Percutaneous aortic valvuloplasty in inoperable symptomatic severe aortic stenosis in the very elderly

Aortic valve replacement is the first therapeutic option in patients with symptomatic severe aortic stenosis. Given the fact that percutaneous aortic valve implantation is a relatively new procedure and the need for palliative treatment in symptomatic patients with a high surgical risk, percutaneous balloon aortic valvuloplasty is still employed. The authors describe two cases of percutaneous balloon aortic valvuloplasty in very elderly patients with severe calcified aortic stenosis not suitable for cardiac surgery, exacerbated in one case by significant coronary artery disease and left ventricular systolic dysfunction. The authors also review the role of this procedure in current interventional cardiology.

Small coronary arteries treated with sirolimus-eluting stents: one-year results of the PORTO multicentre registry

AIMS

To assess the effectiveness and safety of sirolimus-eluting stents (SES) in de novo native coronary lesions in small vessels (</= 2.5 mm).

METHODS AND RESULTS

PORTO was a multicentre, prospective registry, performed in 274 patients. Of these, 120 (43.8%) patients were diabetic. A total of 324 lesions were treated with 347 SES. The primary end-point was 6-month in-stent late luminal loss (LL); secondary end-points included in-stent and in-segment binary restenosis (BR), target lesion revascularisation (TLR), target vessel revascularisation (TVR) and major adverse cardiac events (MACE) rate at six months and one-year. Pre-specified subgroup analysis included the comparison between diabetic and non-diabetic patients, and patients with stents of different diameter (2.25 mm vs. 2.5 mm) and length (</= 18 mm vs. >/= 23 mm).The mean (SD) reference vessel diameter of the treated segment was 2.08 (0.33) mm and lesion length 11.04 (6.0) mm. After six months, LL was 0.07 (0.37) mm. BR was 5.1% in-stent and 9.1% in-segment. At one year, TLR was 5.6% and TVR was 9.0%. MACE rate was 2.6% at six months and 8.6% at one year with 2.3% cardiac death and 1.5% non-fatal myocardial infarction. Stent thrombosis rate at one year was 0.8% per protocol. There were more MACE in diabetic patients (12.8%) than in non-diabetic (5.4%, p=0.046), but no other significant differences in clinical and angiographic parameters were noted between the subgroups analysed.

CONCLUSIONS

The use of SES for lesions in very small coronary arteries proved to be safe and efficacious, irrespective of the size and length of the stents, with low restenosis and repeat revascularisation rates at one year.

Anomalous origin of the circumflex coronary artery--two case reports

As shown in many series, congenital coronary artery anomalies are found in 0.6 to 1.5% of patients undergoing coronary angiography. Various types of coronary anomalies have been described, many involving the circumflex artery. The second most common anomaly is of the circumflex arising from the right sinus of Valsalva, while origin in the right coronary artery is also frequent. The most common anomaly is absence of the left main coronary artery, the anterior descending and circumflex arteries originating separately in the left coronary sinus. Such anomalies are usually benign, although earlier and more aggressive atherosclerosis is more likely than in normal coronaries and myocardial ischemia can result. Although rare, this can manifest as sudden death. Conventional coronary angiography may be unable to determine the three-dimensional course of the anomalous vessel. The development of multislice computed tomography and its application to cardiac imaging mean that it is now possible to visualize the coronary arteries non-invasively and to obtain more accurate information on their proximal course. We present two cases of congenital anomaly of the circumflex coronary artery diagnosed with the aid of multislice computed tomography.

Acute coronary syndromes in smokers: clinical and angiographic characteristics

Smoking is a major and reversible risk factor for coronary artery disease. The present work aims to define the risk factors, angiographic and clinical characteristics and evolution of acute coronary syndromes in smokers.

METHODS

We studied 521 consecutive patients with acute coronary syndrome admitted to the intensive care unit who underwent catheterization. We assessed the population in terms of risk factors, pathology (unstable angina or acute myocardial infarction), coronary morphology, left ventricular function, the need for intervention, evolution and complications over a one-year period. The characteristics of smokers were then compared with those of non-smokers.

RESULTS

Of the 521 patients with acute coronary syndrome (391 men), 182 (35 %) were smokers. The smokers were younger than the non-smokers (56.3+/-9.5 versus 66.4 +/- 7.8; p < 0.001), were more frequently male (91 versus 66%; p < 0.001), and presented more risk factors (43% with 3 or more risk factors versus 17% in non-smokers; p < 0.001), more obesity (11 versus 5%; p < 0.01), and less diabetes (19 versus 37%; p < 0.001). Smokers presented greater prevalence of acute myocardial infarction (57 versus 40%; p < 0.001) and less unstable angina. Coronary morphology was not significantly different in smokers compared to non- smokers and left ventricular function after the aculte coronary syndrome was similar in both groups. Smokers less frequently underwent surgery during hospitalization (22% versus 35%; p < 0.01) but needed angioplasty as often as non-smokers (48% versus 16%; NS). Smokers presented more frequent complications (angina, heart failure, re-infarction or CABG) than non-smokers (26% versus 17%; p < 0.01), during the first year of follow-up. One-year mortality was similar in both groups. The results were not significantly different when adjusted for gender.

CONCLUSIONS

On average, acute coronary syndrome occurred 10 years earlier in smokers than in non-smokers. The former generally presented more risk factors, lower prevalence of diabetes and higher of obesity, more myocardial infarctions and less unstable angina. After the acute coronary syndrome, at one year, smokers presented more complications than non-smokers but had similar mortality.

Percentage of coronary anomalies in a population of patients undergoing coronary angiography: a retrospective study

Coronary artery anomalies, although less frequent than congenital anomalies of the heart chambers and valve morphology, should be considered in a wide range of ages, in both sexes and as a possible etiology in myocardial ischemia, infarction, and sudden death, as well as in the planning of heart surgery for coronary revascularization, correction of congenital heart malformations or valve replacement. Between January 1996 and June 2002 we reviewed our catheterization database and carried out a retrospective study of the 3660 angiographies performed in our cardiology department. The patients were referred for positive ischemic test, acute coronary syndrome and/or valvular heart disease. From the 3660 angiographies we identified 25 patients (0.68%) with coronary artery anomalies and report the prevalence and types of these anomalies in the population studied. We also assessed the presence of coronary artery disease.

Left main coronary artery originating in the right sinus of Valsalva

A forty-one-year-old male, with no risk factors for coronary artery disease (CAD) and with moderate alcohol intake, was admitted in 1992 to Portalegre Hospital with heart failure due to viral cardiomyopathy. He was re-admitted in 1998 with acute pulmonary edema and was put on mechanical ventilation for 48 hours, and transferred to Pulido Valente Hospital when stable. The physical exam was without abnormalities. ECG showed first degree AV block, left ventricular hypertrophy and 2 mm ST depression in the precordial leads. The echocardiogram revealed left ventricular dilatation and depressed systolic function. Coronary angiography showed single-vessel CAD and coronary artery anomaly. Dobutamine stress echocardiography was halted due to hypertension, making it impossible to evaluate ischemic response. Holter monitoring showed five-complex ventricular tachycardia. The patient was discharged medicated with amiodarone, with indication for cardiac scintigraphy and electrophysiological study.

New classification of aortic dissection with reference to a case report

The authors present a case report of a patient who was diagnosed with aortic dissection during a hemodynamic exam following acute myocardial infarction. With reference to this case, the European Society of Cardiology's latest classification of aortic dissection, published in 2001, is also presented. The patient had the usual risk factors described for aortic dissection, which are simultaneously those for coronary disease. The patient reported an isolated episode in the past of retrosternal pain, radiating to the back, which may have been caused by the aortic dissection. Since then he had been asymptomatic. Four years later, the patient was admitted to hospital following an anteroseptal acute myocardial infarction; fibrinolysis was contraindicated due to recent episodes of rectal bleeding and the patient underwent hemodynamic study (coronary angiography). Due to difficulties in manipulating the guide wire during this exam, aortography was performed, which showed aneurysm and Stanford type B aortic dissection of the thoracic aorta. During hospitalization, a thoracic-abdominal CT scan was performed, which confirmed chronic type B aortic dissection (with intraluminal thrombi). The authors present their reasons for considering this case to be Class 4 according to the new sub-types/classes of aortic dissection of the European Society of Cardiology (ESC): Class 1--Classical aortic dissection Class 2--Intramural hematoma/hemorrhage Class 3--Subtle/discrete aortic dissection Class 4--Plaque rupture/ulceration Class 5--Iatrogenic/traumatic aortic dissection. The authors consider this case to be of interest because of its rarity, the risk that fibrinolysis could have represented, and its categorization according to the latest classification of aortic dissection by the ESC.

[Prognosis significance of blood homocysteine after myocardial infarction]

INTRODUCTION AND AIMS

Homocysteinemia is an independent risk factor of coronary artery disease and of myocardial infarction. In the present study we intend to relate fasting homocystein levels to prognosis after a myocardial infarction.

METHODS

From 1990 to 1992, we studied fasting homocysteinemia levels on a group of 112 patients aged under 56 years that had suffered a myocardial infarction between 3 and 12 months before. We obtained, the patients names, addresses, phone numbers and physicians' name. Seven years later (on average) we collected data regarding the patients evolution, consulting medical records, their physicians or by personal contact. We evaluated complications, namely mortality, vascular morbidity, such as unstable angina, re-infarction, stroke, and the need for invasive procedures (catheterism, PTCA, CABG). According to previous studies of the group, we used a cut-point of 10.10 mumol/L to define patients with normal or pathological levels of homocysteinemia. We excluded all patients that took vitamin B supplements, co-factors of HC metabolism, during this follow-up.

RESULTS

We were able to obtain data on 110 patients. Patients with normal HC levels (n = 62) presented less global complications (26 versus 72%, p < 0.0001), non significant tendency to have lower mortality (1.6 versus 6%), had lower morbidity (14 versus 36%, p < 0.01) and lower invasive procedure need (18 versus 48%, p < 0.001). In the group with pathological homocystein levels (n = 48), those with higher homocystein levels presented a higher degree of complications.

CONCLUSIONS

In this population with myocardial infarction under 56 years of age, a high homocysteinemia level is an important prognostic factor. This study suggests that we can improve the prognosis and decrease the complications after myocardial infarction by lowering elevated homocystein levels.

[Cardiac amyloidosis: review of the literature]

The authors review the clinical impact of cardiac amyloidosis and new aspects concerning the management of this disease in the literature. Cardiac amyloidosis accounts for 5-10% of non-coronary myocardial disorders. It is a distinct form of cardiomyopathy with a severe prognosis. The authors review the role of endomyocardial biopsy and the relative sensitivity of non-invasive diagnostic methods. Chemical and genetic typing of amyloid, which is of considerable clinical value, is also reviewed due to recent evidence of treatment for different types of systemic and cardiac amyloidosis, such as the most common hereditary form caused by transthyretin gene mutation.

[Pharmacological stimulation with dipyridamole in thallium-201 myocardial perfusion scintigraphy: a study of the secondary effects]

To evaluate the safety of intravenous dipyridamole thallium-201 imaging as an alternative to exercise thallium imaging in the evaluation of coronary artery disease, clinical data from 140 patients were retrospectively analyzed. Adverse effects were experienced by 39 patients (27.9%) with a total number of 52 effects: chest pain (23), dizziness (13), headache (7), nausea (7), dyspnea (2). All patients presented complete relief of symptoms. In 15 patients administration of aminophylline was necessary. Major effects (fatal and non fatal myocardial infarction and acute bronchospasm) were not registered. Vital sign data change observed after infusion of dipyridamole was: decreased blood pressure and increased pulse rate. Patient's age and incidence of coronary artery disease did not differ significantly in the subgroup of patients with adverse effects versus the group of patients without it.

[Acute juvenile myocardial infarct. A clinical case and review of the literature]

Authors report one case of myocardial infarction in a young man 23 years old. Prevalence of acute myocardial infarction under the age of 35-40 years is not negligible. Pathogenic mechanisms, risk factors, clinical presentation, prognosis, and findings in selective coronary angiography are reviewed.

[Significance of the persistence of ST segment elevation in anterior infarction]

OBJECTIVE

Persistent ST segmentary elevation in anterior myocardial infarction was classically attributed to ventricular aneurysm. This association is now considered controversial. We studied the association between this electrocardiographic finding and the left ventricular wall motion abnormalities and global function.

DESIGN

Retrospective study.

SETTING

Patients admitted to Hospital de Pulido Valente Coronary Care Unit in Lisbon with anterior myocardial infarction who were submitted to angiographic study.

PATIENTS

94 patients were included in the study.

METHODS

The global ejection fraction, the regional wall motion abnormalities, the coronary artery disease extension, the patency and the proximal involvement of the left anterior descending artery were investigated.

RESULTS

56 of the 94 patients (60%) had persistent ST segment elevation and 38 (40%) had isoelectric ST segment. The ejection fraction was markedly depressed in the group with elevated ST segment (36.2 SD 17.6) in contrast with the group with isoelectric ST segment (49.3 SD 14.8) (p < 0.001). The group with persistent ST segment elevation had more advanced degrees of left ventricular asynergy (42/58-75%) than the group with isoelectric ST segment (12/38-32%) (p = 0.02). The other studied angiographic variables did not differ between the two groups.

CONCLUSIONS

The group with persistent ST segment elevation was associated with advanced degrees of left ventricular asynergy and greater left ventricular function depression. The ventricular aneurysm was exclusive of the first group.

[Homocysteinemia as a risk factor for early myocardial infarct--a case-control study]

PURPOSE

To investigate if hyper-homocysteinemia represents an independent risk factor of early coronary disease.

METHODS

We studied a group of patients under 45 years old, that suffered a myocardial infarction from 3 months and 1 year before the study. The patients were matched with a group of normal controls of a check-up program, in terms of age, sex, smoking habits, presence of hypertension, obesity, (Quetelet Index), presence of diabetes, basal glycemia, total cholesterol, LDL and HDL cholesterol. Later we measured to patients (Pts) and controls (Cts) the plasmatic basal homocysteinemia (B HC) and 6 hours after a methionine overload of 0.1 g/kg body weight (L HC).

RESULTS

[table: see text]

CONCLUSIONS

In this study hyper-homocysteinemia appears as an independent risk factor of early coronary disease. The measurement of homocysteinemia after the methionine loading test was more discriminative than the basal measurement.

[What is the value of myocardial perfusion studies with isotopes in patients with complete left bundle branch block?]

The prognosis of left bundle branch block is determined by associated cardiovascular disease. Exercise electrocardiography is not helpful in detecting ischemia in these patients. Exercise thallium-201 scintigraphy has been widely accepted for that purpose. The authors made an overview of several studies suggesting that exercise thallium-201 scintigraphy has low specificity regarding left anterior descending coronary artery disease. They also review the mechanisms of perfusion defects in patients with left bundle branch block without coronary artery disease. One important question to be clarified is weather small defects are unrelated to coronary artery disease. Finally the authors analyse a few methods to increase diagnostic accuracy of perfusion scintigraphy in left bundle branch block. First the employment of a new criterium that requires the apex to be abnormal to indicate left anterior descendent artery disease. Second Pharmacological Stress with Dipyridamole or Adenosine. Third imaging with Tc-99m-MIBI.