Ventricular arrhythmias during exercise testing and 24-hour ECG tape recording in patients with ischaemic heart disease and in normal individuals

The occurrence of ventricular arrhythmias (VA) during resting ECG, maximal bicycle exercise testing and 24-hour ECG tape recording (24-ETR) was studied in 24 patients and 24 matched normal persons. The patients were on treatment with beta-receptor blocking agents or verapamil for ischaemic heart disease (IHD), verified by coronary angiography. The matched persons showed no signs of heart disease. VA did not occur in any of those studied on a 60-second resting ECG. During exercise testing, one patient and six normal subjects had VA. During 24-ETR, VA were found in 16 patients and 11 normal persons. The maximum heart rate during exercise and the average heart rate during ETR did not differ significantly between individuals with and without VA in the groups of patients and normal subjects, respectively. It is concluded that in IHD patients receiving beta-blocking agents or verapamil, 24-ETR is a more reliable indicator of VA than exercise ECG testing. In normal individuals the two methods are of similar value.

Continued improvement of clinical outcome and cost effectiveness following intravascular ultrasound guided PCI: insights from a prospective, randomised study

OBJECTIVE

To investigate in a prospective randomised study both long term clinical effects and cost effectiveness of percutaneous coronary interventions (PCI) with or without intravascular ultrasound (IVUS) guidance.

METHODS

108 male patients with stable angina referred for PCI of a significant coronary lesion were randomly assigned to IVUS guided PCI or conventional PCI. Individual accumulated costs of the entire follow up period were calculated and compared in the randomisation groups. Effectiveness of treatment was measured by freedom from major adverse cardiac events.

RESULTS

Cost effectiveness of IVUS guided PCI that was noted at six months was maintained and even accentuated at long term follow up (median 2.5 years). The cumulated cost level was found to be lower for the IVUS guided group, with a cumulated cost of &163 672 in the IVUS guided group versus &313 706 in the coronary angiography group (p = 0.01). Throughout the study, mean cost per day was lower in the IVUS guided PCI group (&2.7 v & 5.2; p = 0.01). In the IVUS group, 78% were free from major adverse cardiac events versus 59% in the coronary angiography group (p = 0.04) with an odds ratio of 2.5 in favour of IVUS guidance.

CONCLUSION

IVUS guidance results in continued improvement of long term clinical outcome and cost effectiveness. The results of this study suggest that IVUS guidance may be used more liberally in PCI.

[Coronary atherosclerosis assessed by coronary angiography or intravascular ultrasound]

Intensive lowering of serum cholesterol in patients with ischaemic heart disease may retard atherosclerotic progression, and may even cause a limited regression in some patients and partly restore endothelial function. Coronary angiography has been the standard method to evaluate coronary anatomy. However, coronary angiography delineates only the vessel lumen as a silhouette, a perspective that is incapable of reflecting the irregular nature of the atherosclerotic vessel wall changes. Three-dimensional intravascular ultrasound provides cross-sectional and longitudinal images of both the vessel lumen and wall and the plaque volume can be measured in entire arterial segments. Three-dimensional intravascular ultrasound is a reliable technique to measure progression and regression of atherosclerosis in coronary arteries.

Reproducibility of intravascular ultrasound and intracoronary Doppler measurements

The aim of this study was to evaluate the reproducibility of intravascular ultrasound (IVUS) and intracoronary (IC) Doppler flow velocity measurements. The use of IVUS and IC Doppler has been suggested as a means for percutaneous coronary intervention (PCI) guidance in a series of studies. This would require an acceptable level of accuracy and reproducibility of these two methods for lesion evaluation. In this study, the main focus was on the issue of reproducibility. One hundred and eight patients referred for PCI entered into the study. Inter- and intraobserver variability was measured. Catheter difference was assessed. On-line and off-line measurements were compared. MUSIC criteria were assessed off-line, twice. Calculated and measured diameters were compared. After having obtained initial IC Doppler measurements, the Doppler wire was immediately withdrawn and repositioned for reacquisition of Doppler measurements. IVUS measurements are reproducible and reliable off-line and, to a slightly lesser degree, on-line. Area measurements should be performed more than once and the mean used for vessel description. Lumen diameters should be calculated from the mean of the area measurements. A measuring technique consensus should be reached and adhered to. CFR measurements can be used to determine reduced vs. normal flow reserve. In this study, it was found that proximal to distal velocity ratio and diastolic to systolic velocity ratio variability made these parameters unsuitable for PCI guidance.

Myocardial perfusion imaging and coronary angiography in patients with known or suspected stable angina pectoris

INTRODUCTION

The patho-physiological cause of angina pectoris is myocardial ischaemia, which can be objectified by myocardial perfusion imaging (MPI).

METHODOLOGY

MPI was undertaken prior to coronary angiography (CAG) in 86 randomly selected patients with known or suspected stable angina pectoris.

RESULTS

Among 78 adequately stressed patients, MPI was normal in 28 (36%) and showed reversible and irreversible perfusion abnormalities in 30 (38%) and 20 patients (26%), respectively. Coronary angiograms were normal in 28 (36%) and revealed at least one > or = 50% stenosis in 50 patients (64%) (16 with single and 34 with multi vessel disease). Using angiography as a reference, the sensitivity and specificity of MPI in detecting coronary artery disease was 88% and 93%, respectively.

DISCUSSION

MPI demonstrates regional hypoperfusion whereas CAG depicts anatomical stenosis in epicardial arteries. Both modalities are potentially relevant in patients with stable angina pectoris. The functional significance of coronary artery lesions is, however, variable and MPI can demonstrate normal myocardial perfusion in the presence of moderate lesions. MPI exhibited a high sensitivity and specificity regarding significant lesions. More than one third of the subjects had a normal MPI and a normal CAG. Patients with stable angina pectoris and a normal MPI have a very low risk of cardiac events and do usually not require further invasive investigation or therapy. Reversible ischaemia and irreversible ischaemia with demonstration of viable tissue call for coronary revascularisation.

Interpretive intra- and interobserver reproducibility of rest/stress 99Tcm-sestamibi myocardial perfusion SPECT in a consecutive group of male patients with stable angina pectoris before and after percutaneous transluminal angioplasty

BACKGROUND

Observer variability of 99Tcm-sestamibi myocardial perfusion imaging (MPI) has rarely been investigated. The aim of our study was to evaluate the interpretive reproducibility with this technique.

PATIENTS

We report on 108 consecutive male patients with stable angina pectoris, investigated before and after percutaneous transluminal angioplasty (PTCA).

METHODS

A 2-day rest/stress 99Tcm-sestamibi gated single photon emission computed tomography (SPECT) protocol was used. MPI was interpreted by two independent observers without knowledge of clinical data, using a 20-segment scoring model.

RESULTS

Intra- and interobserver agreement was found to be good to excellent (kappa = 0.71-0.85) with regard to the overall diagnosis as well as the individual vessel diagnosis (kappa = 0.60-0.87). However, agreement was higher for left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX) vascular territories than for the right coronary artery (RCA) territory. Moderate to good intraobserver agreement (kappa = 00.54-0.68) and slightly lower interobserver agreement (kappa = 0.52-0.56) was found for segmental score interpretation. When comparing the interpretive reproducibility before and after PTCA intra- and interobserver agreement was better after PTCA, probably reflecting the increase in normal scans after revascularization.

CONCLUSIONS

In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was moderate to good.

[Myocardial scintigraphy and coronary arteriography in patients with known or suspected stable angina pectoris]

INTRODUCTION

Myocardial perfusion imaging (MPI) demonstrates regional hypoperfusion, whereas coronary angiography shows anatomical stenoses in epicardial arteries. Both modalities are potentially relevant in patients with stable angina pectoris.

MATERIALS AND METHODS

MPI was undertaken before angiography in 86 randomly selected patients with stable angina pectoris.

RESULTS

Of 78 adequately stressed patients, MPI was normal in 28 (36%) and showed reversible and irreversible perfusion abnormalities in 30 (38%) and 20 patients (26%), respectively. Coronary angiograms were normal in 28 (36%) and revealed at least one > or = 50% stenosis in 50 patients (64%) (16 with single vessel and 34 with multivessel disease). With angiography as reference, the sensitivity and specificity of MPI in the detection of coronary artery disease were 88% and 93%, respectively.

DISCUSSION

Patients with stable angina pectoris and a normal MPI have a very low risk of cardiac events and do not usually require invasive investigation and therapy. Reversible ischaemia and irreversible ischaemia with viable tissue call for coronary revascularisation.

Cost-effectiveness analysis of intravascular ultrasound guided percutaneous coronary intervention versus conventional percutaneous coronary intervention

OBJECTIVE

Investigation of the cost-effectiveness of intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) compared to PCI guided by coronary angiography (CAG).

METHODS

One hundred and eight men referred for PCI, were randomized to IVUS or CAG guided PCI. After 6 months, the patients were subjected to a study related clinical and invasive follow-up investigation by CAG, IVUS and intracoronary Doppler flow measurements. Incremental costs of IVUS guided procedures and costs of re-interventions were estimated using the Activity Based Costing (ABC) method.

RESULTS

Patients randomized to IVUS guided PCI experienced an improved clinical outcome, with lower angina levels than patients in the CAG guided group. The initial cost of performing IVUS guidance was increased due to extra procedure time, IVUS catheters and slightly more balloons and stents, but fewer patients in the IVUS guided group needed re-intervention. Overall, these savings outweighed the initial cost increase.

CONCLUSION

Our data suggest that when performing IVUS guided PCI, costs as well as benefits increase. The increased benefits measured as cost savings resulting from less restenosis outweigh the cost increase from performing the IVUS guided PCI as opposed to CAG guided PCI.

Three dimensional intravascular ultrasonic assessment of the local mechanism of restenosis after balloon angioplasty

OBJECTIVE

To assess the mechanism of restenosis after balloon angioplasty.

DESIGN

Prospective study.

PATIENTS

13 patients treated with balloon angioplasty.

INTERVENTIONS

111 coronary subsegments (2 mm each) were analysed after balloon angioplasty and at a six month follow up using three dimensional intravascular ultrasound (IVUS).

MAIN OUTCOME MEASURES

Qualitative and quantitative IVUS analysis. Total vessel (external elastic membrane), plaque, and lumen volume were measured in each 2 mm subsegment. Delta values were calculated (follow up - postprocedure). Remodelling was defined as any (positive or negative) change in total vessel volume.

RESULTS

Positive remodelling was observed in 52 subsegments while negative remodelling occurred in 44. Remodelling, plaque type, and dissection were heterogeneously distributed along the coronary segments. Plaque composition was not associated with changes in IVUS indices, whereas dissected subsegments had a greater increase in total vessel volume than those without dissection (1.7 mm(3) v -0.33 mm(3), p = 0.04). Change in total vessel volume was correlated with changes in lumen (p < 0.05, r = 0.56) and plaque volumes (p < 0.05, r = 0.64). The site with maximum lumen loss was not the same site as the minimum lumen area at follow up in the majority (n = 10) of the vessels. In the multivariate model, residual plaque burden had an influence on negative remodelling (p = 0.001, 95% confidence interval (CI) -0.391 to -0.108), whereas dissection had an effect on total vessel increase (p = 0.002, 95% CI 1.168 to 4.969).

CONCLUSIONS

The mechanism of lumen renarrowing after balloon angioplasty appears to be determined by unfavourable remodelling. However, different patterns of remodelling may occur in individual injured coronary segments, which highlights the complexity and influence of local factors in the restenotic process.

[DANAMI. A Danish study of invasive versus conservative treatment of patients with post-infarction ischemia who had received thrombolytic therapy]

INTRODUCTION

To compare an invasive strategy employing percutaneous transluminal coronary angioplasty (PTCA) or coronary artery by-pass grafting (CABG) with a medical strategy in patients who had received thrombolytic treatment for first acute myocardial infarction (AMI), and with signs of inducible ischaemia.

METHODS

In a prospective study 1008 patients were randomized, 503 to invasive treatment, of whom 266 (52.9%) had PTCA, and 147 (29.2%) CABG, 505 to conservative treatment, of whom eight (1.6%) were revascularized within two months.

RESULTS

After a median follow-up of 2.4 years the mortality in the invasive group was 3.6% vs. 4.4% (p = 0.45) in the conservative group, re-infarction incidence was 5.6% vs. 10.5% (p = 0.0038) and percentage of admissions with unstable angina was 17.9% vs. 29.5% (p < 0.00001).

DISCUSSION

We conclude that post-infarct patients with inducible ischaemia should be referred to coronary angiography and revascularised accordingly.

Emergency coronary artery bypass surgery after failed percutaneous transluminal coronary angioplasty

Coronary complications caused by percutaneous transluminal coronary angioplasty (PTCA) may necessitate emergency coronary artery bypass grafting (CABG). In 1994-1998, 132 patients (1.5% of the patients registered in the Danish PTCA registry) underwent CABG within 24 h because of angioplasty complications. We reviewed the files of 86 patients who had emergency operations within 6 h and found that 35% suffered from 1-vessel disease. Fifty-eight percent were taken directly to the operating room from the cardiovascular laboratory, and 13% were given preoperative cardiovascular resuscitation. The vessels most frequently injured were the right coronary artery and the left anterior descending branch (LAD). The patients received a mean of 2.4 coronary bypasses each. Forty-three percent of the patients with lesions of the left main coronary artery and/or the LAD received a vein graft to the LAD. A perioperative Q-wave myocardial infarction developed in 51% of the patients. The in-hospital mortality rate was 12%. These results are inferior to those obtained after elective surgery. Local cardiothoracic backup is vital when PTCA is performed in an unselected patient group.

Correlation between serial changes in left-sided heart chambers and atrial natriuretic peptide and N-terminal pro atrial natriuretic peptide after a first myocardial infarction. An echocardiographic study

Dilatation of the left ventricle predicts morbidity and mortality after acute myocardial infarction. We compared serial echocardiographic examinations of the left atrium and ventricle with measurements of plasma atrial natriuretic peptide (ANP) and plasma N-terminal pro atrial natriuretic peptide (NT-proANP) in 22 patients during the first 6 months following a first myocardial infarction. ANP, but not NT-proANP, was found to be significantly correlated to the diastolic/systolic size of the left atrium (r = 0.58/0.60) and the systolic size of the left ventricle (r = 0.43) in the acute phase 2-4 days after infarction. At 10-12 days after the infarction, we found a significant correlation between all sizes of the left-sided chambers and ANP, whereas NT-proANP only correlated with the left atrial sizes. Three months after the infarction, all sizes of the left-sided chambers correlated with both ANP and NT-proANP, with the exception of a non-significant correlation between NT-proANP and the left atrial diastolic size. After 6 months only the area of the diastolic and systolic left atrium correlated with plasma ANP and only the systolic size of the left atrium correlated with NT-proANP. The percentage change in the size of the left atrium, but not the left ventricle, correlated significantly with the percentage change in both ANP (r = 0.57) and NT-proANP (r = 0.70). We conclude that the distension of the left atrium rather than the dilatation of the left ventricle is related to the concentration of ANP and NT-proANP after an acute myocardial infarction.

Intravascular ultrasound in equivocal coronary angiography

Intravascular ultrasound (IVUS) is a well-established diagnostic tool that supplements coronary angiography in the evaluation of angiographical intermediate lesions as well as guiding Percutaneous transluminal coronary angioplasty. In this case report we describe the benefit of IVUS in diagnosing pseudostenosis as opposed to angiographically suspected guidewire induced dissection, and suggest the use of IVUS in all cases where angiography is equivocal. We also report a case of preoperative IVUS where the IVUS finding resulted in further coronary artery bypass grafting and suggest IVUS as a feasible alternative to probing of coronary arteries suspected of stenosis during coronary artery bypass grafting.

[Evaluation of functional importance of coronary artery stenosis by intracoronary Doppler blood flow velocity measurement]

Intracoronary doppler blood flow velocity measurements supply important information for clinical decision making during angioplasty, especially with regard to stenoses of ambiguous severity. In the presence of an intermediate stenosis of unknown physiological impact (40-60%), determination of normal flow parameters (coronary flow reserve: CFR, diastolic to systolic velocity ratio: DSVR and proximal to distal velocity ratio: P/D) will make deferment of treatment acceptable. Post-angioplasty success can be based on restoral of normal flowparameters. The inability to achieve normal CFR immediately after angioplasty does not indicate an unsuccessful procedure, it remains to be shown whether a lack of normalization of DSVR and/or P/D does so. Continuous post-lesional flow monitoring can show and quantify the existence of collateral flow.

Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI). DANish trial in Acute Myocardial Infarction

BACKGROUND

The aim of the DANish trial in Acute Myocardial Infarction (DANAMI) study was to compare an invasive strategy of percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) with a conservative strategy in patients with inducible myocardial ischemia who received thrombolytic treatment for a first acute myocardial infarction (AMI).

METHODS AND RESULTS

Of the 503 patients randomized to an invasive strategy, PTCA was performed in 266 (52.9%) and CABG in 147 (29.2%) from 2 to 10 weeks after the AMI. Of the 505 patients in the conservative treatment group, only 8 (1.6%) had been revascularized 2 months after the AMI. The patients were followed up from 1 to 4.5 years. The primary end points were mortality, reinfarction, and admission with unstable angina. At 2.4 years' follow-up (median), mortality was 3.6% in the invasive treatment group and 4.4% in the conservative treatment group (not significant). Invasive treatment was associated with a lower incidence of AMI (5.6% versus 10.5%; P=.0038) and a lower incidence of admission for unstable angina (17.9% versus 29.5%; P<.00001). The percentages of patients with a primary end point were 15.4% and 29.5% at 1 year, 23.5% and 36.6% at 2 years, and 31.7% versus 44.0% at 4 years (P=<.00001) in the invasive and conservative treatment groups, respectively. At 12 months, stable angina pectoris was present in 21% of patients in the invasive treatment group and 43% in the conservative treatment group.

CONCLUSIONS

Invasive treatment in post-AMI patients with inducible ischemia results in a reduction in the incidence of reinfarction, fewer admissions due to unstable angina, and lower prevalence of stable angina. We conclude that patients with inducible ischemia before discharge who have received treatment with thrombolytic drugs for their first AMI should be referred to coronary arteriography and revascularized accordingly.

[Angiopeptin versus placebo for reductin of restenosis after PTCA treatment. A randomized, double-blind study]

Angiopeptin, a somatostatin analogue, inhibits intimal hyperplasia after (percutaneous transluminal coronary angioplasty) (PTCA) in several animal models. This pilot study sought to determine the effect of subcutaneous infusion of angiopeptin on clinical events and restenosis in patients undergoing successful PTCA. One hundred and twelve patients were randomized to receive continuous subcutaneous angiopeptin (750 micrograms/day) or placebo infusion from the day before PTCA and for the following four days in a double-blind study. Eighty patients had a successful PTCA, and 75 of these patients with 94 lesions underwent angiography 6 +/- 2 months after PTCA. All 112 patients underwent clinical follow-up at 12 months. The 12-month event rate (death, myocardial infarction, coronary artery bypass grafting and re-PTCA) was reduced from 34% to 25% (p = 0.30) by angiopeptin by intention to treat analysis. Restenosis (> or = 50% diameter stenosis) was significantly reduced in lesions treated with angiopeptin (12% vs 40%; p = 0.003). Late lumen loss was also significantly reduced after angiopeptin treatment (0.12 +/- 0.46 mm vs 0.52 +/- 0.64 mm; p = 0.003). In conclusion, continuous subcutaneous angiopeptin infusion for five days tended to decrease clinical events and restenosis after PTCA.

Treatment of anomalous origin of the left coronary artery from the pulmonary artery in adulthood

A 47-year-old female patient underwent surgical correction of a recently diagnosed anomalous left coronary artery. The artery originated from the pulmonary artery, and the patient had suffered from pulmonary hypertension and congestive heart failure. The follow-up after 3 and 6 months showed only slight improvement in the patient's condition.

Randomized double-blind Scandinavian trial of angiopeptin versus placebo for the prevention of clinical events and restenosis after coronary balloon angioplasty

Angiopeptin, a somatostatin analogue, inhibits intimal hyperplasia after percutaneous transluminal coronary artery balloon angioplasty (PTCA) in several animal models. This pilot study sought to determine the effect of subcutaneous infusion of angiopeptin on clinical events and restenosis in patients undergoing successful PTCA. One hundred twelve patients were randomized to receive continuous subcutaneous angiopeptin (750 micrograms/day) or placebo infusion from the day before PTCA and for the following 4 days in a double-blind study. An additional subcutaneous injection of 375 micrograms of angiopeptin or saline was given immediately before PTCA. Eighty patients had a successful PTCA, and 75 of these patients with 94 lesions underwent angiography 6 +/- 2 months after PTCA. All 112 patients underwent a 12-month clinical follow-up examination. Age, sex, smoking, diabetes, hypertension, hyperlipidemia, and morphologic features of stenosis were similar in both groups. The hierarchical 12-month event rate (death, myocardial infarction, coronary artery bypass grafting, and repeated PTCA) was reduced from 34% to 25% (p = 0.30) by angiopeptin by intention-to-treat analysis. Restenosis (> or = 50% diameter stenosis) was significantly reduced in lesions treated with angiopeptin (12% vs 40%; p = 0.003). Late lumen loss also was significantly reduced after angiopeptin treatment (0.12 +/- 0.46 mm vs 0.52 +/- 0.64 mm; p = 0.003). In conclusion, continuous subcutaneous angiopeptin infusion for 5 days tended to decrease clinical events and restenosis after PTCA.

[Recanalization of occluded coronary arteries with percutaneous transluminal coronary angioplasty]

Percutaneous transluminal coronary angioplasty (PTCA) was attempted in 56 totally occluded coronary arteries. The occlusions were estimated to be between two weeks to six months old, less than 4 cm long and accessible to PTCA. Primary technical success was achieved in 40 cases (71%) with best results if the time from AMI to PTCA was less than six months. Twenty-six patients were without recurrence in the follow-up period which was longer than six months. In the follow-up period eight patients had re-PTCA performed and six had coronary artery bypass grafting (CABG). There were significantly more patients in the group of failed PTCA who had CABG than in the group of successful PTCA. At clinical follow-up examination 23 patients (41%) were free of symptoms and seven (13%) had less pain than before PTCA. One patient died in heart failure (mortality 1.8%) within 24 hours after failed PTCA. PTCA of totally chronically occluded coronary arteries is a method with acceptable good primary success, especially if the occlusion is not too old. There is a good symptomatic effect if the PTCA is successful. The procedure reduces the need for CABG and is associated with few complications in stable angina pectoris. PTCA is cheaper and less traumatic for the patients and with much shorter recovery period compared to CABG. PTCA is considered indicated in total chronic occlusions in selected cases.

[Percutaneous transluminal coronary angioplasty in ischemic heart disease]

Percutaneous transluminal coronary angioplasty (PTCA) is a transarterial catheterization technique for dilatation of coronary artery stenoses. Together with coronary artery bypass grafting (CABG) the method forms the basis for the invasive revascularization, both in the case of stable and unstable angina pectoris as well as an acute myocardial infarction (AMI), where thrombolytic therapy is contraindicated. The main indications are primarily patients with few and/or short coronary artery stenoses, whereas CABG is primarily performed in other situations and always in case of left main coronary stenoses. The primary success rate is 85-95% with clinical recurrence and cardiac events in 15-30% of patients with one-vessel disease and 25-50% with multi-vessel disease. Early recurrence is mainly due to restenosis, while late (> 8 months) is mostly caused by new-developed stenoses. The complications are few; acute occlusion at the site of dilatation occurs in 5-10%, leading to acute CABG in approximately 3% and non-fatal AMI in 2%. Mortality is less than 1%. Taking differences in the patient populations related to indications into account, the results of PTCA equal those of CABG as regards recurrence of anginal pain, AMI and mortality and are superior to antianginal medical treatment.

Short- and long-term survival after aortic balloon valvuloplasty for calcified aortic stenosis in 137 elderly patients

Percutaneous transluminal balloon aortic valvuloplasty was performed in 137 patients with symptomatic severe calcified aortic stenosis (50 men and 87 women, mean age 77 years) between December 1986 and September 1990. The purpose of the study was to evaluate short- and long-term survival after balloon aortic valvuloplasty, mean follow-up was 19 months. At the time of balloon aortic valvuloplasty congestive heart failure (NYHA III-IV) was present in 89%, angina pectoris in 47%, and syncope in 31% of the patients. Aortic balloon dilatation produced significant decreases in peak pressure gradient from 91 +/- 34 mmHg to 40 +/- 26 mmHg (p < 0.001). The procedure related mortality was 8% (11 pts) and the 30-days mortality 17% (23 pts). Severe complications occurred in 25% of the patients during the procedure and within the first 24 hours. Immediate clinical improvement was noted in 68% of the patients surviving the treatment. The overall survival rate was at one, two, three and four years follow-up 63%, 40%, 28%, and 21%, respectively. These survival rates were all statistically different from the survival rates in an age- and sex-matched background population (p < 0.001). A multivariate Cox analysis revealed that only female sex and angina before treatment seemed to improve survival.

CONCLUSION

The long-term outcome after aortic balloon valvuloplasty for severe aortic stenosis is so poor that we recommend aortic valve replacement as the initial treatment in these patients, if at all possible.

Acute myocardial infarction during early pregnancy

A 29-year-old woman with two previous births, suffered a non-fatal Q-wave myocardial infarction early in the second trimester of pregnancy. She gave uncomplicated birth to a healthy child 25 weeks later. Post-partum coronary arteriography revealed a 66% stenosis on the left anterior descending coronary artery. The patient was successfully treated with percutaneous transluminal coronary angioplasty.

Cardiac troponin T and CK-MB mass release after visually successful percutaneous transluminal coronary angioplasty in stable angina pectoris

The incidence of cardiac troponin T (Tn-T) and creatine kinase (CK) isoenzyme MB mass release was studied in 23 patients with stable angina pectoris undergoing visually successful percutaneous transluminal coronary angioplasty (PTCA). Serial blood samples were drawn for measurement of serum Tn-T, CK-MB mass, total CK activity, CK-MB activity, and lactate dehydrogenase isoenzyme (LD-1). ST segment monitoring was carried out during PTCA and for the following 24 hours. None of the patients showed electrocardiographic (ECG) evidence of myocardial infarction. However, Tn-T was elevated in three patients (0.23 to 1.32 micrograms/L), and in these three and an additional three patients CK-MB mass was also elevated (7.0 to 27.5 micrograms/L). Total CK activity and LD-1 were only elevated in one of these six patients. None had elevated CK-MB activity. ST segment depression on ECG recording was not predictive of Tn-T or CK-MB mass release. Patients with elevated Tn-T or CK-MB mass did not differ with respect to demographic data, stenosis characteristics, or in the PTCA procedure. We conclude that CK-MB mass uncovers clinically and ambulatory electrocardiographically inapparent severe myocardial ischemia/minor myocardial damage (microembolization) in 26% (6 of 23) of patients after visually successful PTCA; 13% (3 of 23) had elevated Tn-T, indicating minor myocardial damage. The application of these markers in the future could be of considerable value for determining the efficacy of coronary angioplasty and atherectomy, as well as for drug therapy in connection with such procedures.

Iodixanol and ioxaglate in cardioangiography: a double-blind randomized phase III study

A new non-ionic, dimeric contrast medium iodixanol (Nycomed AS, Norway) has a very low osmolality and is isotonic with blood. It has been compared with ioxaglate (Hexabrix, Laboratoire Guerbet, France) in a double-blind, randomized, parallel trial. The aims of the trial were to evaluate and compare the safety (vital signs, adverse events, discomfort and clinical-chemical parameters in blood and urine) and radiographic efficacy (diagnostic information and radiographic density) of iodixanol 320 mg I/ml vs ioxaglate (Hexabrix 320 mg I/ml) in coronary angiography and left ventriculography. Seventy-six patients referred for cardioangiography, two patients were withdrawn, 36 receiving iodixanol and 38 ioxaglate were included in the trial. Six patients (16%) in the iodixanol group and 16 (42%) patients in the ioxaglate group reported adverse events (P = 0.02). One serious adverse event occurred in the iodixanol group where a patient experienced transient cortical blindness and transitory global amnesia, but the patient recovered completely the day after the examination. Twenty-six patients reported injection-associated sensation of warmth in the iodixanol group versus 34 in the ioxaglate group (P = 0.06). Following contrast injection there were no differences between the groups regarding vital signs (ECG, heart rate, left ventricular pressures). Both contrast media were well tolerated by the kidneys, and on average only minor effects on clinical-chemical parameters in blood and urine were observed in the two groups. The radiographic efficacy was good in both groups.

[Neurohormonal activity in heart insufficiency]

The maintenance of cardiac pumping ability in the presence of a primary disturbance of myocardial contractility and/or an excessive haemodynamic strain on the heart is dependent on several compensatory mechanisms. Particular attention has formerly been paid to the importance of the Frank-Starling mechanism and cardiac hypertrophy and dilatation in maintaining a blood supply sufficient to cover the metabolic needs of various tissues in heart failure. In recent years, however, it has been found that certain neurohormonal systems (the sympathetic nervous system, the renin-angiotensin-aldosterone system, atrial natriuretic peptide and several locally acting vaso-active substances) undergo considerable changes according to the degree of heart failure. These compensatory mechanisms support the circulation wholly or partially in acute heart failure, however sustained neurohormonal activation may be harmful in chronic heart failure, where several neurohormonal factors may be activated to ill-effect. The most significant neurohormonal systems and their importance in heart failure are reviewed on the basis of the available literature.

Reproducibility of the acute rejection diagnosis in human cardiac allografts. The Stanford Classification and the International Grading System

Transplantation has become an accepted treatment of many cardiac end-stage diseases. Acute cellular rejection accounts for 15% to 20% of all graft failures. The first grading system of acute cellular rejection, the Stanford Classification, was introduced in 1979, and since then many other grading systems have evolved. Most recently, the International Grading System was introduced in The Journal of Heart and Lung Transplantation. In this study the interobserver reproducibility of both the Stanford Classification and the International Grading System is evaluated using Kappa statistics. Three observers evaluated 168 endomyocardial biopsy specimens according to the Stanford Classification and 100 endomyocardial biopsy specimens according to the International Grading System. The evaluation was carried out blindly. Kappa values of 54.1% and 51.5%, respectively, were obtained, both significantly above zero but not optimal. In addition to the interobserver reproducibility analysis of the two grading systems, the International Grading System is discussed. In the original description of the grading system terms such as focal, multifocal, and aggressive infiltrates and myocyte damage and myocyte necrosis are used. These terms create some difficulties in understanding or interpreting the various grades. The main problem is to distinguish between grade 1A and grade 3A. Despite the difficulties, the grading system is easy to use, but a revision is needed.

Neurohormonal systems during progression of heart failure: a review

In the presence of a primary disorder in myocardial contractility and/or extraordinary hemodynamic pressure on the heart, ventricular performance depends on several compensating mechanisms. In the past, studies were mostly focused on the importance of the Frank-Starling mechanism and the hypertrophy and dilation of the heart in maintaining a circulation sufficient for metabolic intake during heart failure. Recently, however, the existence of neurohormonal systems has been demonstrated (the sympathetic nervous system, the renin-angiotensin system, atrial natriuretic peptide and several locally produced vasoactive substances), which change considerably according to the severity of the heart failure. While these compensatory mechanisms support the circulation in patients with acute heart failure, in whole or in part, neurohormonal activation over an extended period of time might be harmful to patients with chronic congestive heart failure since several neurohormonal factors might be inappropriately activated. This article will review the key neurohormonal systems and their importance in heart failure on the basis of the current literature.

The hemodynamic and prognostic significance of echo-Doppler-proven mitral regurgitation in patients with dilated cardiomyopathy

Data from cardiac catheterization at rest and during exercise in 57 patients with dilated cardiomyopathy (DCM) were analyzed to evaluate the bearing of mitral regurgitation (MR) detected by color Doppler echocardiography (CDE) on prognostically important invasive hemodynamic parameters and survival. The etiology of DCM was coronary artery disease in 21 patients and unproven ('idiopathic') in 36 patients. MR was detected by CDE in 34 patients (60%) with an agreement of 93% compared to left ventriculography. Mean age, etiology of DCM and duration of symptoms were similar in patients with and without MR, while patients with MR were in a higher NYHA class, had lower ejection fraction (LVEF) (25 +/- 13 vs. 35 +/- 17%; p < 0.02), larger left ventricular volumes (356 +/- 138 vs. 268 +/- 61 ml; p < 0.01) and higher left ventricular end-diastolic pressure (LVEDP) (21 +/- 9 vs. 13 +/- 7 mm Hg; p < 0.01). At rest, right-sided pressures were higher in patients with MR compared to patients without MR (pulmonary wedge pressure 20 +/- 9 vs. 10 +/- 3 mm Hg, mean pulmonary arterial pressure 30 +/- 11 vs. 20 +/- 8 mm Hg, mean right atrial pressure 9 +/- 4 vs. 4 +/- 2 mm Hg, all p < 0.001), but no significant differences were found in cardiac index (CI) or stroke index (SI).(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous transluminal coronary angioplasty in acute myocardial infarction]

The attitude towards the treatment of acute myocardial infarction is currently changing. As an example of one of the new methods, a successful case of acute percutaneous transluminal coronary angioplasty is presented. Which of the new therapeutic regimens provides the best prognosis is unknown, but considering the resources and the hitherto published studies, intravenous thrombolysis seems in general to be the most advantageous, while the others ought only to be used on special indications.

Hypotension during exercise caused by venodilatation

A 54-year-old woman without organic heart disease presented with presyncopal symptoms during work. A decreased cardiac output was demonstrated by haemodynamic measurements during exercise. Treatment with fludrocortisone and ephedrine was initiated with a good haemodynamic and symptomatic result.

[Percutaneous pulmonary balloon valvuloplasty in Denmark]

Percutaneous balloon valvuloplasty of valvular pulmonary stenosis (PPB) was carried out for the first time in 1982 and is now regarded as the primary method of treatment of this condition. The results of the first PPB treatments in Denmark are presented here. PPB was planned in 28 patients and was carried out in 25 (22 children and 3 adults). PPB was carried out on two occasions in one patient. Twenty-three patients had isolated valvular pulmonary stenosis and two patients had Fallot's anomaly. No complications of significance occurred after the treatments. The average gradient for all dilatations was 77 +/- 24 mm Hg prior to and 36 +/- 23 (p less than 0.0001) immediately after PPB. The gradient was reduced by more than 50% in 68% of the patients. In 14 patients, the gradients over the pulmonary valve was measured by Doppler technique or by cardiac catheterization greater than 6 months after PPB. In these patients, the average gradient was 69 +/- 21 mm Hg prior to PPB, 29 +/- 12 mm Hg (p less than 0.0001) immediately after PPB and 27 +/- 9 mm Hg (p less than 0.0001) at the most recent control examination, on an average 12 months (range 6-24 months) after PPB. In the same patient group, significant reduction of the electrocardiographic right-sided hypertrophy was found at the most recent control examination. It is concluded that PPB is an effective and safe treatment of valvular pulmonary stenosis.

[Nifedipine in primary pulmonary hypertension while waiting for heart-lung transplantation]

Primary pulmonary hypertension is a disease of unknown etiology. No effective treatment is known. Heart-lung transplantation is a new possibility for these otherwise healthy young persons. A woman aged 27 years was treated successfully with the calcium-channel-blocker, nifedipine, with a good hemodynamic result after the initial treatment and three weeks thereafter.