Safety and efficacy of repeat transradial access for cardiac catheterization procedures

To determine the safety and efficacy of repeat transradial cardiac catheterization, 1,362 consecutive transradial procedures were examined. Repeat transradial procedures were identified (group I, n = 73) and compared with index procedures (group II, n = 1,289). Baseline patient characteristics, procedure success rates (100% vs. 97.9%; P = NS), complication rates (0% vs. 0.08%; P = NS), and procedure times (23.9 +/- 27.3 min vs. 18.2 +/- 14.7 min; P = NS) were similar between groups. This study suggests that repeat transradial catheterization procedures can be performed safely and successfully in appropriately selected patients.

Transradial cardiac catheterization in elderly patients

The safety and efficacy of transradial cardiac catheterization in elderly patients is unknown. This study examines procedure success rates for transradial catheterization in appropriately selected patients < 70 (n = 195) and >/= 70 (n = 83) years old. Elderly patients were less likely to be selected for the transradial approach (46% vs. 61%; P = 0.05). Although patients >/= 70 years old were more often female (39.7% vs. 24.1%; P = 0.008) and had a smaller body surface area (1.89 +/- 0.18 vs. 2.01 +/- 0.24 m2; P = 0. 001), procedure success rates did not differ (95.1% vs. 94.8%; P = NS). Procedure-related variables including procedure time (15.4 +/- 12.6 vs. 16.1 +/- 11.6 min; P = NS), amount of radiographic contrast (90.1 +/- 31.9 vs. 86.4 +/- 29.8 cc; P = NS), and number of catheters used (1.5 +/- 0.9 vs. 1.5 +/- 0.7; P = NS) were similar between groups. We conclude that transradial catheterization can be safely and effectively performed in selected elderly patients. Cathet. Cardiovasc. Intervent. 51:287-290, 2000.

Visual and quantitative computerized assessment of disease severity on peripheral angiograms

PURPOSE

This study was designed to determine and compare the intra- and interobserver variability of visual and computerized assessment of peripheral arterial disease (PAD) severity from lower extremity angiograms, and to correlate quantitative angiographic measures with clinical predictors of PAD.

PATIENTS AND METHODS

Peripheral angiograms of 13 segments from the ilio-femoral-popliteal system were evaluated on two separate occasions by nine radiologists and with a quantitative computerized method. In a separate study, images from 18 patients undergoing diagnostic lower extremity angiography were analyzed with use of quantitative angiography and the results were compared with clinical and lipid risk factors.

RESULTS

The data demonstrate that computerized assessment of peripheral angiograms is associated with lower intra- and interobserver variability than visual assessment of the same films. Despite this, there was excellent intraobserver and good interobserver agreement on the presence or absence of a severe lesion with visual assessment. Quantitative computerized measures of disease severity correlate with several known predictors of large vessel PAD.

CONCLUSION

Computerized assessment of peripheral angiograms may be a useful tool in the clinical and investigational evaluation of PAD.

Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques

In order to monitor the incidence and types of peripheral vascular complications in a single institution, we prospectively entered 1,579 coronary angioplasty cases into a computer data base during the years 1991 and 1992. Various periprocedural risk factors were analyzed. The patients were followed closely to identify complications that occurred outside the laboratory or after discharge from the hospital. Peripheral vascular complications occurred in 37 patients (2.37%) and included hematoma 20 (1.27%), retroperitoneal bleeding 7 (.44%), false aneurysm 6 (.38%), occlusion 1 (.06%), infection 2 (.13%), and cholesterol emboli 1 (.06%). Risk factors for complications by multivariate analysis were older age, female gender, and clinical evidence of peripheral vascular disease. Other factors potentially related to vascular trauma or bleeding tendency that were not risk factors in this series were clinical presentation, use of heparin or thrombolytic agents, blood clotting parameters, and arterial sheath size. There was no significant difference between the femoral and brachial approaches in frequency of complications (2.5% vs. 1.6%), but femoral complications tended to carry greater morbidity.

Variability in measures of coronary lumen dimensions using quantitative coronary angiography

OBJECTIVES

The purpose of this study was to determine the true total variability of quantitative coronary angiographic measures and their components in the clinical setting.

BACKGROUND

Many studies describe quantitative coronary angiographic variability on the basis of repeated quantitative coronary angiographic measures from the same cineangiogram. Although these studies characterize well the performance of quantitative coronary angiographic analysis methods, they do not include other potentially important sources of variability in results of this procedure, such as day to day variations in patients and equipment or variability in selection of frames for analysis.

METHODS

Coronary angiograms from 20 patients who underwent diagnostic angiography followed by percutaneous transluminal coronary angioplasty an average of 2.9 days later were reviewed. A total of 30 lesions well visualized in both films were analyzed multiple times using an automated first-derivative edge-detection quantitative coronary angiographic technique.

RESULTS

The coefficient of variation for quantitative coronary angiographic measures of the same lesions from separate angiograms ranged from 8.11% to 14.01%. Average diameter was the least variable and percent diameter stenosis the most variable. Day to day variations in the patient, procedure and equipment accounted for an average of 30% of the total variability. Of the remaining variability, only 13.26% was due to variability in frame selection.

CONCLUSIONS

These results provide useful information for planning clinical studies using quantitative coronary angiography, identify areas where additional improvements in this technology are needed and define more clearly the applicability of quantitative coronary angiography in the setting of routine clinical practice.

Sources of error in quantitative coronary angiography

Many studies have reported the accuracy of quantitative coronary angiography (QCA) based on experiments using moderated-size phantoms imaged under unrealistic radiographic conditions. However, these observations may not be generalizable to the setting of clinical angiography. To determine QCA accuracy in a realistic radiographic setting and evaluate the impact of the x-ray system line spread function, plexiglass phantoms were imaged inside and out of a human thorax. A realistic radiographic background was associated with a 38% increase in variability of results (p < 0.05). Low concentrations of contrast and large image intensifier input screens were associated with significantly larger errors and variability in results (p < 0.05). There was a systematic overestimation of diameter in the smallest phantom. A mathematical model of the x-ray line spread function was developed that explains the observed overestimation of the smallest phantom and provide a rational approach for correction of the line spread function for QCA. Many factors encountered in clinical coronary angiography such as nonuniform radiographic background, low concentrations of contrast, and small vessel diameters have a significant adverse impact on the accuracy and/or variability of gradient-based edge detection QCA systems.

Ischemic cardiomyopathy: endomyocardial biopsy and ventriculographic evaluation of patients with congestive heart failure, dilated cardiomyopathy and coronary artery disease

OBJECTIVES

This study was designed to define clinical and pathophysiologic similarities and differences between patients with ischemic and idiopathic dilated cardiomyopathy.

BACKGROUND

Significant coronary artery disease in patients with new onset congestive heart failure due to dilated cardiomyopathy has important prognostic and therapeutic implications.

METHODS

Clinical, histologic, ventriculographic and hemodynamic features of patients with dilated cardiomyopathy who underwent coronary angiography were reviewed.

RESULTS

Patients with ischemic cardiomyopathy (n = 21) compared with those with idiopathic cardiomyopathy (n = 40) had similar presenting symptoms, durations of illness, and coronary risk factor profiles, with the exception of a greater prevalence of cigarette smoking (71% vs. 39%, p = 0.028) and male gender (100% vs. 70%, p = 0.014). Endomyocardial biopsy specimens from patients with ischemic cardiomyopathy demonstrated a greater prevalence of replacement fibrosis (48% vs. 8%, p = 0.001) and a lesser degree of histologically assessed myocyte hypertrophy (mean grade 0.5 +/- 0.7 vs. 1.3 +/- 1.3, p = 0.015). Although ventriculographically determined regional dyskinesia was present in both groups, there was a higher prevalence of two or more adjacent segments in the ischemic cardiomyopathy group (50% vs. 10%, p = 0.03). This ischemic group had hemodynamic variables associated with a worse prognosis: higher pulmonary artery wedge pressure (23 +/- 10 vs. 15 +/- 9 mm Hg, p = 0.006) and lower cardiac index (2.0 +/- 0.5 vs. 2.3 +/- 0.5 liters/min per m2, p = 0.044). Also, in this group, patients had a mean of 2.6 +/- 0.7 diseased vessels; 15 (71%) of 21 patients had triple-vessel disease and 18 (86%) of 21 had at least one occluded or suboccluded artery.

CONCLUSIONS

1) Patients with ischemic and idiopathic cardiomyopathy may be clinically indistinguishable unless coronary angiography is performed. 2) A greater prevalence of replacement fibrosis and a lesser degree of myocardial hypertrophy in patients with ischemic cardiomyopathy may account for the greater extent of hemodynamic decompensation observed at presentation.

Coronary angioplasty in cardiac transplant patients. Results of a multicenter study

BACKGROUND

Accelerated allograft atherosclerosis is the main cause of death of cardiac transplant recipients after the first year after transplantation. Because no medical therapy is known to prevent or retard graft atherosclerosis and transplantation is associated with a shortened allograft survival, alternative, palliative therapy with percutaneous transluminal coronary angioplasty (PTCA) has been attempted. Because no single medical center has performed angioplasty in a large number of cardiac transplant recipients, representatives of 11 medical centers retrospectively analyzed their complete experience of coronary angioplasty in cardiac transplant patients to determine the safety, efficacy, limitations, and long-term outcome of angioplasty in allograft coronary vascular disease.

METHODS AND RESULTS

Thirty-five patients underwent 51 angioplasty procedures for 95 lesions 46 +/- 5 months (mean +/- SEM) after transplantation. The primary indications for angioplasty included angiographic coronary disease in 22 cases (43%) and noninvasive evidence of ischemia in 18 procedures (35%). Angiographic success, defined as less than or equal to 50% post-PTCA stenosis, occurred in 88 of 95 lesions (93%). Mean pre-PTCA stenosis was 83 +/- 1.1%; mean post-PTCA stenosis was 29 +/- 2.1% (p less than 0.0001). Periprocedural complications included myocardial infarction and late in-hospital death in one patient and three groin hematomas. Twenty-three of the 35 patients (66%) had no major adverse outcome such as death, retransplantation, or myocardial infarction at 13 +/- 3 months after angioplasty. Four patients died less than 6 months after angioplasty, and four died more than 6 months after angioplasty (range, 6-23 months). Two patients had retransplantation 2 months after PTCA, and one patients had retransplantation 18 months after angioplasty.

CONCLUSIONS

Coronary angioplasty may be applied in selected cardiac transplant recipients with comparable success and complication rates to routine angioplasty. Whether angioplasty prolongs allografts survival remains to be determined by a prospective, controlled trial.

Contrast echocardiographic mapping of collateralized myocardium in humans before and after coronary angioplasty

Conventional coronary arteriography is able to demonstrate the presence of coronary collateral vessels but cannot delineate the specific region of myocardium to which they supply blood. To test the hypothesis that contrast echocardiography can specifically identify collateralized myocardium, contrast echocardiographic perfusion "maps" were compared in patients with (n = 12) and without (n = 12) angiographic evidence of coronary collateral flow, both before and after coronary angioplasty. Contrast echocardiographic images of the mid-left ventricle in the short-axis view at end-diastole were obtained after separate injections of a sonicated contrast agent into both the right and the left coronary arteries. A computer-based contouring system was used to determine the individual areas of myocardium perfused by each of the two coronary arteries and then to superimpose the images of the two perfusion beds. The resulting area of overlapping perfusion represented myocardium receiving blood flow from both coronary systems and was defined as collateralized myocardium. To normalize for heart size, overlap area was expressed as a percent of total myocardial area, which was the area between endocardium and epicardium in the short-axis view. To adjust for differences in vascular distribution, overlap area was expressed as a percent of the perfusion area of the recipient vessel. In patients with angiographic collateral flow, the recipient vessel was that vessel receiving the collateral flow. In patients without angiographic collateral flow, the right coronary artery was considered the recipient vessel. Overlap area was 1.3 +/- 0.4% of total myocardial area and 6.6 +/- 1.7% of recipient vessel area in patients without angiographic evidence of collateral flow compared with 30.6 +/- 2.5% and 89.2 +/- 6.4%, respectively, in patients with angiographic collateral flow (p less than 0.001 for both). In four patients in whom angiographic collateral flow was abolished by angioplasty, overlap area decreased from 30.3 +/- 5.3% to 6.8 +/- 2.7% of total myocardial area and from 100% to 18.5 +/- 5.4% of recipient vessel area (p less than 0.05 for both). Thus, contrast echocardiography is able to map the specific myocardial territory perfused by coronary collateral flow and document an immediate reduction in perfusion in this territory when collateral flow is abolished by angioplasty.

Is atrial activation beneficial in heart transplant recipients?

Because of the distortion of atrial morphology that occurs during cardiac allograft transplantation in humans, the beneficial effects of properly sequenced atrial and ventricular activation are unclear in these patients. To evaluate the atrial contribution to ventricular pump performance in heart transplant recipients, arterial pressure and cardiac output during pacing from either chamber were measured in nine patients 10 +/- 1 days after transplantation. Systolic, diastolic and mean systemic arterial pressures were significantly higher during atrial pacing compared with ventricular pacing: 143 +/- 23 versus 125 +/- 20 mm Hg, 73 +/- 15 versus 66 +/- 14 mm Hg and 94 +/- 17 versus 84 +/- 16 mm Hg, respectively (p less than 0.05 for all). In addition, cardiac output decreased from 5.5 +/- 1.4 to 4.6 +/- 1.5 liters/min (p less than 0.005) for atrial versus ventricular pacing. Thus, there is a significant atrial contribution to cardiac performance in patients after heart transplantation. This may have clinical implications in those patients who later require a permanent pacemaker.

Coronary artery aneurysm formation following percutaneous transluminal coronary angioplasty: treatment of associated restenosis with repeat percutaneous transluminal coronary angioplasty

Restenosis following coronary angioplasty can usually be treated effectively and safely by repeated angioplasty. However, the presence of a complex lesion morphology may bias the clinician away from angioplasty toward either recommending bypass surgery or continuing medical therapy alone in spite of recurrence of the symptoms which were sufficient indication for the initial angioplasty. One type of complex morphology at the site of the restenosis is due to the presence of a focal, eccentric aneurysmal dilatation similar in appearance to a saccular aneurysm. In two previously reported cases in the literature both were referred to bypass surgery. We report eight additional cases including the use of repeat successful angioplasty in six of the cases in spite of the potential problems posed by the complexity of the restenosed lesion. In addition, this case review suggests that this type of complex lesion morphology with restenosis may be more common when the initial angioplasty was associated with deep arterial injury, as in patients whose initial angioplasty was done in an infarct-related vessel or was associated with evidence of a large dissection.

Diminished cardiac hypertrophy and muscle performance in older compared with younger adult rats with chronic atrioventricular block

The combined effect of advancing age and hemodynamic overload on cardiac muscle function has received little attention. In male, Sprague-Dawley rats, we studied the interaction of chronic atrioventricular heart block induced by transvenous electrocautery for 4-12 months (mean, 7 months) and age at study (12, 19 +/- 0.7, and 24 +/- 0.2 months) on cardiac hypertrophy and muscle function compared with age-matched, sham-operated controls. Hypertrophy was determined by the ratio of heart weight to tibial length. Muscle function was first determined from the mechanical variables of the isometric contraction of an excised, thin, left ventricular trabecular muscle bathed at 29 degrees C under a variety of calcium concentrations and stimulation patterns. Then, in the same muscles after disruption of membranes with Triton X-100, the force-pCa curve of the myofibrils was obtained. No hypertrophy occurred with aging in the control group, but alteration in hypertrophy with age occurred in the block group such that the youngest animals with block had the most hypertrophy (170%) and the oldest animals with block the least hypertrophy (120%). The tension developed by cardiac muscle and the duration of the isometric contraction were not affected by age in the control group but were significantly affected by age in the block group. The young animals with block had a markedly prolonged contraction duration and almost twice the developed tension compared with the older animals with block or with controls. The age-related difference in muscle contraction duration in the block group was associated with, and may have only been secondary to, the age-related difference in the extent of cardiac hypertrophy. For developed tension, the age-related difference in the block group could not be explained by differences in the extent of cardiac hypertrophy. Rather, this difference was attributable to both an increased myofibrillar force-generating capacity in the young block and to an impairment in excitation-contraction coupling in the old block. The results show that during long-term block, age exerted not only a significant effect on the extent of cardiac hypertrophy but also an independent effect on the developed tension of cardiac muscle.

Double vs single balloon technique for aortic balloon valvuloplasty

Percutaneous aortic valvuloplasty using a single dilating balloon has been associated with significant but modest reduction in transvalvular pressure gradient and increase in valve area. The balloon diameter is usually 20 mm or smaller to avoid disruption of aortic root structure and to permit forward blood flow during inflation. To evaluate the safety and efficacy of valvuloplasty using a combination of balloons with larger maximum inflated diameters, we compared results of aortic valvuloplasty in 21 patients using either the single or double balloon technique. Mean maximum inflated balloon diameter was 19.4 mm +/- 1.4 for the single balloon technique, while the mean sum of diameters for the simultaneous double balloon technique was 36.3 mm +/- 3.9. The mean age, aortic annulus diameter, and predilatation aortic valve area were not different among groups. Mean aortic transvalvular gradient reduction and mean aortic valve area increase were greater for the double balloon technique. The procedure was well tolerated with no major complications. No change in the degree of aortic regurgitation was noted. The double balloon technique for aortic valvuloplasty is safe and more effective at improving aortic valve area and transvalvular gradient than the conventional single balloon technique.

Initial and late results of coronary angioplasty for early postinfarction unstable angina

Unstable angina that occurs in the early postinfarction period is associated with an increased incidence of unfavorable cardiac events despite aggressive medical therapy. We examined the results of coronary angioplasty in 47 consecutive patients with postinfarction unstable angina who were referred for the procedure 12.9 +/- 7 days following myocardial infarction, 14 of which were Q wave and 33 of which were non-Q-wave. Coronary angioplasty was performed on a total of 55 arteries with a mean predilatation stenosis of 95 +/- 8%. These included 46 infarct-related arteries and nine noninfarct arteries. Double-vessel angioplasty was performed in eight patients. Successful coronary angioplasty (greater than 30% reduction of predilatation stenosis) was achieved in 43 patients (91%), with a mean residual stenosis of 33 +/- 28%. There was one in-hospital death, one patient required emergency bypass surgery, and two patients had early reocclusion resulting in myocardial infarctions. The 39 patients who had successful angioplasty procedures and who were discharged from the hospital without an unfavorable outcome were followed for 16.3 +/- 7 months, and repeat coronary angioplasty was required in five patients from 45 to 105 days after the initial procedure. Two patients had subsequent elective bypass surgery, one had a recurrent myocardial infarction, and one patient had a noncardiac death. For selected patients with suitable coronary anatomy, coronary angioplasty appears to offer an efficacious therapeutic option for early postinfarction unstable angina.

Coronary angiography and intracoronary thrombolytic therapy in the coronary care unit: an alternative approach

The feasibility, safety and efficacy of performing left heart catheterization, coronary angiography, and intracoronary thrombolytic therapy in the coronary care unit setting were examined in 17 patients with acute ischemic syndromes presenting at a time when routine catheterization facilities were not available. In all cases, cardiac catheterization and coronary angiography were performed in the coronary care unit without difficulty using a portable image intensifier and a portable video recording system, and selective intracoronary streptokinase was safely administered in 13 patients with a total coronary occlusion, with successful thrombolysis in seven patients (54%). No adverse effects attributable to the performance of these procedures in the coronary care unit were observed. This approach might allow for a more prompt response and wider availability of intracoronary thrombolytic therapy for patients presenting with acute myocardial infarction.

ATPase activity and force production in myofibrils and twitch characteristics in intact muscle from neonatal, adult, and senescent rat myocardium

To determine whether age-associated alterations in the cardiac muscle twitch could be related to altered myofibrillar ATPase activity or to an altered force-pCa relationship, these variables were measured in rat cardiac preparations across a broad age range. Between 2 and 6 months, maximum ATPase activity in detergent treated myofibrils decreased approximately two fold (0.166 +/- 0.01 v. 0.078 +/- 0.02 microM Pi/min X mg protein, P less than 0.001), but did not change with further aging (12 or 24 months). The Ca2+-dependent force in thin 'Triton skinned' papillary muscles was not age-related. ATPase activity and force exhibited identical Ca2+ sensitivity from the submicromolar to micromolar range: for ATPase activity pCa for 50% activity averaged 6.1 and Hill coefficients averaged 4.5; pCa for 50% force development was 6.1 and Hill coefficients of the force-pCa relation averaged 4.5; no age differences in these parameters were observed. In the intact muscles prior to skinning, neither twitch force nor the maximum rate of force production were age-related; however, indices of the time course of contraction, time to peak force, half relaxation time, and their sum, increased progressively, changing by approximately 30% from 2 to 24 months (P less than 0.001). Since the decline in ATPase activity occurred over the maturational period only, and did not change with further ageing, while the twitch duration changed progressively with age, it is concluded that the twitch prolongation of the senescent myocardium cannot be directly related to the age-related decline in myofibrillar ATPase activity.

Effect of sodium on calcium-dependent force in unstimulated rat cardiac muscle

It has previously been demonstrated that 1) changes in superfusate calcium concentration [Ca2+]o within the low millimolar range result in changes in "resting" force and in the light-scattering properties of unstimulated rat cardiac muscle, and 2) if [Ca2+]o is increased from zero to millimolar concentrations, i.e., reperfusion with Ca2+ after a Ca2+-free period, a large influx of Ca2+ occurs and is associated with a substantial increase in resting force. The present study determined whether the Ca2+ influx in either case was influenced by intracellular sodium (Na+i). In unstimulated isometric rat right ventricular papillary muscles equilibrated at 29 degrees C, [Ca2+]o was increased from 1 to 4 mM or from 0 to 2 mM under conditions that vary Na+i, and the resulting change in intracellular calcium concentration [( Ca2+]i) was monitored by changes in both resting force and the frequency of intensity fluctuations in laser light scattered by the muscle. In each case, lowering Na+i by equilibration in lowered extracellular sodium concentration [( Na+]o) or enhancing [Na+]i by equilibration in the absence of extracellular potassium or in the presence of ouabain markedly lowered and enhanced respectively the apparent Ca2+ influx in response to the step increase in [Ca2+]o. Thus, in unstimulated rat cardiac muscle, Na+i modulates the Ca2+ influx resulting from a step increase in [Ca2+]o both under physiological conditions and following a period of Ca2+-free superfusion, i.e., the "Ca2+ paradox." A passive influx of Ca2+ down its electrochemical gradient would not depend on Na+i, and the voltage-time dependent slow Ca2+o channel is inactivated under the experimental conditions employed. The results are best explained by a sarcolemmal Na+-Ca2+ exchange mechanism and suggest that the reversal potential of this electrogenic exchanger is exceeded during a step increase in [Ca2+]o even at the transmembrane potential of resting muscle.