Diagnosis, management, and clinical outcome of cardiac tamponade complicating percutaneous coronary intervention

Cardiac tamponade is an uncommon but life-threatening complication of percutaneous coronary intervention (PCI). The purpose of the present study was to characterize the incidence, management, and clinical outcome associated with this complication. We analyzed a prospective database of 25,697 PCIs performed at William Beaumont Hospital (Royal Oak, Michigan) between October 1993 and December 2000. Cardiac tamponade was observed in 31 of 25,697 PCI procedures (0.12%). Cardiac tamponade was diagnosed in the catheterization laboratory in 17 of 31 patients (55%), and 14 patients (45%) had a delayed presentation (mean time from PCI 4.4 hours). Cardiac tamponade was twice as frequent after use of atheroablative devices compared with percutaneous transluminal coronary angioplasty and stenting (0.26% vs 0.11%, p <0.05). All patients with immediate cardiac tamponade had coronary artery perforation. In 11 of 14 patients with delayed tamponade (79%), no actual site of perforation could be identified. A moderate or large pericardial effusion was observed in 20 patients, and 9 had small effusions without typical echocardiographic features of tamponade. Pericardiocentesis was performed in 30 patients; 19 patients (61%) were treated successfully with aspiration alone, but 12 patients (39%) required further emergency surgical intervention. In-hospital complications included death (42%), emergency surgery (39%), myocardial infarction (29%), and transfusion (65%). Cardiac tamponade is an uncommon but important complication of PCI and is associated with high mortality and morbidity. Most cases are recognized in the catheterization laboratory, but delayed cardiac tamponade may occur and must be considered as a cause of late hypotension after PCI.

Occlusion of a saphenous vein graft aneurysm with a vein-covered stent

A 67-year-old man was admitted with unstable angina, 15 years after saphenous vein graft bypass surgery. Cardiac catheterization demonstrated a large saccular aneurysm arising from the proximal segment of the vein graft to the obtuse marginal artery. Intravascular ultrasound revealed the opening of the aneurysm that measured 15 mm in length. The aneurysm was successfully occluded by deployment of a vein-covered stent.

Initial experience with hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction: results of a pilot study utilizing intracoronary aqueous oxygen therapy

OBJECTIVES

The purpose of this study was to evaluate the feasibility and safety of intracoronary hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction (MI).

BACKGROUND

Hyperoxemic therapy with aqueous oxygen (AO) attenuates reperfusion injury and preserves left ventricular (LV) function in experimental models of MI.

METHODS

In a multi-center study of patients with acute MI undergoing primary angioplasty (PTCA), hyperoxemic blood (pO(2): 600 to 800 mm Hg) was infused into the infarct-related artery for 60 to 90 min after intervention. The primary end points were clinical, electrical and hemodynamic stability during hyperoxemic reperfusion and in-hospital major adverse cardiac events. Global and regional LV function was evaluated by serial echocardiography after PTCA, after AO infusion, at 24 h and at one and three months.

RESULTS

Twenty-nine patients were enrolled (mean age: 58.9+/-12.6 years). Hyperoxemic reperfusion was performed successfully in all cases (mean infusion time: 80.8+/-18.2 min; mean coronary perfusate pO(2): 631+/-235 mm Hg). There were no adverse events during hyperoxemic reperfusion or the in-hospital period. Compared with baseline, a significant improvement in global wall motion score index was observed at 24 h (1.68+/-0.24 vs. 1.48+/-0.24, p < 0.001) with a trend toward an increase in ejection fraction (48.6+/-7.3% vs. 51.8+/-6.8%, p = 0.08). Progressive improvement in LV function was observed at one and three months, primarily due to recovery of infarct zone function.

CONCLUSIONS

Intracoronary hyperoxemic reperfusion is safe and well tolerated after primary PTCA. These preliminary data support the need for a randomized controlled trial to determine if hyperoxemic reperfusion enhances myocardial salvage or improves long-term outcome.

Immediate effect of percutaneous myocardial laser revascularization on hemodynamics and left ventricular systolic function in severe angina pectoris

Experimental data suggest that myocardial revascularization with a high-energy laser may cause a significant reduction in left ventricular (LV) function immediately after creation of myocardial channels. We sought to determine if percutaneous myocardial laser revascularization (PMR) causes immediate deterioration in hemodynamic parameters or regional LV systolic function. PMR was performed in 40 patients (mean age 62.9 +/- 10.8 years) using the Eclipse Holmium laser (26 had PMR alone; 14 patients underwent PMR plus percutaneous coronary intervention). Intracardiac pressures and left ventriculograms were recorded before and after PMR. Regional wall motion was assessed using the centerline method. A mean of 18 +/- 5 channels were created per patient. There was no significant change in LV ejection fraction immediately after PMR (56 +/- 9% vs 55 +/- 10%, p = 0.25). No deterioration in regional wall motion was demonstrated in the lased region (mean chord motion for anterior wall PMR: -1.5 +/- 0.8 before vs -1.5 +/- 0.8 after the procedure, p = 0.93; inferior wall PMR: -1.5 +/- 0.9 before vs - 1.6 +/- 0.8 after the procedure, p = 0.43). Similarly, there was no change in the number of hypokinetic chords in the treated region. Systemic blood pressure, LV end-diastolic pressure, heart rate, and right-sided heart pressures were not significantly different after laser revascularization. In patients with refractory angina, PMR did not cause immediate deterioration in hemodynamic status or regional LV function.

A randomized study of direct coronary stent delivery compared with stenting after predilatation: the NIR future trial. On behalf of the NIR Future Trial Investigators

This randomized trial compared a strategy of direct stenting without predilatation (n = 39) with conventional stenting with predilatation (n = 42) in patients with suitable lesions in native vessels > or = 2. 5-mm diameter to be covered by either a 9- or 16-mm-length NIR Primo stent. Equipment cost [mean (median) +/- SD] was less in those with direct stenting [$1,199 (979) +/- 526] than in those with predilatation [$1,455 (1,285) +/- 401, P < 0.001]. There was no significant difference in contrast use or fluoroscopy time. Procedural time was shorter in the direct stenting group. The clinical outcome at 1 month was satisfactory in both groups. In selected patients, a strategy of direct stenting is feasible, costs less, and is quicker to perform than the conventional strategy of stenting following predilatation.

Ventricular septal aneurysm: a complication of myocardial infarction

We report the case of a ventricular septal aneurysm in a patient with a previous inferior myocardial infarction. Two-dimensional echocardiography demonstrated a cystic cavity in the muscular septum with a small communication into the left ventricle. No evidence of left-to-right shunt was detected with Doppler echocardiography or during left ventriculography.

Stent longitudinal flexibility: a comparison of 13 stent designs before and after balloon expansion

Longitudinal flexibility is an important property of coronary stents, facilitating delivery and allowing the expanded stent to conform to vessel contour. Subjective descriptions of flexibility abound, but there are few independent quantitative data to aid stent selection. A three-point bend test was employed to measure stiffness, the reciprocal of flexibility, for 13 stent designs in the unexpanded (bare) state, then after expansion with a 3.5-mm balloon. For eight of the designs, stiffness of the proprietary stent/balloon delivery system was also measured. In the unexpanded state, there was a wide spread of stiffness, which ranged from 0.5+/-0.2 to 91.5+/-10.0 g force/mm, depending on design. Stiffness was least for the coil (Wiktor and Crossflex) and hybrid (AVE GFX and Bard XT) designs. The MultiLink was the most flexible and the Crown the stiffest of the slotted tube designs. All stents became stiffer upon expansion. For most manufacturer-mounted stents, the delivery balloon was the main determinant of stent/balloon delivery system stiffness. Manufacturer-mounted stent profile ranged from 1.15+/-0.11 mm for the Jostent to 1.53 +/- 0.05 mm for the MultiLink system. Independent quantitative assessment of characteristics such as flexibility and profile should aid rational comparison of stent designs.

Gelfoam embolization of a distal coronary artery guidewire perforation

A guidewire-induced distal coronary artery perforation presenting with cardiac tamponade was occluded by distal Gelfoam embolization via an infusion catheter. This extends the treatment options for this rare complication of coronary interventional procedures. Cathet. Cardiovasc. Intervent. 49:214-217, 2000.

Cardiac surgery in octogenarians--The Green Lane Hospital Experience 1995-1998

BACKGROUND

An increasing number of patients aged 80 years and over are being considered and accepted for cardiac surgery.

AIM

To review the experience of surgery in this elderly group of patients at our institution.

METHODS

Hospital records of octogenarians undergoing surgery between January 1995 and September 1998 were reviewed and follow-up was obtained by general practitioner (GP) and patient questionnaires.

RESULTS

Thirty-seven patients underwent cardiac surgery. The mean age was 82.8+/-1.4 years (range 80.8 to 86.2 years). Twenty-three (62%) were male. All were independent pre-operatively with severe symptoms and minor co-existing morbidity. All operations were urgent except two (emergency). Twenty patients (54%) had isolated coronary surgery, six (16%) aortic valve replacement alone, and 11 (30%) combined surgery. There were four (11%) early deaths and five (14%) peri-operative neurological events. The mean duration of post-operative intensive care stay was 2.4+/-3.9 days (range 0.05 to 16, median 1.0) and post-operative hospital stay 14.0+/-13.9 days (range 0 to 79, median 11). At the time of follow-up (mean duration 20.0+/-11.2 months) two further patients had died (non-cardiac). Twenty-six of the 31 survivors were living at home (23 independently), one with relatives, and four in residential care. Their cardiac symptoms were well controlled. The GPs of all hospital survivors, and all surviving patients themselves, felt that cardiac surgery had been beneficial.

CONCLUSIONS

Cardiac surgery in the very elderly has been reserved for those with severe disease or symptoms and little co-morbidity. Early mortality is higher than for the general population undergoing cardiac surgery, but post-operative resource use is acceptable and the intermediate-term outcome for survivors is good.

Cardiac allograft vasculopathy: the green lane hospital experience 1987-1998

AIMS

To determine the prevalence of cardiac allograft vasculopathy in heart transplant recipients at Green Lane Hospital and to examine potential risk factors for vasculopathy.

METHODS

We retrospectively reviewed the coronary angiograms of all cardiac transplant recipients. Angiography was usually performed one, two and five years after operation. The diagnosis of allograft vasculopathy was made if there was any evidence of coronary artery disease. Patients' medical records were reviewed for potential risk factors.

RESULTS

Ninety-one patients underwent cardiac transplantation between December 1987 and March 1998. One year survival was 87%. Angiographic evidence of coronary disease was present in 30 patients and in three patients coronary lesions were first identified at post mortem. Vasculopathy was present in 25%, 35% and 61% of patients at one two and five years following transplant. Donor-acquired lesions could not be excluded as few patients had immediate postoperative angiograms for comparison. Five late deaths have been due to vasculopathy. Recipient age, race, donor age and ischaemic time were similar for those with and without vasculopathy. Frequency or severity of acute rejection episodes, cytomegalovirus infection, lipid profiles, diabetes and hypertension were not significantly different in patients with vasculopathy.

CONCLUSION

Cardiac allograft vasculopathy is a common finding after heart transplantation. No definite risk factors were identified in this patient group.

Hydroxyproline excretion following renal transplantation: comparison with values found in primary hyperparathyroidism

The amounts of total hydroxyproline (THP), free hydroxyproline (FHP) and non-dialysable hydroxyproline (NDHP) excreted in the urine by six patients with chronic renal failure who received kidney transplants and six patients with primary hyperparathyroidism were studied. Following transplantation three of the four patients with radiological evidence of hyperparathyroidism developed hypercalcaemia and excreted more than 360 mumol THP/24 hours on at least one occasion. The remaining patients were normocalcaemic and excreted less THP and a higher proportion of NDHP. In all patients with primary hyperparathyroidism, THP excretion fell after adenoma removal but there was an increased excretion of NDHP:THP. It is suggested that studies of hydroxyproline excretion may contribute to clinical assessment of healing of renal osteodystrophy and involution of the parathyroid glands after renal allograft transplantation.

Acute zinc toxicity in haemodialysis

A country patient on home haemodialysis suffered acute nausea, vomiting, and fever during dialyses when she used water stored in a galvanized tank. She subsequently was found to have severe anaemia with raised plasma and erythrocyte zinc concentrations. Intercurrent hospital haemodialyses and subsequent home dialyses with deionized water were symptom-free.Experimental haemodialyses of dogs against small concentrations of zinc showed a disproportionate rise in plasma zinc and possible uptake of zinc by the liver.