Percutaneous mitral valvuloplasty with severe pulmonary artery hypertension

The aim of this study was to assess the initial and midterm outcome of patients with severe pulmonary hypertension undergoing percutaneous mitral valvuloplasty (PMV). Accordingly, the baseline characteristics, immediate results and follow-up of 64 consecutive patients with severe pulmonary artery hypertension (systolic pulmonary artery pressure > or = 60 mm Hg on cardiac catheterization) (group I) were analyzed and compared with those of 194 consecutive patients with lower pulmonary pressures (group II). Patients in group I were more symptomatic (New York Heart Association functional class > or = III, 72 vs 40%, p < 0.001) and had higher echocardiographic scores (8.6 +/- 2 vs 7.4 +/- 1, p < 0.05). Before PMV, mitral gradient was higher (17 +/- 6 vs 13 +/- 5 mm Hg, p < 0.025) and mitral valve area smaller (0.79 +/- 0.2 vs 0.96 +/- 0.2 cm2, p < 0.005) in group I patients, who also had higher pulmonary vascular resistances (469 +/- 299 vs 157 +/- 125 dynes s-1 cm-5, p < 0.005). On multivariate analysis patients in group I were more symptomatic, had smaller mitral valve areas and higher mitral gradients. PMV success (area gain > 50% without complications) was similar (89 vs 87%) in both groups. After PMV final mitral gradient (5 +/- 2 vs 4 +/- 2 mm Hg) and area (1.82 +/- 0.5 vs 1.87 +/- 0.5 cm2) were similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and late results of percutaneous mitral valvuloplasty for mitral stenosis associated with mild mitral regurgitation

To assess the influence of mild mitral regurgitation (MR) on the initial and long-term results of percutaneous mitral valvuloplasty (PMV), the baseline characteristics, early results and follow-up of 102 consecutive patients with mild MR before PMV (group I) were prospectively analyzed and compared with those of 186 consecutive patients without MR (group II). Age, gender and symptomatic status were similar in both groups, but more patients in group I were in atrial fibrillation (70 vs 54%, p < 0.05) and had had a previous episode of pulmonary edema (25 vs 14%, p < 0.05). On echocardiography, patients in group I had larger left atria (58 +/- 12 vs 53 +/- 10 mm, p < 0.05) and more calcified mitral valves (score 1.9 +/- 0.8 vs 1.5 +/- 0.7, p < 0.05), but the total echocardiographic score (8.0 +/- 2 vs 7.3 +/- 2) was similar in both groups. Baseline hemodynamic data were also similar in both groups. On multivariate analysis, group I patients were only independently associated with more calcified mitral valves and larger left atria. PMV success (area gain > or = 50% without complications) was similar (88 vs 86%) in both groups, but mitral valve area gain was smaller (0.8 +/- 0.3 vs 1.0 +/- 0.3 cm2, p < 0.05) in group I. After PMV an increase in the severity of MR > or = 2 grades (17 vs 6%, p < 0.05) occurred more frequently in group II patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty for post-infarction angina in elderly patients

To assess the short-term outcome of percutaneous coronary angioplasty (PTCA) for post-infarction angina in elderly patients, we have retrospectively evaluated the results of 88 procedures of PTCA (98 lesions attempted), performed for post-infarction angina (PIA), in 84 patients of > or = 65 years (elderly group), and compared the results obtained with those of 165 PTCAs (200 lesions attempted) in 161 patients of < 65 years old with PIA (young group). Angiographic success was obtained in 91 (93%) vs. 181 (91%) of lesions attempted in the groups, respectively. Complete revascularization was achieved in 54 (61%) patients treated in the elderly group vs. 106 (65%) in the young group. PTCA success was obtained in 78 (89%) procedures vs. 147 (89%) of both groups. No patients required emergency coronary surgery, two patients (2%) had a reinfarction in the elderly group vs. five patients (3%) in the young group, and two patients died (one in the elderly and one in the young group). In conclusion, PTCA for PIA in elderly patients provides a high clinical success rate with a low frequency of complications, similar to the results obtained in young patients.

[Color-coded Doppler in the diagnosis of vascular complications following heart catheterization]

To determine the value of color Doppler in the diagnosis of vascular complications resulting from cardiac catheterization 5 consecutive patients, with the clinical suspicious of vascular iatrogenesis potentially requiring surgical repair, were analyzed. In 2 patients a femoral mass developed after a diagnostic catheterization but 3 patients underwent previously an interventional catheterization technique. In 3 patients color Doppler readily visualized a systolic jet originated in the femoral artery entering an anterior echo-free cavity, and a reversal flow in diastole, suggesting a femoral pseudoaneurysm. In 1 patient the clinical diagnosis of arteriovenous fistulae was confirmed by color Doppler which demonstrated a continuous turbulent flow within the femoral vein. In the remaining patient a diagnosis of simple femoral haematoma was made after the demonstration of a relatively echogenic structure overlying the femoral artery and vein but not interfering with their flows. In the 3 patients with femoral pseudoaneurysms and in the patient with arteriovenous fistulae the diagnosis was confirmed by angiography and during surgery. Our preliminary findings underscore the value of color Doppler, using the technology currently available in echocardiographic laboratories, in the differential diagnosis of vascular complications after cardiac catheterization.

Midterm outcome of patients with asymptomatic restenosis after coronary balloon angioplasty

Although many patients with restenosis after balloon coronary angioplasty have recurrence of angina, others remain asymptomatic. To assess the clinical implications of asymptomatic coronary restenosis, we analyzed clinical and angiographic characteristics of 277 consecutive patients with restenosis, 133 (48%) of whom were asymptomatic (group I) and 144 (52%) symptomatic (group II). Restenosis was documented 6 to 9 months after the index procedure, or earlier if angina recurred, and was defined as a greater than 50% lumen narrowing (visual estimation). Group I (asymptomatic group) included fewer female (9% vs. 18%, p less than 0.05) and hypertensive patients (38% vs. 56%, p less than 0.005) and more patients with a previous myocardial infarction (48% vs. 28%, p less than 0.05) and single-vessel disease (67% vs. 55%, p less than 0.05). Before angioplasty, symptoms had lasted for a shorter period (10 +/- 25 vs. 23 +/- 42 months, p less than 0.001), ischemia after a recent infarction was a more frequent indication (21% vs. 10%, p less than 0.05) and total revascularization more frequently obtained (74% vs. 63%, p less than 0.05) in group I than in group II patients. Only a normal blood pressure, previous myocardial infarction, single-vessel disease and a shorter duration of symptoms were independent correlates of asymptomatic restenosis. No differences were found in stenosis severity before angioplasty (90% in both groups) or after angioplasty (22% +/- 12% vs. 24% +/- 16%).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of results of percutaneous transluminal coronary angioplasty with and without selective requirement of surgical standby

To determine the outcome of percutaneous transluminal coronary angioplasty (PTCA) with the use of 2 different strategies of surgical coverage, the results of 1,283 consecutive PTCAs were analyzed. In 269 procedures (21%) (patients considered at high risk should acute vessel closure occur--standby group) the operating room and the surgical team were ready for an immediate intervention. In the remaining 1,014 procedures (79%) (backup group), although the surgical team was "in house," they were not necessarily ready for an immediate intervention. Mean age of the population was 58 +/- 10 years and 84% of patients were men. Coronary risk factors, medical treatment, clinical indication for PTCA, previous coronary surgery and left ventricular ejection fraction were similar in both groups. Dilatation was more frequently multiple (23 vs 16%, p less than 0.05), or performed in the left anterior descending coronary artery (71 vs 46%, p less than 0.001), in bypass grafts (4 vs 2%, p less than 0.02), in proximal coronary segments (72 vs 57%, p less than 0.001) or in lesions at bifurcation (35 vs 28%, p less than 0.02) in the standby than in the backup group, respectively. PTCAs were less frequently performed during the same diagnostic procedure (15 vs 34%, p less than 0.001) in the standby group. Angiographic success was obtained in 91 and 92% of the attempted lesions and PTCA success in 89 and 88% of the procedures in the standby and backup groups, respectively. The incidence of death (1 vs 0.7%), acute myocardial infarction (2.9 vs 2.7%) and emergency surgery (0.7 vs 0.1%) was also similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transluminal percutaneous coronary angioplasty of the left coronary artery]

This paper describes our preliminary experience with left main coronary angioplasty in 8 patients (9 procedures). In 6 patients the left main coronary artery was "protected" either by previous by-pass surgery (4 patients) or by collateral vessels from the right coronary artery (2 patients). Three patients had a total occlusion of the left main coronary artery and 2 of them had a recent or acute myocardial infarction and the coronary angiogram suggested a thrombotic occlusion of the infarct-related artery. Three patients were not considered surgical candidates and an additional patient, who was in cardiogenic shock, required an emergency coronary angioplasty as "rescue" procedure. A successful dilatation was achieved in 6 patients (including a patient with successful deployment of a Palmaz-Schatz stent) but, unfortunately, one them eventually died 7 days later from a femoral sepsis related to the procedure. However in the 2 remaining patients--with a total occlusion of the left main coronary artery in relation with a myocardial infarction--the dilatation procedures were unsuccessful. One patient underwent a successful repeat coronary angioplasty for restenosis of left main coronary artery. Our preliminary experience confirms previous reports suggesting the value of coronary angioplasty in patients with left main coronary artery disease providing a careful selection of possible candidates is performed prior to the procedure.

Involvement of platelet-activating factor and tumour necrosis factor in the pathogenesis of joint inflammation in rabbits

We have studied the participation of platelet-activating factor (PAF) in antigen-induced arthritis in rabbits, as well as the possible co-operation between PAF and tumour necrosis factor (TNF) in their ability to induce joint inflammation when injected into the knees of healthy rabbits. The administration of two structurally different PAF receptor antagonists, BN52021 and Alprazolam, from 4 h before the intra-articular injection of ovalbumin in preimmunized rabbits, induced an important reduction in the synovial fluid volume, in the amount of cells infiltrating the articular cavity and the synovial membrane, as well as in the prostaglandin E2 (PGE2) concentration. Furthermore, proteoglycans of the articular cartilage, which were found diminished in animals with non-treated arthritis, were well preserved in rabbits treated with PAF antagonists. All the synovial fluids from joints with arthritis had detectable amounts of PAF. The injection of either TNF or PAF into the joints of normal rabbits induced a mild inflammation. When TNF was administered 1 h before PAF, a synergistic response was noted in the synovial fluid volume, in the accumulation of leucocytes, and in the amount of PGE2. The administration of BN50726, a hetrazepine with a potent PAF-receptor antagonist effect, induced a diminution in those parameters. Our results suggest that PAF may be an early and important mediator of joint damage, and that TNF can amplify the inflammatory response induced by PAF. PAF receptor antagonists could play some role in the treatment of inflammatory joint diseases.

[The correlation between measurements performed by intravascular echography and quantitative digital angiography in large- and small-caliber arteries]

Intravascular ultrasound is a new promising technique that appears as a very useful complement to standard angiography in the study of atherosclerosis. Specifically, intravascular ultrasound provides by itself, information of great value concerning vessel wall characteristics. Nevertheless, before taking any decision with the results provided by this new technique, we must validate this information with that provided by other more conventional techniques like standard angiography. Accordingly, we have analyzed in 25 patients, 50 images of the abdominal aorta and 77 images of the coronary arteries taken from arterial segments free of atherosclerotic involvement. With the use of a calibrated small grid located over the patient's thorax, we have analyzed "in the same points" the images obtained with intravascular ultrasound and those provided by contrast angiography using a quantitative angiographic analysis. In the abdominal aorta the vessel diameter measured by intravascular ultrasound and angiography was 17.8 +/- 0.39 mm vs 18.6 +/- 0.42 mm (NS), whereas in the coronary arteries it was 2.76 +/- 0.39 mm vs 2.98 +/- 0.37 mm (NS), respectively. The correlation between both techniques was good for both types of arteries (r = 0.93 in the abdominal aorta and r = 0.87 in the coronary arteries). We conclude, that in our experience and with the methodology used, there is a good correlation between the measurements of the vessel diameters obtained by both intravascular ultrasound and digital angiography in arteries of different sizes, being the correlation even better in large arteries.

[The evaluation of the results after coronary angioplasty by intracoronary Doppler and quantitative angiography. The correlation of both methods]

To study the importance of measuring coronary flow reserve immediately after coronary angioplasty we have analysed the results obtained after 28 angioplasties performed in 21 patients. Coronary flow reserve was measured with a 3F intracoronary catheter selectively placed in the dilated artery. Corresponding coronary angiography was analysed with an automatic edge detection program (ARTREK) and visual estimation. Coronary flow reserve increased in 26/27 cases after angioplasty from 2.4 +/- 1.3 to 4.1 +/- 2.7 (p less than 0.001). A correlation was found between minimal luminal area and minimal luminal diameter after coronary angioplasty, and coronary flow reserve (r = 0.46; p less than 0.05 and r = 0.47; p less than 0.05, respectively). The finding of a normal coronary flow reserve (greater than or equal to 3.5), had a 100% specificity but only 56% sensitivity to detect angiographic success (residual stenosis less than 50%). However 47% of patients with angiographic success did not reach normal values of coronary flow reserve. Visual estimation of the stenosis had a good correlation with automatic evaluation but significant scattering was observed at visual levels less than or equal to 25%. Visual assessment underestimated residual stenosis in all but one of the procedures. We conclude that coronary flow reserve is a potentially useful index for assessing the results after angioplasty that may complement coronary angiography. Nonetheless substantial differences between both methods exist in a significant number of cases. The relative merits of both methods, as well as the particular circumstances in which coronary flow reserve should be used, require further studies.

Comparison of results of percutaneous mitral valvuloplasty in patients with large (greater than 6 cm) versus those with smaller left atria

To determine whether the presence of an aneurysmatic (severely enlarged) left atrium (greater than 60 mm on echocardiography) influences results of percutaneous mitral valvuloplasty (PMV), the clinical, echocardiographic and hemodynamic characteristics and the results of this technique were compared in 46 consecutive patients with aneurysmatic left atrium (group I) and 125 consecutive patients without such echocardiographic finding (group II). Left atrial size was 70.5 +/- 8 vs 50.1 +/- 6 mm (p less than 0.005) in groups I and II, respectively. Patients in group I were older (57 +/- 12 vs 48 +/- 12 years, p less than 0.025), more symptomatic (New York Heart Association functional class greater than or equal to III or IV: 67 vs 42%, p less than 0.05), and had atrial fibrillation more frequently (91 vs 44%, p less than 0.001). The echocardiographic score (8.9 +/- 1.9 vs 7.5 +/- 2, p less than 0.005) and the incidence of mild mitral regurgitation on angiography before PMV (54 vs 30%, p less than 0.01) was also higher in group I patients. Hemodynamic parameters before PMV were similar in both groups, but after the procedure, final mitral valve area (1.61 +/- 0.5 vs 1.95 +/- 0.4 cm2, p less than 0.05) and the absolute increase in mitral area (0.81 +/- 0.3 vs 1.02 +/- 0.3 cm2, p less than 0.05) were lower and mean pulmonary artery pressure (35 +/- 10 vs 28 +/- 9 mm Hg, p less than 0.025) was higher in group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Conventional and color Doppler echocardiography in mitral balloon valvotomy]

With the aim of assessing the value of conventional echocardiography and Doppler and colour Doppler during and in the follow-up of percutaneous mitral valvotomy we have studied prospectively 100 consecutive patients with 1 (90%), 6 (69%) and 12 (53%) months follow-up. Age was 50 years and 80% were women. The single balloon technique was used in 68%, mitral valve area increased from 0.9 +/- 0.2 to 1.8 +/- 0.3 cm2 and decrease in pulmonary artery pressure was 10 +/- 0.05 mmHg. We found that: 1) percutaneous mitral valvotomy produced and acute and transient decrease in left ventricular ejection fraction (pre 69 +/- 9%, post 61 +/- 10% p less than 0.001; 1 month 70 +/- 10; 2) a severe mitral regurgitation appeared in 4% of patients and 17% of patients had a moderate degree of regurgitation after valvotomy; 3) after valvular dilation an increase in the width of the aliasing greater than 29% predicted a successful procedure (final area greater than 1.5 cm2) with a sensibility 80% and specificity 94%, and 4) colour Doppler detected an atrial septal defect immediately after valvular dilation in 77% of patients, and permitted non invasive follow-up of the left to right shunt. At one year a left to right shunt at the atrial level persisted roughly in 1/3 of patients. We conclude that colour Doppler Echocardiography during percutaneous mitral valvotomy is useful for a rapid assessment of the increase in valve area, the detection and quantification of mitral regurgitation induced by valvular dilation and the follow-up in these patients.

[The usefulness of intravascular echography during the percutaneous dilatation of aortic coarctation]

An intravascular ultrasound study was performed in a patient, to assess the anatomy of aortic coarctation and the results obtained after percutaneous dilation with a balloon catheter. Intravascular ultrasound imaging provides important additional information, not obtainable with other diagnostic procedures, regarding aortic wall structure and thickness. After balloon dilation, aortic disruption was clearly observed, accounting, together with the stretching of the outer layers of the aortic wall, for the increase in aortic luminal area. Intravascular ultrasound permitted also the accurate assessment of the improvement obtained. Intravascular imaging was clearly superior not only to conventional angiography, but also to transesophageal echocardiography in detecting the mechanism of dilation. We conclude that ultravascular ultrasound, with the additional information that it provides, may help in the selection of patients for percutaneous dilation of the coarctation as well as contributing to the identification of the mechanism of dilation.

[Coronary angioplasty with a rotary atherotome]

Several new coronary dilatation systems, including those using laser energy, atherectomy devices and stent implantation, are being developed as alternative or complementary procedures to coronary artery balloon angioplasty. We report our initial experience performing coronary angioplasty with a new rotational atherectomy device, the transluminal extraction catheter, which simultaneously cut and aspirate fragments from the atherosclerotic plaque. The components of the whole system are a special guidewire to cross the stenosis, the atherectomy catheter and the conduction-control unit. This unit, connected when the atherectomy catheter is positioned across the lesion, produces rotation of the conical bladder located in the catheter distal tip and simultaneous aspiration of residual particles. The procedure was performed in 11 patients in whom 13 lesions were dilated. All patients were male (mean age 55 +/- 23 years, range 45-77). The reason for the angioplasty was stable angina in 2 patients and unstable angina in the remaining seven. Initial success (residual stenosis less than 50% of vessel diameter) was obtained in 10 of 13 lesions. In two, conventional balloon angioplasty was required to improve atherectomy result. The only unsuccessful procedure was in a proximal right coronary artery venous graft, in which a large dissection occurred. Patient had angina but no myocardial infarction. Pathologic examination of aspirated material revealed fibrous tissue in 12 cases and cholesterol crystals in four. We conclude, with the limitation of a preliminary study, that rotational atherectomy with the transluminal extraction catheter is a useful procedure to relief coronary stenosis of the coronary arteries.

[The results of percutaneous transluminal coronary angioplasty in lesions with thrombi]

Previous studies have suggested that the results of coronary angioplasty are poorer when the attempted lesion has a thrombus associated. With the aim of assessing the results of coronary angioplasty in lesions with thrombus, 1,192 consecutive coronary lesions attempted were prospectively analyzed. Of these, 88 (7%) had associated an angiographic intraluminal filling defect consistent with thrombus (group I) and were compared with the remaining 1,104 lesions (93%) without thrombus (group II). Age (56 +/- 12 vs 59 +/- 10 years) was similar in both groups, but patients in group I required more frequently dilatation after a myocardial infarction (acute phase or following thrombolytic therapy) (36% vs 12%, p less than 0.005) but infrequently for stable angina (6% vs 21%, p less than 0.005). Left ventricular ejection fraction (60 +/- 13% vs 63 +/- 12%) and the number of diseased vessels (1.46 +/- 0.7 vs 1.58 +/- 0.8) were similar in groups I and II, respectively, but lesions in group I were less frequently located in the left anterior descending coronary artery (35% vs 53%, p less than 0.025). Furthermore, lesions in group I were more frequently total occlusions (35% vs 4%, p less than 0.001), and were more severe (94 +/- 6% vs 87 +/- 8%, p less than 0.005), eccentric (81% vs 54%, p less than 0.005), irregular (72% vs 32%, p less than 0.005) and more frequently located at bend points (31% vs 17%, p less than 0.05). Primary angiographic success was lower in group I (79% vs 92%, p less than 0.001) and, after dilatation, the incidence of luminal irregularities (34% vs 15%, p less than 0.001) and early reocclusion (10% vs 1%, p less than 0.05) was higher in this group. However, when patients presenting with total occlusions were excluded from both groups primary angiographic success was similar (90% vs 91%) for groups I and II, respectively. We conclude that: 1) Lesions with intracoronary thrombus usually present other unfavourable angiographic characteristics for dilatation. 2) Results of coronary angioplasty in lesions with thrombus are similar to those obtained in other lesions when totally occluded vessels are excluded.