Major dissection during coronary angioplasty: outcome using prolonged balloon inflation versus coronary stenting

BACKGROUND

Abrupt or threatened closure is the major acute complication following conventional coronary angioplasty with a persistent incidence of 2% to 10%.

OBJECTIVES

In order to evaluate the safety and efficacy of endoluminal stenting and autoperfusion balloon angioplasty in the setting of abrupt or threatened closure following coronary angioplasty, the short- and long-term clinical and angiographic follow-up of respectively 45 and 51 patients treated by either method were compared.

METHODS

From August 1986 through August 1992, consecutive patients treated by either endoluminal stenting or autoperfusion balloon angioplasty for abrupt closure following coronary angioplasty, were entered into an observational trial that requested clinical follow-up and repeat angiography at 6 months.

RESULTS

Except for vessel localization, baseline clinical, angiographic and procedural characteristics were comparable. The in-hospital clinical and angiographic outcome was similar (p = 0.85) with 69% event-free patients in both treatment groups. The postprocedural minimal luminal diameter was larger following stenting: 2.67 +/- 0.76mm versus 2.07 +/- 0.70mm (autoperfusion balloon) (p = 0.0002). At follow-up, there were less events in the stent group: 11% versus 34% for the autoperfusion balloon angioplasty group, (p = 0.03). Restenosis rates were 5% (2/37 patients, stent) versus 27% (11/41 patients, autoperfusion balloon) (p = 0.02).

CONCLUSIONS

Autoperfusion balloon angioplasty and endoluminal stenting are effective and safe therapeutic options for abrupt or threatened closure following coronary angioplasty with a comparable short-term clinical and angiographic outcome. However, during follow-up, more complications occur following autoperfusion balloon angioplasty. This is explained by a higher restenosis rate in this treatment group.

[Pseudomesotheliomatous carcinoma in HIV infection]

HISTORY AND FINDINGS

A 32-year-old man, known to have been HIV-positive for 6 years, was admitted to hospital because of dyspnoea and dry cough. For 8 months he had an HIV illness in stage C3 (Center for Disease Control and Prevention, Atlanta) with fever, weight loss and obviously reduced general and nutritional state. There was almost total auscultatory dullness over the right hemithorax and the chest radiogram showed massive right pleural effusion, as well as broad pleural deposits which were suspicious of tumours. The first pleural aspiration recovered 1000 ml exudate. An infectious cause could not be identified. As the effusion was refractory to treatment (301 of effusion were drained over several days), thoracoscopy was performed despite the patient's poor general condition. It revealed extensive tumour masses over the right pleura.

COURSE

After the endoscopy the patient's condition deteriorated rapidly and he died 3 weeks after admission, only 1 1/2 months after onset of the first symptoms. Histological examination of the endoscopically obtained biopsy revealed large-cell carcinoma. The form of growth indicated that it was a pseudomesotheliomatous carcinoma.

CONCLUSION

No previous case of this type of tumour in an HIV-positive patient has been reported. This patient's course was less favourable than is expected in those without HIV infection.

[Abnormalities of the atrial septum in adults: kind, prevalence and clinical relevance]

To classify interatrial septal anomalies in adults, 24,458 Doppler-echocardiographic studies performed between 1. 1. 1987 and 31. 12. 1992 were reviewed. Patients below 16 years of age or with complex congenital heart disease, or after surgical closure of an atrial septal defect, were excluded. Additionally, all 823 transesophageal echocardiographies done between 1. 1. 1993 and 31. 12. 1994 were analyzed to see whether a patent foramen ovale was present. Among 294 patients with interatrial septal anomalies (prevalence 1.2%; male:female = 1:1.4), 298 congenital anomalies of the interatrial septum were detected. 63% of interatrial septal anomalies constituted newly detected anomalies. Age ranged from 16 to 84 (median 43) years. In 21% of the patients the left-to-right shunt was > or = 50% (QP/QS > or = 2). In 25% pulmonary hypertension was present and 25% of the patients underwent surgery. A patent foramen ovale was present in 0.16% of all transthoracal and in 5.7% of all transesophageal echocardiographies. Secundum defects constituted 46%, atrial septal aneurysms 24%, patent foramen ovale 13%, atrioventricular canals 11%, and superior sinus venosus defects with anomalous pulmonary venous return 6% of all diagnoses. Associated anomalies were mitral valve prolapse in 14%, pulmonary valve stenosis in 3%, left-sided persistent vena cava superior and Chiari network in 2% each, anomalous pulmonary venous return, ventricular septal defect, bicuspid aortic valve, and Ebstein's anomaly in 1% each. 4% of the patients showed further cardiac lesions.

CONCLUSIONS

Anomalies of the interatrial septum in adults were frequent and often newly detected. In a high percentage of patients with interatrial septum the left-to-right shunt was hemodynamically relevant.

[Balloon angioplasty for restenosis of coronary endoprostheses]

Between March 1991 and June 1994, the authors treated restenosis (> or = 50%) of coronary endoprostheses in 17 men aged 39 to 72 years by balloon angioplasty. The stents had been implanted for de novo stenosis in 14 patients, restenosis in 1 patient and for acute occlusion in 2 patients. The vessels treated were the left anterior descending artery (1 case), the left circumflex artery (2 cases), the right coronary artery (7 cases) and venous bypass grafts (7 cases). The endoprostheses used were 5 Wallstents in 4 patients, 13 Wiktor stents in 11 patients and 2 Palmaz-Schatz in 2 patients. Clinically, the patients with restenosis presented with class II angina (6 patients), class III (8 patients) and class IV (3 patients) of the Canadian Cardiovascular Society Classification. Conventional balloon angioplasty was performed 17 months (range: 3 to 87 months) after stent implantation and resulted in immediate clinical and angiographic success (residual stenosis < or = 50% on quantitative analysis) in all patients. In particular, there were no dissections. The minimal lumenal diameter (MLD) and percentage stenosis changed from 1.04 mm (range: 0.87 to 1.20) and 72% (range: 68 to 76) respectively before stent implantation to 2.83 mm (range: 2.46 to 3.20) and 23% (range: 20 to 27) after stent implantation. Restenosis resulted in a MLD and percentage stenosis of 0.89 mm (range: 0.77 to 1.01) and 73% (range: 69 to 78) respectively. After angioplasty of the stent, they returned to 2.68 mm (range: 2.29 to 3.06) and 27% (range: 23 to 30) respectively. The patients were not anticoagulated after angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Stand-by versus stent-by during percutaneous transluminal coronary angioplasty

To evaluate the impact of a more liberal use of endoluminal stenting on the incidence of emergency coronary artery by-pass grafting, we analyzed our attitude toward abrupt or threatened closure after percutaneous transluminal coronary angioplasty from 1986 through 1993. In 3083 procedures performed, 204 (6.6%) patients had abrupt or threatened closure. The incidence of closure or threatened closure remained stable during the 8 years, ranging between 5% (1986) and 8% (1987) (p = 0.89). Endoluminal stent implantation was attempted in 92 patients and successfully achieved in 90 (98%), and emergency bypass grafting had to be performed in 41 patients. The proportion without adverse end point (death or myocardial infarction) was higher in the patients treated by endoluminal stenting than in patients treated with bypass grafting (71/90 (79%) patients vs 17/41 (40%) patients, respectively; p < 0.0001). The use of bailout stenting gradually increased from 0.4% (1986) to 5.6% (1993) of all procedures (p = 0.0001), whereas the incidence of emergency bypass grafting decreased from 2.7% (1986) to 0.7% (1993) (p = 0.04). Meanwhile, the incidence of myocardial infarction remained stable between 5.6% (1988) and 1.8% (1992) (p = 0.1), and death rates decreased from 1.4% (1988) to 0.2% (1993) (p = 0.05). It is concluded that "stent-by" is a highly effective therapeutic approach (79% in the present study) toward closure after coronary angioplasty and that, although surgical "stand-by" is certainly mandatory for selected cases, routine stand-by is questionable.

[Retrospective analysis of early and late results following surgical intervention in supraventricular arrhythmia]

The results of surgical procedures for treatment of supraventricular tachycardias were assessed in 65 patients undergoing operation between January, 1980 and December, 1993. Indications for intervention were WPW (59 patients), atrial fibrillation (5 patients) and atrial flutter (1 patient). All cases of WPW were refractory to medical treatment and 14 of 58 patients had one or several syncopes, 4 of whom had to be resuscitated. The surgical treatment of these patients was dissection of an accessory atrioventricular pathway. 15 of these patients underwent heart operation for a different indication at the same time. A total of 60 accessory pathways were diagnosed preoperatively, while 4 were located intraoperatively. The reoperation rate was 3% (2 patients) due to persistent WPW. Incidence of total AV block after the operation was 7% (4 patients). In the late postoperative stage, 12 patients developed supraventricular tachycardias, but none of these cases required surgical treatment. The actuarial survival rate after 10 years was 100%, and after 14 years 96%. We conclude that surgical dissection of accessory pathways offers a good alternative in cases of unsuccessful catheter ablative procedures or in cases of concomitant heart surgery. In 6 patients with mitral valve surgery, associated chronic atrial fibrillation was found. A concomitant Maze-procedure was performed for the purpose of surgically converting the atrial fibrillation to a stable sinus rhythm. The early postoperative results are promising.

Initial experience with the "Big-Skinny" angioplasty catheter

We describe our initial experience with the "Big Skinny" angioplasty catheter, currently only available as an investigational device and in sizes of 4.5, 5, and 6 mm. Six patients with severe angina pectoris were successfully dilated with this angioplasty catheter and have remained asymptomatic up until a mean follow-up period of 6 months. However, because of the large profile of the catheter, sufficient back-up with an adequate guiding catheter should be obtained and predilation with a smaller angioplasty catheter should be performed. The use of this catheter may be a more simple alternative for the treatment of oversized vessel stenosis than the "hugging balloon" technique or directional atherectomy. Otherwise, it may be considered as an adjunct technique in order to optimize the angiographic result after stenting or directional arthrectomy in this particular indication.

[Isolated lung transplantation--evaluation of patients and initial results]

Between November 1992 and May 1994 we performed 10 single and 5 double lung transplants in patients with end-stage lung diseases due to lymphangioleiomyomatosis (4), cystic fibrosis (3), pulmonary hypertension (3), pulmonary fibrosis (3) and chronic obstructive lung disease (2). In the 13 patients (87%) surviving for median 245 (19-567) days, FEV1 improved from median 640 ml to 1410 ml and the 12-minute walk distance from median 315 to 1100 meters. 10 patients (77%) enjoy a good or even excellent quality of life. 2 patients died 11 and 62 days postoperatively, due to multi-organ failure and invasive pulmonary aspergillosis respectively. The main postoperative problems are fungal and cytomegalovirus infections and chronic rejection in the form of bronchiolitis obliterans. In Switzerland as elsewhere, lung transplantation has become an established modality for the management of end-stage diseases of the lung and pulmonary circulation.

Aneurysm of the superior mediastinal veins

A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine.

[Surgical therapy in unstable angina pectoris]

In order to assess the value of surgical revascularization of coronary arteries in patients with unstable angina pectoris, a series of 551/3397 consecutive patients belonging to New York Heart Association (NYHA) class IV was investigated. Fulfillment of at least two of the following criteria is mandatory for diagnosis unstable angina pectoris: slightly increased CK (< 300 IU/l), modified ECG at rest (decreased ST-T, increased ST), therapy-resistant post-infarction angina, therapy-resistant angina at rest, increased severity, duration or frequency of angina attacks within the last three months, insufficient therapeutic response. Patients with acute myocardial infarction were excluded from analysis. 362/551 patients out of the investigated cohort fulfilled criteria of unstable angina pectoris NYHA class IV; in 189/551 patients, criteria of stable angina pectoris NYHA class IV were fulfilled (controls). The mean follow-up period for these patients was 72 +/- 33 months (24 +/- 144 months). There were no differences regarding age, percentage of patients with three vessel disease, ejection fraction of the left ventricle and of cardiogenic shock. The mean number of aortocoronary grafts was 3.8 +/- 1.3 in patients with unstable angina, compared to 3.4 +/- 1.5 in patients with stable angina pectoris (p < 0.05). An intra-aortic balloon pump had to be applied in 8% of patients with unstable angina compared to 3% in stable angina. A mortality of 2% within 30 days of surgery was registered in unstable compared to 3% in stable angina pectoris (n.s).(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency endoluminal stenting for abrupt vessel closure following coronary angioplasty: a randomized comparison of the Wiktor and Palmaz-Schatz stents

In order to compare the efficacy of two different stent types in case of bailout stenting, 65 patients, with abrupt or threatened vessel closure following coronary angioplasty, were randomly assigned to either Wiktor (Medtronic Inc., Minneapolis, MN, 33 patients) or Palmaz-Schatz (Johnson & Johnson Interventional, Warren, NJ, 32 patients) stent implantation. Stenting was technically feasible in all except one patient and immediately successful in reverting ischemia and vessel closure in 60 patients (92%). At hospital discharge, complication rates were comparable: early vessel closure, 18% (Wiktor) versus 13% (Palmaz-Schatz) (P = 0.53); any clinical event (such as death, myocardial infarction, and surgical revascularization): 18% (Wiktor) versus 22% (Palmaz-Schatz) (P = 0.71). At 6 months follow-up, these complication rates remained equal: restenosis, 38% (Wiktor) versus 27% (Palmaz-Schatz) (P = 0.42); any clinical and angiographic (vessel closure and restenosis) event: 45% (Wiktor) and 41% (Palmaz-Schatz) (P = 0.69). Baseline, direct postprocedural, and follow-up quantitative coronary analysis data were similar, with, however, an exception for the postprocedural residual stenosis [28% (24-32%) (Wiktor) and 21% (18-23%) (Palmaz-Schatz] (means and 95% confidence intervals). In conclusion, despite a discrete postprocedural angiographic benefit observed with the Palmaz-Schatz stent, the long-term clinical and angiographic outcome is similar in both treatment groups. The choice whether to implant a Wiktor or Palmaz-Schatz stent may probably be left to the discretion of the operator and his experience with one particular device.

Outflow tract obstruction after mitral valve repair without an annuloplasty ring

We report that systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction can occur after mitral valve reconstruction without using an annuloplasty ring. A 69-year-old male patient with mitral regurgitation and ischemic heart disease underwent combined mitral valve reconstruction without an annuloplasty ring, and coronary artery bypass grafting. Intraoperative transesophageal echocardiography performed at the end of the operation revealed systolic anterior motion of the mitral valve with significant outflow tract obstruction requiring a second pump run with return to cardiopulmonary bypass and additional mitral valve replacement during the same thoracotomy.

[Occlusion of the distal aorta]

Between 1984 and 1992, 79 patients were operated for occlusion of the infrarenal abdominal aorta. 12/79 (15%) of the patients underwent emergency procedure for an acute Leriche syndrome. 67/79 (85%) of the patients with a chronic occlusion were treated electively. The surgical management includes in our series in 57/79 (72%) cases aortoiliac or aortofemoral prosthetic bypass, in 11/79 (14%) cases aortoiliac endarterectomy, in 6/79 (8%) cases embolectomy and in 5/79 (6%) extraanatomical axillofemoral bypass. For chronic total occlusion of the aorta the most common procedure was prosthetic bypass in anatomical position. For emergency cases embolectomy was performed in 42%. Early morbidity rate was 26% (21/79). The most frequent complications were thromboembolic events in 7 patients, myocardial infarction in 4 patients and renal insufficiency in 4 cases. The 30-day mortality 2.5% (2/79); the cause in both cases myocardial infarction. For atherosclerotic occlusive disease of the infrarenal abdominal aorta the prosthetic bypass is the first-choice surgical procedure. For embolic occlusions and for risk patients other less burdening procedures are available.

Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis

Coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are more effective than medical treatment for the management of ischaemic heart disease. However, patients with single-vessel involvement have been excluded from prospective comparisons of the two methods. We have carried out such a comparison in patients with isolated proximal left anterior descending artery stenosis, conserved left ventricular function, and documented ischaemia. Eligible patients presenting to a single centre were randomly assigned PTCA (68 patients) or left internal mammary grafting (66). The procedures were technically feasible in all cases. The incidence of in-hospital complications was 2% (perioperative myocardial infarction) for CABG and 3% (emergency CABG for acute closure) for PTCA. Clinical and functional status improved similarly in both groups. However, patients in the PTCA group took more antianginal drugs. At median follow-up of 2.5 years, 86% of CABG-treated and 43% of PTCA-treated patients were free from adverse events (p < 0.01; relative risk 2.0 [95% CI 1.7-2.3]). The adverse events that explain this difference were restenosis (32%) requiring subsequent surgical (16%) or percutaneous (15%) revascularisation (1% had medical therapy). Rates of cardiac death and myocardial infarction did not differ between the groups. Both CABG and PTCA improve the clinical status of symptomatic patients with single-vessel coronary artery disease. If patient and physician accept the risk of restenosis and reintervention associated with PTCA, this procedure remains a suitable option and a simpler initial alternative to CABG.

Coronary angioplasty in octogenarians: immediate and long-term results and comparison with a younger population

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) was examined in a group of 91 octogenarians during 133 consecutive procedures and compared to the younger part of our PTCA population (3,443 procedures) during an 8-year study period. Most octogenarians presented with refractory or unstable angina pectoris and multivessel involvement, but had normal left ventricular function. The angiographic success rate was 84%. Technical failure was observed in 12% of cases and complications in 14%. Two early procedure related deaths were observed. Restenosis was estimated at 24%. The proportion surviving and the proportion without cardiac event estimated by the Kaplan-Meier method at 2 years were 0.89 and 0.60, respectively. In comparison to the younger population, the immediate angiographic success was lower as a result of a higher incidence of technical failure (P less than 0.05). Otherwise, no difference in terms of restenosis or overall related complication rate was noted (P greater than 0.1). It is concluded that PTCA is an efficient and safe therapeutic option for octogenarians with severe or refractory angina pectoris. Technical failure is more frequently observed than in younger patients and explains a lower immediate angiographic success. Nevertheless, at 2-years follow-up, a large majority of patients are alive and asymptomatic.

Cavernous destruction of an upper lung lobe in a healthy young man. An unusual roentgenographic presentation of allergic bronchopulmonary aspergillosis

We describe a 32-year-old man with no history of pulmonary disease who presented with extensive cavernous destruction of the right upper lobe as an incidental finding on a chest x-ray film. All major criteria of allergic bronchopulmonary aspergillosis (ABPA) were present. Histologic examination of the resected lobe showed the typical features of ABPA. The differential diagnosis of multiple cavitating lesions should include ABPA.

Endoluminal stenting of narrowed saphenous vein grafts: long-term clinical and angiographic follow-up

From April 1986 through April 1993, 58 intracoronary stents (41 Wall and 17 Wiktor stents) were implanted for the treatment of saphenous vein graft stenosis in 40 symptomatic patients. The indication was a primary stenosis in 44 and restenosis in 14 procedures. In-hospital complications were subacute stent thrombosis (2%), myocardial infarction (2%), and emergency coronary artery bypass grafting (CABG) (2%). Complications during a mean follow-up period of 42+/-27 months were restenosis (35% by patient, 33% by lesion), myocardial infarction (12%), late bypass grafting (12%), and death (7%). On quantitative coronary angiographic analysis, the mean minimal luminal diameter (and its confidence interval) increased from 1.3 mm (1.1-1.5 mm, preprocedure) to 2.9 mm (2.7-3.1 mm, postprocedure) and 2.2 mm (2.0-2.5 mm, 6 months follow-up, 95% angiographic follow-up). Progression of the underlying coronary artery disease and restenosis were the main reasons for a continual decline of the proportion without cardiac event on a Kaplan-Meier estimate. Restenosis occurred in one-third of cases beyond the first 6 months of follow-up. A relative risk ratio analysis for restenosis, performed on 14 variables, disclosed an increased risk for the following variables: (1) stenting of the proximal, distal or anastomosis part of the vein graft (relative risk 2.41, confidence interval: 1.28-3.59), (2) the implantation of stents < 4.5 mm (2.59, 1.18-4.00), and (3) stenting of a redo-CABG vein graft (2.37, 1.17-3.58). Saphenous vein graft stenting seems to be characterized by excellent immediate clinical and angiographic results; in particular, stent thrombosis is rare.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ectopic ossification as a cause of vague abdominal pain following heart surgery: a case report]

Vague abdominal pain after cardiac surgery was caused by ectopic ossification in the distal part of sternotomy. The rarity of this complication (one case seen in recent years, operation volume: 1200 cases/year) prompted us to review the literature, where only 6 cases are described. Diagnostic problems and therapy are discussed.

[Cardiovascular interventions in elderly patients]

From January 1981 to December 1990, 204 patients between 70 and 81 years of age underwent aortocoronary bypass-surgery, and 20 patients age 80 years or older underwent valvular surgery. The operative mortality rate (30-day mortality) of aortocoronary bypass-surgery was 6.8%; actuarial survival rate at 1 and 5 years was 92% and 86%, respectively. The operative mortality rate of valvular surgery was 15%; actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. The mean follow-up was 25 months. Most patients undergoing myocardial revascularization (71%) and all the patients undergoing valvular surgery were preoperatively in New York Heart Association (NYHA) functional class III or IV, at the end of the follow-up in NYHA functional class I or II (95%). A rapid rise in the number of heart operations in the elderly is evident. It is associated with increased but acceptable operative risk. Longterm results and postoperative improvement of functional status are satisfactory.

Rapid screening of the Y chromosome in idiopathic sterile men, diagnostic for deletions in AZF, a genetic Y factor expressed during spermatogenesis

A rapid molecular screening programme has been established for the long arm of the human Y chromosome in Yq11 in order to quickly detect small interstitial deletions in this chromosome region. They have been observed in idiopathic sterile males with azoospermia and a severe oligozoospermia and are therefore indicative for deletion of AZF gene sequences. AZF (i.e. azoospermia factor) is a genetic factor located in Yq11 which controls human spermatogenesis. The screening programme is based mainly on a multiplex PCR approach using a series of Y-specific primers amplifying single DNA loci in Yq11. The order of all Y-DNA loci can be unequivocally arranged along the whole long Y arm. Therefore, any detected deletion can be quickly mapped in relation to the proposed position of AZF. Benefits and pitfalls of this new diagnostic Y screening method will be discussed.