS

After the procedure, angiographic analysis showed a higher incidence of final thrombolysis in myocardial infarction (TIMI) flow grade 3 in the AngioJet group (93.3% vs 83.3%, P = 0.034). In addition, mean corrected TIMI frame count (cTFC) was significantly lower in the AngioJet group (22.4 vs 32.4, P = 0,0004). At 1-year follow-up, patients treated with AngioJet showed a significantly lower incidence of death (3.33% vs 13.33%,P < 0.001), major adverse cardiac events (MACE: 10% vs 30%, P = 0.026), and need of revascularization (6.67% vs 20%, P = 0.013).

CONCLUSIONS

Data of the present study highlight that AngioJet thrombectomy in selected AMI patients at high risk for distal thrombotic embolization results not only in immediately improved angiographic results as compared to conventional PTCA but, indeed, seems to be associated with a significantly better long-term clinical outcome.

An active lifestyle improves outcome of primary angioplasty in elderly patients with acute myocardial infarction

BACKGROUND

Regular physical activity has been shown to improve outcome of acute myocardial infarction (AMI) in the elderly population. The aim of this study was to evaluate whether the positive role of an active lifestyle on cardiac prognosis extends to elderly patients with AMI who undergo primary percutaneous transluminal coronary angioplasty (PTCA).

METHODS

We prospectively studied 180 patients with AMI aged > or = 70 years and treated with primary PTCA. In all patients, physical activity levels before AMI were quantified by a score derived from the Physical Activity Scale for the Elderly (PASE). Cardiac deaths and nonfatal cardiac events were evaluated within 30 days and 1-year from primary PTCA.

RESULTS

A high PASE score was significantly associated with a strong reduction of 30-day cardiac deaths (from 23.1% to 4%; P for trend = .021) and overall nonfatal events (from 21.1% to 10%; P for trend = .01). Accordingly, at 1 year of follow-up, the incidence of cardiac mortality and nonfatal events significantly decreased with increasing PASE score (from 28.8% to 8% and from 55.7% to 14.5%, respectively). Logistic regression analysis indicated that physical activity before AMI was an independent predictor of increased survival in those patients that showed the highest PASE scores. In addition, at 6 months of follow-up, although low ejection fraction and recurrent angina strongly predicted 1-year mortality, high PASE scores still predicted a better outcome.

CONCLUSIONS

Our data indicate that an active lifestyle may favorably affect early and late outcomes of primary PTCA in the elderly population.

Prior Exercise Improves Age-Dependent Vascular Endothelial Growth Factor Downregulation and Angiogenesis Responses to Hind-Limb Ischemia in Old Rats

Downregulation of hypoxia-inducible factor 1 (HIF-1) and vascular endothelial growth factor (VEGF) are shown to be involved in age-dependent impairment of angiogenesis. In this study, we explore whether prior exercise is able to affect these molecular patterns favorably and to enhance neoangiogenesis in old Wistar rats with hind-limb ischemia. At day 7 after surgery, HIF-1alpha and VEGF expression increased in the ischemic muscle of trained animals. Exercise increased capillary density and limb perfusion as revealed by histologic, angiographic, and dyed bead techniques. Furthermore, exercise capacity and limb trophism have significantly improved in trained aged rats. In these animals, the reduction of VEGF serum levels has reflected the comprehensive improvement in local ischemia evoked by exercise. In conclusion, prior exercise represents a valid tool to counteract age-related molecular alterations resulting in impaired angiogenesis in response to ischemia.

Retrospective analysis of coagulation factor II receptor (F2R) sequence variation and coronary heart disease in hypertensive patients

OBJECTIVES

The purpose of this study was to evaluate the role of genetic variants within the coagulation factor II receptor (F2R) in the occurrence of coronary heart disease (CHD).

METHODS AND RESULTS

Four SNPs (-1738 G/A, 2860 G/A, 2930 T/C, and 9113 C/A) and an ins/del polymorphism -506-/GGCCGCGGGAAGC (D/I), replicating a consensus sequence for Ets-1 transcription factor, and their related haplotypes were tested for association to CHD in 1600 hypertensive patients divided in 2 groups according to presence (cases, n=559) and absence (controls, n=1041) of CHD. Allele I at -506 locus was associated with increased risk of CHD under additive, dominant, and recessive models of inheritance (all P<0.01). Three haplotypes carrying I allele were consistently associated with an increased risk of CHD (all P<0.05). Patients homozygous for the C allele at the 2930 locus also showed an increased risk of CHD (P<0.05). To test the functionality of -506 locus, nuclear extracts were incubated with -506D and -506I sequences by EMSA and F2R promoter activity (F2R-A) were assessed in HUVECs transfected with vectors carrying -506D and -506I sequences and exposed to hypoxia. Presence of the -506I sequence was associated with a 26% reduction of affinity binding to nuclear proteins and to blunted F2R-A in response to hypoxia as compared with the -506D sequence (all P<0.05).

CONCLUSIONS

F2R genetic variants may influence the natural history of CHD in patients at high risk of cardiovascular events.

Endovascular Stent Grafts as a Safe Secondary Option for Paraanastomotic Abdominal Aortic Aneurysm

OBJECTIVE

To describe our experience of endovascular repair of para-anastomotic aortic aneurysm.

METHODS AND RESULTS

From March 2001 to December 2004 we identified 6 patients with a para-anastomotic aortic aneurysms following previous open repair of abdominal aortic aneurysm. All patients were treated with endovascular surgery under epidural anaesthesia. There were no major complications, surgical conversions or deaths. Four patients received a bifurcated aortic stent-graft, and two an aorto-uniliac stent-graft followed by a femoro-femoral bypass. At follow-up (mean 26.1+/-10.2 months) there were no deaths, endoleaks or graft migrations observed.

CONCLUSION

Endovascular surgery, avoiding general anesthesia and re-laparotomy, is the ideal technique for treatment of this complication resulting from failed primary conventional AAA repair.

Steroid-eluting stents in patients with acute coronary syndrome: the dexamethasone eluting stent Italian registry

OBJECTIVE

To assess immediate and mid-term clinical and angiographic outcomes of the dexamethasone drug-eluting stent (D-DES) in patients with acute coronary syndrome (ACS).

PATIENTS AND METHODS

A prospective, nationwide, controlled, registry. Inflammation plays a key role in ACS, and the anti-inflammatory effects of local elution of dexamethasone in unstable plaques may represent a valid therapeutic approach. All patients had ACS on admission (n = 332). 81.5% of the patients had unstable angina and 18.5% had non-ST elevation myocardial infarction (MI). 47% had ST-T segment changes, 59% had troponin elevation, 77% had elevated C-reactive protein levels and 48% had intermediate-high Thrombolysis in Myocardial Infarction risk score. Patients were treated according to an early invasive approach with 420 D-DES in 387 coronary lesions. Primary end point was the cumulative incidence of death, MI and ischaemia-driven target vessel revascularisation (TVR) at 6 months.

RESULTS

At 30 days, 2 (0.6%) patients died, and sub-acute stent thrombosis occurred in 2 patients. At 6 months, 328 (98.8%) patients were controlled, 3 (0.9%) patients had died, 7 (2.1%) had MI and 28 (8.5%) underwent ischaemia-driven TVR. Therefore, the primary end point occurred in 11.5% of patients. At multivariate analysis, multi-vessel coronary artery disease (odds ratio (OR) = 2.16, 95% CI = 1.47 to 3.17, p = 0.0001) and vessel diameter < or =2.75 mm (OR = 1.64, 95% CI = 1.08 to 2.49, p = 0.02) were independent predictors of 6-month clinical events. Global angiographic restenosis rate was 33.3%.

CONCLUSION

This is the first large, multicentre analysis of the clinical and angiographic outcomes obtained with D-DES implanted in ACS. D-DES offers a low rate of clinical events at 6 months, but has no anti-restenosis effect.

Major complications following endovascular surgery of descending thoracic aorta

We evaluated the impact of major complications on clinical outcome in a series of patients undergoing endovascular repair (EVAR) of descending thoracic aorta. From March 2001 to June 2005, 51 patients underwent EVAR for descending aortic diseases. Thirty-five were treated in emergency (60.7%) and 41 (80.4%) were in III-IV ASA class. There were no deaths, surgical conversion or paraplegia. A neurologic complication occurred in one patient (1.9%). Eleven major systemic complications occurred in 5 patients. One patient showed a primary type I endoleak at discharge, resolved spontaneously after 9 months. Three (5.9%) vascular injuries occurred during the endovascular procedure, requiring an emergency rescue iliac-femoral artery bypass. At follow-up (29+/-14 months), there was an overall mortality rate of 5.1% (3/51); 2 deaths (3.9%) were procedure related. Two secondary EVARs (3.9%) were successfully performed, one for a late type I endoleak six months after EVAR in a traumatic patient, and a second for a late rupture distally to the stent-graft implanted 36 months before in an acute type-B dissected patient. EVAR for descending aortic diseases is associated with decreased mortality and complications, however, long-term follow-up and additional studies are mandatory to detect late failure and to confirm clinical safety of this procedure.

Percutaneous coronary interventions in Europe 1992-2003

AIMS

The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe. We report the data of the year 2003 and give an overview of the development of coronary interventions since 1992, when the first data collection was performed.

METHODS AND RESULTS

Questionnaires were distributed yearly to delegates of all national societies of cardiology represented in the European Society of Cardiology to collect the case numbers of all local institutions and operators. The overall numbers of coronary angiographies increased from 1992 to 2003 from 684,000 to 1,993,000 (from 1,250 to 3,500 per million inhabitants). The respective numbers for percutaneous coronary interventions (PCI-coronary angioplasty) and coronary stenting procedures increased from 184,000 to 733,000 (from 335 to 1,300) and from 3,000 to 610,000 (from 5 to 1,100), respectively. Germany has been the most active country for the past years with 653,000 angiographies (7,800), 222,000 angioplasties (2,500), and 180,000 stenting procedures (2,200) in 2003. The indication has shifted towards acute coronary syndromes, as demonstrated by raising rates of interventions for acute myocardial infarction over the last decade. The procedures are more readily performed and safer, as shown by increasing rate of "ad hoc" PCI and decreasing need for emergency coronary artery bypass surgery (CABG). In 2003, use of drug-eluting stents had further increased. However, an enormous variability is reported with the highest rate in Portugal (55%).

CONCLUSION

Interventional cardiology in Europe is still expanding, mainly but not exclusively due to rapid growth in the eastern European countries. A number of new coronary revascularization procedures introduced over the years have all but disappeared. Only stenting has experienced an exponential growth. The same can be forecast for drug-eluting stenting.

Stenting and abciximab in primary angioplasty: a review of current status

Improvement of stent deployment techniques and advances in antiplatelet therapy have shown that stenting in the setting of ST-elevation myocardial infarction (STEMI) is safe and effective. Randomized trials have found that as compared to balloon angioplasty, coronary stenting does not reduce mortality and reinfarction, despite the reduction in target vessel revascularization. Furthermore, these benefits seem to be reduced when applied to unselected patients with STEMI. Direct stenting represents an attractive strategy with potential benefits in terms of myocardial perfusion. Future randomized trials are needed to evaluate if this strategy is associated with a significant impact on outcome, and to provide cost-benefit analysis of an unrestricted use of drug-eluting stent in this high-risk subset of patients. Data from randomized trials have shown that the additional use of abciximab reduces mortality in primary angioplasty. Since the feasibility of long-distance transportation has been shown in several randomized trials, early pharmacological pretreatment may confer further advantages by early recanalization and shorter ischemic time, particularly in high-risk patients. Further large randomized trials are needed to clarify the potential role of small molecules in primary angioplasty for STEMI.

Ischemic neoangiogenesis enhanced by beta2-adrenergic receptor overexpression: a novel role for the endothelial adrenergic system

Beta2-adrenergic receptors (beta2ARs) are widely expressed, although their physiological relevance in many tissues is not yet fully understood. In vascular endothelial cells, they regulate NO release and vessel tone. Here we provide novel evidence that beta2ARs can regulate neoangiogenesis in response to chronic ischemia. We used in vivo adenoviral-mediated gene transfer of the human beta2AR to the endothelium of the rat femoral artery and increased beta2AR signaling resulting in ameliorated angiographic blood flow and hindlimb perfusion after chronic ischemia. Histological analysis confirmed that beta2AR overexpression also produced benefits on capillary density. The same maneuver partially rescued impaired angiogenesis in spontaneously hypertensive rats (SHR), whereas gene delivery of the G-protein-coupling defective mutant Ile164 beta2AR failed to provide ameliorations. Stimulation of endogenous and overexpressed beta2AR on endothelial cells in vitro was found to regulate cell number by inducing proliferation and [3H]-thymidine incorporation through means of extracellular receptor-activated kinase and vascular endothelial growth factor. The beta2AR also has novel effects on endothelial cell number through stimulation of proapoptosis and antiapoptosis pathways involving p38 mitogen-activated protein kinase and PI3-kinase/Akt activation. Therefore, beta2ARs play a critical role in endothelial cell proliferation and function including revascularization, suggesting a novel and physiologically relevant role in neoangiogenesis in response to ischemia.

Endovascular vs. Open Surgery of Abdominal Aortic Aneurysm in High-Risk Patients: A Single Center Experience

BACKGROUND

We compared two groups of high-risk patients with abdominal aortic aneurysm to assess the safety and efficacy of endovascular repair vs. open surgery.

METHODS

From January 1998 to July 2003, sixty-two high-risk patients were divided into two groups: group A consisted of 28 (46 %) open surgery patients and group B consisted of 34 (54 %) patients who underwent endovascular repair.

RESULTS

Four patients (14.3 %) in the open surgery group died, while no deaths occurred in the endovascular group ( p < 0.05). There were 14 complications in 8 patients of the open surgery group versus 2 complications in 2 patients of the endovascular group ( p = 0.01). At follow-up there were 4 (16.6 %) deaths in group A and 3 (8.8 %) in the endovascular group ( p = n. s.).

CONCLUSIONS

While the use of endovascular repair in patients who are physiologically fit for open surgical repair remains controversial, we believe that patients with multiple or advanced comorbidities, i.e. high-risk patients, can benefit from the endografting procedure.

[Current concepts of the physiopathology of coronary beta-adrenergic receptors, and their clinical applications]

Beta-adrenergic vasodilation plays a key role in the regulation of coronary blood flow, in particular during sympathetic nervous system activation. Beta1-adrenergic receptors are mostly represented in epicardial coronary vessel, while beta2 receptors are located in microvasculature. Coronary atherosclerosis is associated with a significant impairment of beta-adrenergic receptor response. This might contribute to precipitate myocardial ischemia.

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization

AIMS

The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD).

METHODS AND RESULTS

Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%).

CONCLUSION

The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.

Role of β 2 Adrenergic Receptors in Human Atherosclerotic Coronary Arteries

Background— Adrenergic regulation of coronary vasomotion is balanced between α 1 -adrenergic–mediated (α 1 -AR) constriction and β 2 -adrenergic–mediated (β 2 -AR) relaxation. This study aimed at assessing the role of β 2 -ARs in normal, mildly atherosclerotic, and stenotic human coronary arteries.

Methods and Results— During intracoronary (IC) infusion of increasing doses of the β 2 -AR agonist salbutamol (0.15, 0.3, and 0.6 μg/min) and the endothelial vasodilator acetylcholine (1, 3, and 10 μg/min), we measured (1) changes in lumen diameter (LD) by quantitative coronary angiography in 34 normal, 55 mildly atherosclerotic, and 42 stenotic coronary artery segments and (2) changes in average peak velocity (APV) and coronary blood flow (CBF) with the use of Doppler flow wire in 11 normal, 10 mildly atherosclerotic, and 11 stenotic coronary arteries. In 6 of 11 stenotic coronary arteries, the protocol was repeated after an IC bolus (12 μg/kg) of the α-adrenergic blocker phentolamine. In 6 of 11 normal coronary arteries, the protocol was repeated after an IC infusion (60 μmol/min) of N G -monomethyl- l -arginine (L-NMMA), a nitric oxide inhibitor. Neither salbutamol IC infusion nor acetylcholine significantly changed heart rate or blood pressure, whereas L-NMMA slightly increased blood pressure. In normal coronary arteries, salbutamol increased LD (LD max %: 11±2, P <0.05), APV (APV max %: 53±17, P <0.05), and CBF (CBF max %: 57±17, P <0.05), whereas L-NMMA caused a blunted APV (APV max %: 27±6, P <0.05) and CBF (CBF max %: 29±6, P <0.05) response to salbutamol. In mildly atherosclerotic coronary arteries, the salbutamol increase in LD (LD max %: 10±2, P <0.05), APV (APV max %: 33±12, P <0.05), and CBF (CBF max %: 37±12, P <0.05) was preserved. In stenotic coronary arteries, salbutamol induced a paradoxical reduction in LD (LD max %: −6±2, P <0.05), APV (APV max %: −15±9, P <0.05), and CBF (CBF max %: −15±6, P <0.05), which was no longer observed after phentolamine. Acetylcholine increased LD (LD max %: 14±3, P <0.05), APV (APV max %: 61±20, P <0.05), and CBF (CBF max %: 67±19, P <0.05) in normal coronary arteries. In mildly atherosclerotic coronary arteries, acetylcholine induced a significant reduction in LD (LD max %: −15±2, P <0.05) and no changes in APV (APV max %: −6±13, P =NS) and CBF (CBF max %: −10±13, P =NS). In stenotic coronary arteries, acetylcholine significantly reduced LD (LD max %: −15±3, P <0.05), APV (APV max %: −15±9, P <0.05), and CBF (CBF max %: −15±6, P <0.05).

Conclusions— In severely atherosclerotic coronary arteries, β 2 -adrenergic vasodilatation is impaired, and this might contribute to alter the vasomotor balance, further precipitating myocardial ischemia during sympathetic activation.

Endovascular procedures in critical leg ischemia of elderly patients

PURPOSE

Purpose of this study was to evaluate angiographic and clinical results of popliteal, infrapopliteal, and multi-level disease percutaneous transluminal angioplasty (PTA) in over-80 years old patients with chronical clitical leg ischemia. In fact such patients with extensive peripheral vascular disease and critical limb ischemia (CLI) are generally poor surgical candidates.

METHODS

Between 1998 and 2003, 37 elderly patients aged 80-89 years old (mean age 83.3) with critical leg ischemia were treated with PTA. All patients were at high surgical risk. 31/37 (81.5%) patients had chronic non-healing wounds, and 14/37 (37%) had multi-level disease of superficial femoral, popliteal and crural arteries. One hundred and two lesions were treated by angioplasty. Immediate angiographic and 1 year clinical results were retrospectively analyzed.

RESULTS

The overall procedural success rate was 32/37 (84.2%). There were three major complications (7.9%), but no deaths, and three technical failures, all were of infrapopliteal lesions. After 1 year, 27 patients could be followed, five patients died during the first year of unrelated causes. Twenty-three patients (85.2%), were clinically re-occluded within 1 year, but complete and partial wound healing was achieved in 80% (16/20) and rest pain improvement in 57% (4/7), so that overall limb salvage was 74% (20/27).

CONCLUSIONS

Elderly patients with multi-level CCLI have a short patency term following angioplasty of 14.8% after 1 year. Nevertheless, this temporary vascular patency enables wound healing or improvement in 74% of these patients, thus such endovascular interventions are recommended in this age group.

Estimation of coronary flow reserve by Tc-99m sestamibi imaging in patients with coronary artery disease: comparison with the results of intracoronary Doppler technique

BACKGROUND

This study compared coronary flow reserve (CFR) estimated by technetium 99m sestamibi imaging with the results obtained with intracoronary Doppler in patients with coronary artery disease. Intraobserver and interobserver reproducibility of the radionuclide-estimated CFR was also assessed.

METHODS AND RESULTS

Fourteen consecutive patients (mean age, 54 +/- 7 years) with documented coronary artery disease in whom percutaneous coronary intervention was planned underwent dipyridamole (0.74 mg/kg) sestamibi imaging and intracoronary Doppler within 5 days. Myocardial blood flow (MBF) was estimated by measurement of first transit counts in the pulmonary artery and myocardial counts from single photon emission computed tomography images. Estimated CFR was expressed as the ratio of stress MBF to rest MBF. In the study vessels, CFR was 1.36 +/- 0.43 as estimated by sestamibi and 1.39 +/- 0.42 by intracoronary Doppler ( P = .69). A significant relationship between CFR estimated by sestamibi and CFR obtained by intracoronary Doppler was observed ( r = 0.85, P < .001). On Bland-Altman analysis, the mean difference between CFR by sestamibi and by Doppler was 0.03 and the intraclass correlation coefficients for intraobserver and interobserver reproducibility were high (all P < .001) for both global and regional CFR.

CONCLUSIONS

This study demonstrates a good agreement between CFR estimated by sestamibi imaging and by intracoronary Doppler results and a lack of intraobserver and interobserver variability of this noninvasive approach.

Thoracic aortic emergencies: impact of endovascular surgery

BACKGROUND

Conventional surgery for thoracic aortic emergencies, such as contained or free rupture of thoracic aortic aneurysms, acute type B dissections, and traumatic rupture of the thoracic aorta, is frequently associated with a high rate of mortality and morbidity. To obviate this risk, endovascular surgery is considered to be a valid alternative procedure.

METHODS

From March 2001 to July 2002, 15 of 22 patients with acute thoracic aortic syndromes were submitted to endovascular surgery: 3 patients (20%) for traumatic rupture, 4 patients (26.7%) for contained or free rupture of thoracic aortic aneurysm, and 8 patients (53.3%) for acute type B dissection evolving to rupture. Computed tomographic scan was diagnostic in all patients. The stent grafts were introduced through the femoral artery.

RESULTS

In the endovascular group there were no perioperative deaths or open conversions. The intraoperative angiography and computed tomographic scan performed on discharge showed no significant endoleaks and successful sealing of the aortic dissection. Average intensive care unit and hospital stay was 1.7 +/- 0.8 and 5.9 +/- 3.0 days. Follow-up ranged between 4 and 23 months and included clinical examinations and serial computed tomographic scan at 3, 6, and 12 months, and every 6 months thereafter. One 84-year-old patient with thoracic aortic aneurysm died of pneumonia 78 days after endovascular surgery. Only one type 1 endoleak was noted in the first patient with traumatic rupture, 3 months after the procedure.

CONCLUSIONS

Endovascular surgery is a safe technique, showing encouraging early and midterm results and allowing for prompt treatment of associated lesions in complex multitrauma patients.

Increased inflammatory status and higher prevalence of three-vessel coronary artery disease in patients with concomitant coronary and peripheral atherosclerosis

The aim of this study was to determine whether patients with coronary artery disease (CAD) and concomitant peripheral arterial disease (PAD) have a greater inflammatory status than those with CAD alone. To this aim, we evaluated PAD (ankle/brachial pressure index <0.9), and measured plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6) and the soluble forms of intercellular adhesion molecule-1 (sICAM-1) and vascular cell adhesion molecule-1 (sVCAM-1) in 234 patients who underwent coronary angiography. Median levels of CRP, IL-6 and sICAM-1 were higher in the CAD without PAD (n=134) and CAD+PAD (n=40) groups than in 60 patients without either disease ("controls"). Median CRP values were higher in patients with CAD+PAD than in patients with CAD alone (4.7 mg/L [1.5; 7.6] vs 2.4 mg/L [0.9; 3.8], p < 0.01).Three-vessel CAD was diagnosed in 60% of CAD+PAD patients and in 21% (p< 0.01) of CAD only patients. After adjustment for confounding factors, only PAD was independently associated with three-vessel CAD (p<0.001). This association was maintained after adjustment for IL-6, the only inflammatory parameter significantly associated with three-vessel CAD at univariate analysis (p<0.01). In conclusion, in CAD the coexistence of PAD is associated with a greater inflammatory status and more widespread coronary atherosclerosis. These results could help to explain the high cardiovascular risk of patients with concomitant CAD and PAD and suggest that PAD be included among the variables used to identify CAD patients for further diagnostic evaluation.

Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE)

OBJECTIVES

We sought to investigate the success rate and the acute and 12-month clinical outcome of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in the contemporary era.

BACKGROUND

The technique of PCI involving CTO has improved over time. However, limited data on acute and follow-up results in patients treated with PCI on CTO in recent years are available.

METHODS

Four hundred nineteen consecutive patients scheduled for PCI of CTO of > or =30 days of duration were enrolled in 29 centers; 390 CTOs were confirmed in 376 patients in an independent core laboratory. The end points were technical and procedural success, in-hospital and 12-month major adverse cardiac events (MACE) occurrence, and 12-month symptomatic status.

RESULTS

Technical and procedural success was obtained in 77.2% and 73.3% of lesions, respectively. In-hospital major adverse cardiac events occurred in 5.1% of patients. Multivariate analysis identified CTO length >15 mm or not measurable, moderate to severe calcifications, duration > or =180 days, and multivessel disease as significant predictors of PCI failure. At 12 months, patients with a successful procedure experienced a lower incidence of cardiac deaths or myocardial infarction (1.05% vs. 7.23%, p = 0.005), a reduced need for coronary artery bypass surgery (2.45% vs. 15.7%, p < 0.0001), and were more frequently free of angina (88.7% vs. 75.0%, p = 0.008) compared with patients who had an unsuccessful procedure.

CONCLUSIONS

Successful PCI was achieved in a high percentage of CTOs with a low incidence of complications. At one-year follow-up, patients with successful PCI of a CTO had a significantly better clinical outcome than those whose PCI was unsuccessful.

[Morphologic and functional abnormalities of the cardiovascular system in patients with hepatic cirrhosis]

During liver cirrhosis many important changes occur in the cardiovascular system and these abnormalities appear more evident as portal hypertension and liver dysfunction progress. The cirrhotic heart develops a series of structural and functional abnormalities consisting in diastolic dysfunction and reduced myocardial reactivity during exercise, likely due to a diminished myocardial beta-adrenergic receptor function. Nevertheless, the peculiarity of the cardiovascular involvement during liver cirrhosis is represented by a progressive development of a hyperdynamic circulation that seems to be due to portal hypertension rather than to liver insufficiency. In fact, it has been hypothesized that this syndrome raise from the venous portal bed and is primarily determined by an increase in blood volume that leads to an enhanced cardiac output. Later, as liver cirrhosis progresses, new important pathogenetic elements occur and lead to a reduction in peripheral vascular resistances and to the full clinical expression of hyperdynamic circulation. The pathogenesis of hyperdynamic circulation is very interesting for scientific research because of the complex and still in part unknown origin. In addition, this syndrome has an important clinical meaning for its severely adverse prognostic value and it represents the pathogenetic background for a number of severe complications of advanced liver cirrhosis.

Relationship between contractile reserve, Tl-201 uptake, and collateral angiographic circulation in collateral-dependent myocardium: implications regarding the evaluation of myocardial viability

BACKGROUND

The aim of this study was to compare collateral angiographic circulation (CC), thallium 201 single photon emission computed tomography (SPECT), low-dose dobutamine echocardiography (LDDE), and their combination in identifying viable myocardium beyond a chronic occlusion.

METHODS AND RESULTS

We studied 33 consecutive patients with a chronic occluded coronary artery and regional ventricular dysfunction who underwent dobutamine infusion (5-10 microg x kg(-1) x min(-1)), Tl-201 SPECT, and coronary revascularization (15 patients underwent coronary artery bypass grafting and 18 patients percutaneous transluminal coronary angioplasty). Echocardiography and Tl-201 SPECT at rest were repeated 90 +/- 48 days after revascularization. For viability assessment, Tl-201 SPECT showed the best sensitivity and accuracy (77% and 72%, respectively) compared with LDDE (64% and 63%, respectively) and CC (74% and 55%, P < .05 vs Tl-201 SPECT). Specificity was significantly better for both Tl-201 SPECT (65%) and LDDE (62%) compared with collateral circulation (27%, P < .001 vs Tl-201 SPECT and LDDE). Furthermore, combined Tl-201 SPECT and LDDE data improved specificity (from 88% to 92%) and positive predictive power (from 75% to 78%) but not global accuracy. A direct relationship between the number of viable segments and global functional recovery after revascularization was found only in the case of Tl-201 SPECT (r = 0.48, P = .04).

CONCLUSIONS

This study demonstrates that CC has a very low specificity in the evaluation of viability in collateral-dependent myocardium and that LDDE has a very low sensitivity, whereas Tl-201 SPECT is the most reliable method, particularly in akinetic segments, and optimally identifies patients who will mostly benefit from revascularization in terms of ventricular functional improvement. No additional advantages in terms of accuracy were found when Tl-201 SPECT and LDDE data were combined.

Immediate and long-term outcome of recanalization of chronic total coronary occlusions

Eighty-three consecutive patients with 85 coronary total occlusions undergoing coronary angioplasty were retrospectively studied. Patients were divided into two groups according to the occlusion age that was < 30 days (subacute total occlusion [STO]: 25 patients; range 1-30 days) or > 30 days (chronic total occlusion [CTO]: 58 patients; range 3-144 months). All procedures were carried out using a hydrophilic guidewire. Clinical success, consisting of crossing the lesion, balloon dilatation, stent deployment without complications, was 96% in STO and 81% in CTO. Multiple stepwise logistic regression analysis identified a family history of coronary artery disease (CAD), left anterior descending and right coronary artery occlusions as independent predictors of a successful procedure. No major events occurred during or immediately after the angioplasty. After a mean follow-up of 24 +/- 2 months, no difference was found in survival or freedom from myocardial infarction or target vessel revascularization among the STO and CTO patients. Successful recanalization by using a hydrophilic guidewire was achieved in a high percentage of chronic total occlusions with a low incidence of complications and a satisfactory late clinical outcome. Family history of CAD and occlusion of left anterior descending or right coronary arteries are independent predictors of procedural success.

Prediction of long-term effects of revascularization on regional and global left ventricular function by dobutamine echocardiography and rest Tl-201 imaging alone and in combination in patients with chronic coronary artery disease

BACKGROUND

The aim of this study was to evaluate the accuracy of low-dose dobutamine echocardiography (DE) and resting thallium 201 single photon emission computed tomography (SPECT) alone and in combination for prediction of functional recovery at late follow-up (1 year) after revascularization.

METHODS AND RESULTS

Twenty-six patients with coronary artery disease and ventricular dysfunction (ejection fraction, 42% +/- 9%) underwent DE and Tl-201 SPECT 14 +/- 9 (mean +/- SD) days before revascularization and repeated echocardiography 12 +/- 5 months thereafter. Discriminant analysis was applied to combine Tl-201 SPECT and DE data to classify dysfunctional segments as viable or nonviable. In 78 akinetic/dyskinetic revascularized segments, Tl-201 SPECT provided a sensitivity of 83% and a specificity of 55%, whereas DE showed a sensitivity of 60% and a specificity of 91%, for prediction of improvement in regional function at follow-up. The combination of data through use of discriminant analysis provided a sensitivity of 80% and a specificity of 86%, with an overall accuracy of 82%, significantly higher than DE (71%; P <.05) and Tl-201 SPECT (73%; P <.05) alone. Moreover, discriminant analysis identified 12 (75%) of 16 patients with and 8 (80%) of 10 patients without significant improvement in ejection fraction at follow-up, with an accuracy of 77%.

CONCLUSIONS

The combination of Tl-201 SPECT and DE data provides higher accuracy than either technique alone for prediction of recovery of regional and global function after revascularization.

Low dose dobutamine echocardiography for predicting functional recovery after coronary revascularisation

OBJECTIVE

To evaluate the effects of chronic coronary occlusion on the accuracy of low dose dobutamine echocardiography in predicting recovery of dysfunctional myocardium after revascularisation.

DESIGN

Retrospective study.

SETTING

Tertiary referral centre.

PATIENTS

53 consecutive patients with >/= 70% stenosis of the left anterior descending coronary artery (LAD) and regional ventricular dysfunction (group 1, non-occluded LAD; group 2, occluded LAD) who underwent dobutamine echocardiography.

INTERVENTIONS

26 patients underwent coronary artery bypass grafting and 27 had percutaneous transluminal coronary angioplasty.

MAIN OUTCOME MEASURES

Baseline studies before revascularisation included cross sectional echocardiography at rest and during dobutamine infusion (5-10 microgram), and coronary angiography. The dobutamine study was performed mean (SD) 35 (28) days before revascularisation. Echocardiography at rest was repeated 90 (48) days after revascularisation.

RESULTS

Of 296 dysfunctional segments, 63 in group 1 (43%; 63/146) and 69 in group 2 (46%; 69/150) (NS) improved at follow up. Mean (SD) regional wall motion score index decreased from 1.97 (0.48) (95% confidence interval (CI) 1.01 to 2.93) before revascularisation to 1.74 (0.52) (95% CI 0.70 to 2.78) at follow up in group 1 (p = 0.001), and from 2.12 (0.41) (95% CI 1.30 to 2.98) to 1.88 (0.36) (95% CI 1.16 to 2.60) in group 2 (p = 0.0006). In group 1, sensitivity (87% v 52%; p < 0.0001), negative predictive value (88% v 65%; p = 0.001), and accuracy (77% v 64%; p = 0.01) were all significantly higher than in group 2, despite the angiographic evidence of collaterals in patients with occluded vessels.

CONCLUSIONS

Dobutamine echocardiography shows reduced sensitivity in predicting recovery of dysfunctional myocardium supplied by totally occluded vessels. Thus caution should be used in selecting such patients for revascularisation on the basis of a viability assessment made in this way.

Diagnostic accuracy of low-dose dobutamine echocardiography in predicting post-revascularisation recovery of function in patients with chronic coronary artery disease: relationship to thallium-201 uptake

It is known that contractile reserve may be blunted if perfusion and coronary flow reserve are reduced. Thus, it is conceivable that the predictive accuracy of dobutamine echocardiography may differ according to perfusion tracer uptake. The aim of this study was therefore to assess the relationship between the level of thallium-201 uptake and the accuracy of dobutamine echocardiography in identifying reversible dysfunction. Sixty-nine patients (age 59+/-8 years, ejection fraction 40%+/-11%) with chronic coronary artery disease scheduled for coronary revascularisation were studied. All patients underwent rest 201Tl single-photon emission tomography and two-dimensional echocardiography at rest and during low-dose dobutamine infusion on the same day before revascularisation and repeated echocardiography at least 30 days thereafter. At follow-up, recovery of function was observed in 49% of 339 dysfunctional segments. The percentage of segments with post-revascularisation recovery of function and the percentage with contractile reserve increased in parallel with 201Tl uptake both in the total group of segments (chi2=35.5, P<0.0001 and chi2=35.9, P<0.0001, respectively) and among the 183 akinetic segments (chi2=44.4, P<0.0001 and chi2=14.6, P<0.05, respectively). The dysfunctional segments were divided into three groups according to 201Tl uptake: (a) uptake <65%, (b) uptake between 65% and 79%, (c) uptake >80%. The positive predictive value increased significantly with the level of 201Tl uptake, and was suboptimal (46%) in akinetic segments with severely reduced 201Tl uptake. The negative predictive value decreased significantly with 201Tl uptake, and it was less than suboptimal (29%) in akinetic segments with normal tracer uptake. Sensitivity was lower in the subset of akinetic segments (42%-63%) than in all dyssynergic segments (63%-76%), whereas specificity was very high in akinetic segments (80%-84%). It is concluded that the accuracy of low-dose dobutamine echocardiography in predicting reversibility of regional dysfunction varies considerably according to 201Tl uptake at rest and to the severity of regional dysfunction.

[Diabetes and ischemic cardiopathy]

Diabetes represents an independent risk factor for coronary artery disease (CAD), and the prognosis in terms of survival rates is worse for diabetic patients who have CAD with respect to those with CAD but no diabetes. An acute coronary event represents a cause of death in more than 30% of diabetics. Experimental studies suggested that the increased incidence of myocardial infarction in diabetics is due to an increased risk of developing atherosclerotic plaque with subsequent ulceration and intracoronary thrombus formation. Structural abnormalities of the coronary vessel wall were associated with an abnormal pattern of coronary flow and of coagulation abnormalities: all these abnormalities explain the epidemiological evidence of widespread and severe vascular atherosclerotic disease in diabetics. Due to the extreme complexity of ischemic vascular disease in patients with diabetes, an optimal therapeutic strategy is based on the correction of elevated blood glucose and lipid levels, of blood pressure, of platelet and coagulation abnormalities and of any other risk factor. Both percutaneous and surgical myocardial revascularization have been proved equally effective for CAD treatment in diabetes, even though a recent randomized trial has shown a significantly improved outcome after surgical revascularization. More recently the characterization of the advanced glycation end-product receptor opened new perspectives in the treatment of the complications of diabetes, and gave a new impact to the need of further investigations, through new randomized trials, of the best therapeutic options for diabetic patients.

Direct coronary stenting: effect on coronary blood flow, immediate and late clinical results

Direct stenting (DS) was attempted in 99 coronary lesions in 94 patients while standard stenting (SS) was attempted in 113 lesions in 103 patients matched for clinical characteristics, stenosis type, and location and stent type. The angiographic result was also evaluated according to TIMI frame count method (TFC) before and after procedure. A clinical follow-up was performed 1 year after the procedure. Before the procedure, TIMI grade 3 flow was detected in 42 cases (42.4%), grade 2 in 40 cases (40.4%), grade 1 in 5 cases (5.1%), and grade 0 in 12 cases (12.1%) in the DS group; these data were similar in SS group. After the procedure, TIMI grade flow was 3 in 90 cases (92.8%) in DS group and in 87 (77.0%) in SS group (P < 0.005); grade 2 was observed in 7 case (7.2%) in DS group and in 25 (22.1%) in SS group (P < 0.005). Major adverse cardiac events during hospitalization and at follow-up were similar in two groups. Radiation exposure time and procedure costs per lesion were significantly reduced in DS group compared to SS group (10.1 +/- 8 min vs. 13.9 +/- 4.7 min, P < 0.001; and 1901 +/- 687 Euro vs. 2352 +/- 743 Euro, P < 0.001, respectively). This study confirms that, in selected patients, direct stenting is a safe and successful procedure, allowing a significant reduction in radiation exposure time and procedural costs compared to standard stenting technique. The angiographic success is confirmed by the improvement in TFC in all cases.

Prediction of improvement in global left ventricular function in patients with chronic coronary artery disease and impaired left ventricular function: rest thallium-201 SPET versus low-dose dobutamine echocardiography

Accurate assessment of myocardial viability permits selection of patients who would benefit from myocardial revascularization. Currently, rest-redistribution thallium-201 scintigraphy and low-dose dobutamine echocardiography are among the most used techniques for the identification of viable myocardium. Thirty-one consecutive patients (all men, mean age 60 +/- 8 years) with chronic coronary artery disease and reduced left ventricular ejection fraction (31% +/- 7%) were studied. Rest 201Tl single-photon emission tomography (SPET), low-dose dobutamine echocardiography and radionuclide angiography were performed before revascularization. Radionuclide angiography and echocardiography were repeated after revascularization. An a/dyskinetic segment was considered viable on 201Tl SPET when tracer uptake was >65%, while improvement on low-dose dobutamine echocardiography was considered a marker of viability. Increase in global ejection fraction was considered significant at > or = 5%. In identifying viable segments, rest 201Tl SPET showed higher sensitivity than low-dose dobutamine echocardiography (72% vs 53%, P<0.05), while specificity was not significantly different (86% vs 88%). In 17 patients, global ejection fraction increased > or = 5% (group 1) while in 14 it did not (group 2). A higher number of a/dyskinetic segments were viable on 201Tl SPET in group 1 than in group 2 (2.6 +/- 1.9 vs 0.6 +/- 1.2, P < 0.005), while no significant differences were observed on low-dose dobutamine echocardiography (1.7 +/- 1.6 vs 1.1 +/- 1.6). A significant correlation was found between the number of a/dyskinetic segments viable on 201Tl SPET and post-revascularization changes in ejection fraction (r = 0.52, P < 0.05), but such a correlation was not observed for low-dose dobutamine echocardiography. Using as the cut-off the presence of at least one viable a/dyskinetic segment, rest 201Tl SPET had a higher sensitivity (82% vs 53%, P = 0.07) and showed a trend towards higher accuracy and specificity (77% vs 58%, and 71% vs 64%, respectively) as compared with low-dose dobutamine echocardiography. In conclusion, these findings suggest that when severely reduced global function is present, rest 201Tl SPET evaluation of viability is more accurate than low-dose dobutamine echocardiography for the identification of patients who will benefit most from revascularization.

Dual chamber pacing in hypertrophic cardiomyopathy: influence of atrioventricular delay on left ventricular outflow tract obstruction

The impact of the duration of atrioventricular (AV) delay on obstruction in hypertrophic cardiomyopathy was evaluated in 12 patients by cardiac catheterization, and in 8 of them also by Doppler echocardiography. The AV delay was programmed in random order at 125, 100 and 75 ms in the invasive study and at 120, 100 and 80 ms after pacemaker implantation. The arterial pressure did not changed throughout the studies, whereas the gradient decreased significantly by reducing the AV delay value; the greater gradient reduction was obtained, in both studies, with the AV delay set between 75 or 80 and 100 ms. QRS duration increased significantly by reducing the AV delay during both studies. The widest QRS was not associated with the smallest gradient in all patients. Changes in gradients were similar during the invasive and noninvasive protocols.

Audit and quality control in angioplasty in Europe: procedural results of the AQUA Study 1997: assessment of 250 randomly selected coronary interventions performed in 25 centres of five European countries. AQUA Study Group, Nucleus Clinical Issues, Working Group Coronary Circulation, of the European Society of Cardiology

AIMS

Percutaneous transluminal coronary angioplasty (PTCA) has become the most widely used major intervention in western medicine. However, there is disparate use of this technique among different European countries and the U.S.A. In an attempt at quality assurance, the working group Coronary Circulation of the European Society of Cardiology has carried out a study on appropriateness, necessity, and performance of PTCA in Europe. The present paper reports on the procedural results of this survey.

METHODS

In a multicentre case-control study in Europe, 750 patients (544 men, 206 women) with documented vascular disease of the From the countries participating in the European Registry of Coronary Intervention, the three countries with the highest absolute PTCA volume (Germany, France, and the United Kingdom) and two randomly selected countries (Belgium and Italy) were chosen for investigation. In these countries, five centres were selected at random according to the following criteria: one centre with >1000, three centres with 300-1000, and one centre with <300 procedures per year. In each of these, 10 cases from the first half of 1997 were randomly identified and all pertinent documentation was collected.

RESULTS

In 250 cases, 325 stenoses were addressed as target lesions. Single vessel disease was present in 41%. History included stable angina in 49%, unstable angina in 32%, atypical chest pain in 6%, no anginal pain in 12%, and acute/subacute myocardial infarction in 13%. The percentage of patients with either positive stress test and/or unstable angina, acute/subacute infarction, previous infarction (within 6 months) or coronary revascularization amounted to 98%. Single vessel intervention accounted for 90%. In 41% balloon-only angioplasty was performed and in 54% at least one stent was implanted with considerable variation among countries. The use of other new devices amounted to only 3%. In 92%, the operators documented a successful procedure. Major complications (myocardial infarction, emergency bypass surgery, or death) were found in 4.8%.

CONCLUSIONS

Based on scrutinized hospital and operator data, the present study revealed a satisfactorily high percentage of justifiable indications, an adequate procedural success rate, and an acceptably low complication rate. Further analysis by an expert panel will address appropriateness, necessity, and procedural performance of the individual cases.

Multicenter evaluation of the XT modular coronary stent: clinical and angiographic results

BACKGROUND

In the past few years, the indications for stent implantation have broadened, along with a larger number of available designs. The Bard XT stent is a new modular stent with an original structure and design.

METHODS

To evaluate the new Bard XT stent, we studied its use in a multicenter experience in 163 patients, with a total of 168 lesions and 180 implanted units.

RESULTS

Despite the predominance of complex lesions, the procedural success rate was 98%, with only a 2% failure of stent implantation. There was only one death (no-reflow phenomenon in a rescue primary PTCA in a patient in cardiogenic shock) without other major periprocedural complications. Centralized QCA showed a statistically significant increase of MLD (from 0.73 +/- 0.43 mm to 2.71 +/- 0.40 mm, p < 0.0001) and DS reduction (from 73.8 +/- 15.1% pre-treatment to 7.8 +/- 0.4% after stent implantation; p < 0.0001). Aspirin and ticlopidine were routinely administered after the procedure. Thirty-day follow-up reported only one case of subacute stent thrombosis (in the first day), treated with re-PTCA.

CONCLUSIONS

In a group of patients with complex lesions, we obtained a high rate of success with a low incidence of complications. The Bard XT stent had a high-performance profile with normalization of vessel diameter and angiographic results similar to the ones obtained with the "slotted tube" stents.

Combined evaluation of rest-redistribution thallium-201 tomography and low-dose dobutamine echocardiography enhances the identification of viable myocardium in patients with chronic coronary artery disease

The purpose of this study was to evaluate whether combined evaluation by discriminant analysis of rest-redistribution thallium-201 tomography and low-dose dobutamine echocardiography enhances the accuracy in identifying viable myocardium in patients with chronic coronary artery disease. Rest-redistribution 201Tl has high sensitivity but low specificity in identifying viable myocardium, while the opposite is true for low-dose dobutamine echocardiography. Forty-six patients underwent low-dose dobutamine echocardiography and rest-redistribution 201Tl tomography on the same day. Rest echocardiography was repeated at least 30 days (mean 40+/-20) after myocardial revascularization. Discriminant analysis was applied to the results of 201Tl tomography and dobutamine echocardiography to classify a/dyskinetic segments as viable or non-viable. In 92 a/dyskinetic segments that were revascularized, rest-redistribution 201Tl tomography yielded an accuracy of 75%, while the accuracy of dobutamine echocardiography was 70% (P<0.05). When discriminant analysis was used, the combined evaluation gave an accuracy of 83% (P<0.05 vs both tests). These findings demonstrate that low-dose dobutamine echocardiography and 201Tl imaging are useful and complementary techniques for identifying viable myocardium in patients with chronic coronary artery disease. Combined evaluation by discriminant analysis significantly improves accuracy, although the cost-effectiveness of such an approach remains to be determined.

Effects of myocardial revascularization on regional thallium-201 uptake and systolic function in regions with reverse redistribution on tomographic thallium-201 imaging at rest in patients with chronic coronary artery disease

OBJECTIVES

There is growing evidence that myocardial segments with reverse redistribution are viable in patients with chronic coronary artery disease. The aim of this study was to assess the effects of myocardial revascularization on systolic function and thallium-201 uptake in such segments.

METHODS

Rest-redistribution thallium-201 tomography before and after myocardial revascularization was performed in 47 patients with chronic coronary artery disease. Regional function was evaluated by two-dimensional echocardiography before and after revascularization according to a 3-point scale (1 = normal, 2 = hypokinetic, 3 = a/dyskinetic). Improvement of dysfunctional segments was defined when systolic function score decreased > or =1 after revascularization. Reverse redistribution was defined as >8% decrease in relative thallium-201 uptake between rest and redistribution images.

RESULTS

Reverse redistribution was found in 27 (57%) of 47 patients, corresponding to 60 (11%) of 564 myocardial segments. Of such segments, 24 (40%) had normal systolic function, 19 (32%) were hypokinetic, and 17 (28%) were a/dyskinetic. Thirty-six segments underwent myocardial revascularization, and reverse redistribution was no longer present in 86% of them subsequent to the procedure. Of 26 dyssynergic segments with reverse redistribution subjected to revascularization, 18 (69%) improved at follow-up.

CONCLUSIONS

The findings of the present study indicate that reverse redistribution is a reversible phenomenon and is often associated with improvement of systolic function following revascularization in patients with chronic coronary artery disease.

Noninvasive evaluation of left ventricular diastolic function in hypertrophic cardiomyopathy

Diastolic dysfunction is common in hypertrophic cardiomyopathy (HC). Previous studies suggest that Doppler transmitral flow velocity profiles, and the left atrial (LA) M-mode echogram can be used noninvasively to evaluate left ventricular (LV) diastolic function. However, this has not been proved in HC. In this study we determined the relation of Doppler transmitral flow velocity profiles and the LA M-mode echograms to invasive indexes of LV diastolic function in patients with HC. We studied 25 patients with HC, while off drugs, and calculated LA global and active fractional shortening and the slope of both early and late displacement of the posterior aortic wall during LA emptying by M-mode echocardiography. We calculated peak velocity of early (E) and atrial (A) filling, E to A ratio, and E-wave deceleration time by pulsed Doppler echocardiography, and simultaneous radionuclide angiography, LV pressures, time constant of isovolumic relaxation tau, and the constant of chamber stiffness k by cardiac catheterization. The time constant of isovolumic relaxation tau correlated with the slope of early posterior aortic wall displacement (r = 0.59; p <0.01). LV end-diastolic pressure correlated with global LA fractional shortening (r = -0.75; p <0.001); the constant of chamber stiffness k correlated with active LA fractional shortening (r = -0.53; p <0.02). In a subset of 13 patients, in whom echocardiography and cardiac catheterization were performed simultaneously, similar results were found. LA M-mode recordings provide a more reliable noninvasive assessment of diastolic function in HC than mitral Doppler indexes.