[Wiktor coronary stent for elective placement with an antiaggregation regimen. WINE study. WINE Group Study]

INTRODUCTION AND OBJECTIVES

The main problems associated with coronary stent implantation are subacute thrombosis and vascular and hemorrhagic complications due to the intensive anticoagulant regime. We studied the complications and the six-month restenosis rate after the elective implantation of a Wiktor stent in patients treated only with antiplatelet drugs.

PATIENTS AND METHODS

The WINE study is an open, observational, multicenter study that included 368 patients (380 lesions) from 11 Spanish hospitals. All patients were treated with aspirin (125-325 mg/day) and ticlopidine (250 mg/12 h for 4 weeks). After hospitalization, a clinical control and clinical and angiographic controls were performed at one and six months respectively.

RESULTS

27 patients were excluded after the procedure because of failed delivery of the stent (5 cases), suboptimal angiographic result (15 cases) or lack of adherence to the antithrombotic regime (7 cases). Among the 341 patients with an adequate result most lesions (76.2%) were type B, including 39.1% type B2 and 8.5% type C. Subacute stent occlusion occurred in two patients (0.6%). Seven patients (2.1%) had vascular complications related to the arterial puncture. No major hemorrhagic complications needing transfusion were found. At six months 64 patients (19.8%) showed angiographic restenosis.

CONCLUSIONS

When the angiographic result after Wiktor stent placement is adequate, the therapy with aspirin and ticlopidine is associated with a very low stent thrombosis rate as well as with a low rate of vascular complications and 6 month angiographic restenosis.

[Is the predischarge exercise test valid in patients younger than 40 years old after myocardial infarct for determination of multivascular disease?]

BACKGROUND AND OBJECTIVES

Conventional exercise testing before hospital discharge is the most useful procedure in order to estimate postinfarction prognosis and in detecting multivessel coronary disease which is associated with a poor long-term prognosis. There are no bibliographic reports about it in younger myocardial infarction survivors. The aim of the study was to evaluate sensitivity, specificity and predictive value of symptoms limited maximal exercise testing for multivessel disease diagnosis in young patients after myocardial infarction.

METHODS

Myocardial infarction survivors until the age of 40 performed symptoms limited maximal exercise testing and had a coronary arteriography before hospital discharge.

RESULTS

A total of 100 consecutive patients were included, although in only 83 of them exercise tests and coronariographic studies were done. In this group, multivessel disease was confirmed in 27 patients (15 with positive tests and 12 with normal exercise testing). In the remaining 56 young adults without multivessel involvement, positive tests were only observed in 15 patients and normal tests in 45. Thus, a sensitivity of 56%, specificity of 73%, positive predictive value of 50% and negative predictive value of 77% were found. When patients showed high risk exercise test criteria, the exercise test positive predictive value increased to 80%.

CONCLUSIONS

Due to the lower sensitivity of this test in young myocardial infarction survivors for detecting multivessel artery disease, we remark on the need for predischarge complementary tests such as isotopic, stress echocardiography or coronariography testing.

[Usefulness of transesophageal echocardiography in the diagnosis of coronary anomalies]

BACKGROUND

Although rare, anomalous coronary arteries are associated with myocardial ischemia and sudden death. Identification is made by angiography but its true course is difficult to determine even with this invasive procedure.

OBJECTIVES

The purpose of this study is to determine the role of transesophageal echocardiography (TEE), Doppler and color flow Doppler, in identifying the origin and course of anomalous coronary arteries.

MATERIAL AND METHODS

Six patients with angiographically confirmed anomalous coronary arteries were studied by TEE, Doppler and color flow Doppler.

RESULTS

The abnormal origin was confirmed in all six patients. In three, the left main originated from the right sinus of Valsalva. In one the right coronary artery from the left sinus of Valsalva. One was a single right coronary artery from the right sinus of Valsalva, and one, had a fistula between the coronary artery and the right ventricle. In four, the TEE was able to demonstrate clearly the course in relation to the great vessels, two were interarterial and one posterior. Color flow Doppler was obtained in four patients. In one patient, there was increase in diastolic flow velocity due to proximal coronary obstruction. One had increase of the systolic flow velocity.

CONCLUSIONS

TEE is useful test for diagnosing the origin of anomalous coronary arteries and confirming its course in relation to the great vessels. Doppler flow Doppler is useful in localization the vessel.

[Follow-up of left ventricular systolic function in the first year following previous infarction]

OBJECTIVES

To follow the left ventricular systolic function changes as assessed by global and regional ejection fraction during the first year of evolution after anterior myocardial infarction, as well as to analyse how the most relevant clinical and angio-graphic parameters influence them.

MATERIALS AND METHODS

Sixty-six consecutive patients with a first infarction of anterior location, completed 1 year of follow-up with radionuclide ventriculography, T1-SPECT after exercise or dypiridamole and cardiac catheterization before discharge; radionuclide ventriculography was repeated 6 and 12 months later. Twenty-five patients underwent revascularization procedures at the time of predischarge, 16 using successful percutaneous angioplasty of the left anterior descending artery and 9 using aorto-coronary graft surgery. Dilated patients were controlled, from an angiographic point, of view 6 months after PTCA.

RESULTS

Predischarge global EF (42.9 +/- 12.6) increased significantly between the 6-month (46.9 +/- 12.8; p < 0.001) and 12-month (47.6 +/- 12; p < 0.001) studies. Differences in these two last studies were minor and had no statistical significance. A significant increase was present in revascularized or medically treated patients; i.e. those who underwent thrombolytic therapy or conventional treatment at admittance as well as mono or multivessel disease patients. No significant differences were detected in the mean ejection fraction in patients without residual stenosis in the infarct-related artery (48.1 +/- 13.3 vs 50 +/- 12.6; NS) or those presenting a pre-discharge ejection fraction > or = 45% (53.5 +/- 7.5 vs 55.1 +/- 3.3; NS). Among different variables tested, predischarge global ejection fraction (negative coefficient) and, to a lesser extent, percutaneous angioplasty were independent predictors of a significant increase of ejection fraction during follow-up. Changes from predischarge to 12 month study were significant in the regional ejection fraction in the anteroseptal (33.1 +/- 14.7 vs 40.1 +/- 13.3; p < 0.001), inferoseptal (34.6 +/- 15.8 vs 42 +/- 16.9; p < 0.001), apical (46.3 +/- 19.1 vs 50.8 +/- 19.7; p < 0.01), antero-medial (50.6 +/- 22.4 vs 56.6 +/- 24.3; p < 0.01) and anteroapical (51.6 +/- 23.5 vs 58 +/- 27.5; p < 0.01) segments. In the anterobasal segment, regional ejection fraction only showed a statistical tendency to increase during follow-up and changes in inferior and lateral segments, distal to the infarcted area, were minor and without statistical significance. The most distinct infarct-related segments, antero- and inferoseptal, showed significant increases in the main group of patients, revascularized or nonrevascularized, undergoing thrombolitic or conventional therapy, with single or multivessel disease. Only patients without residual stenosis of the infarct-related artery (the left descending anterior) disclosed negligible or negative changes without statistical significance. Percutaneously dilated patients showed the highest increase of the infarct-related segments regional ejection fraction. In multivessel disease, the infarct-related segments regional ejection fraction did not increase significantly in surgically treated patients, conversely to those who underwent medical therapy.

CONCLUSIONS

Global and regional ejection fraction of the infarcted area increased significantly during the first year after anterior myocardial infarction, mainly prior to six months patients with significant residual stenosis of the artery related to the infarct. Recovery is present both in patients who underwent thrombolysis or conventional treatment at admittance and revascularization or medical treatment before discharge and is inversely correlated to the predischarge global ejection fraction value. This evolution suggests that a significant amount of stunned myocardium is still present before discharge.

[Detection of residual ischemia after acute anterior myocardial infarction using Thallium-201 SPECT]

OBJECTIVES

To assess the utility of single photon emission computed tomography (SPECT) with Thallium-201 after anterior myocardial infarction at predischarge time in the detection of; a) the prevalence of isotopic redistribution in the infarct area or at a distance; b) the correlation between peri-infarction ischemia and the angiographic state of the infarct-related artery, and c) the correlation between ischemia at a distance and the presence of multivessel disease.

MATERIAL AND METHOD

Seventy-three survivors of an uncomplicated anterior myocardial infarction, 67 men and 7 women, with a mean age of 56 +/- 9 years (34-70 range), underwent T1-SPECT after stress test (62 exercise test and 11 pharmacological Dipyridamole test) as well as coronarographic studies before discharge. Peri-infarction ischemia was defined as redistribution presence in the distribution territory of the left anterior descending artery (LAD) and was assessed in a semi-quantitative way scoring both stress and rest images that allowed the calculation of a redistribution index R (Stress Score-Rest Score/Stress Score). Ischemia at a distance was defined as redistribution presence in the territories of circumflex and right coronary arteries as assessed both by visual analysis (VA) and bull's eye polar maps (BE) or by washout imaging (WO).

RESULTS

Peri-infarction ischemia (R > 0) was found in 48 (65.7%) patients; 43 with and 5 without significant residual lesions in the LAD and the absence of peri-infarction ischemia (R = 0) was found in 25 (34.3%) patients, 19 with and 6 without significant residual lesions in the LAD. Sensitivity and specificity for multivessel disease detection by ischemia at a distance was 64% and 85% respectively, for VA; 60% and 77% for BE; and 95% and 65% for WO. Combinations of different analytical methods (multiparametric approach) showed a decrease in sensitivity but improved specificity and positive predictive value: 60%, 90% and 75%, respectively, for BE & WO; 44%, 90% and 69% for VA & BE and 60%, 92% and 79% for VA & WO.

CONCLUSIONS

TI-SPECT imaging is a useful diagnostic method to detect both peri-infarction ischemia and ischemia at a distance at predischarge time following anterior myocardial infarction. Redistribution presence in the non infarct-area shows a fair sensitivity and a high positive predictive value to detect residual multivessel disease.

[Lipomatous hypertrophy of the interauricular septum: diagnosis with transesophageal echocardiography and computerized tomography]

Transesophageal echocardiographic and computed tomographic imaging in a patient with lipomatous hypertrophy of the interatrial septum and advanced left bundle branch block are presented. Transesophageal echocardiography demonstrated a thickening of the atrial septum sparing the fossa ovalis region. Computed tomographic scan at the level of the interatrial septum showed a mass of fat density, and the HIS bundle electrogram showed an advanced infra-his block after intravenous ajmaline. We stress the utility of transesophageal echocardiography in this disorder, and the possible relationship between lipomatous hypertrophy of the interatrial septum and conduction disturbances.

[Human genital myiasis due to Sarcophaga]

Human myiasis are infestations produced by fly larvae which invade human tissues or cavities. We report a case of semi-specific myiasis which consisted in infestation of the vulvar region of an eighty-six-year old, diabetic patient who was admitted in a clinical center for elderly. The development from larva to adult fly was carried out in the laboratory and it was identified as Sarcophaga. The infestation was resolved extracting the larvae and washing the affected area with an antiseptic solution.

[Acute myocardial infarction secondary to non-penetrating thoracic trauma]

We present a case of acute myocardial infarction located anteriorly in a healthy young man who suffered a blunt chest trauma following a motor vehicle accident, with coronarographic evidence of intimal dissection of the left anterior descending artery and evolution to ventricular aneurysm. We comment on the rare incidence of this entity and the mechanism involved in this case, a coronary contusion with subsequent intimal dissection.

Histamine release following the administration of iodinated contrast media during cardiac catheterization

This study was motivated by the discrepancy in the results of published studies on the amount of histamine released following the intravascular administration of iodinated contrast media (ICM) in humans. From a group of patients due to undergo cardiac catheterization, we selected 45 subjects with no history of atopy. A central blood sample (left ventricle) was taken from each subject before and at various times following the administration of the ICM. We determined total and basal histamine levels in every sample. We did not find any significant difference in the total histamine concentration between the samples taken before and after the administration of the ICM; but the basal histamine concentration rose from 5.32 ng/ml to 11.26 ng/ml (p less than 10(-9)). This increase was inversely proportional to the time that had elapsed between the administration of the ICM and the taking of the sample (p less than 0.01). We believe that the inconclusiveness of the results from studies on histamine release following the administration of ICM may be explained by the dilution and inactivation of histamine in the systemic circulation.