Long-term clinical outcomes of drug-eluting stents vs. bare-metal stents in Chinese geriatric patients

BACKGROUND & OBJECTIVE

Little is known about the relative efficacies of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare-metal stents (BMS) in elderly patients. The objective of this study was to evaluate the clinical outcome for geriatric patients who received either DES or BMS.

METHODS

From January 2002 to October 2005, 199 consecutive Chinese geriatric patients (≥ 75 years old) underwent PCI with coronary DES or BMS implantation at our institution. We analyzed the major clinical end points that included all-cause mortality, cardiovascular death, myocardial infarction, target lesion revascularization (TLR), stent thrombosis, and bleeding complications.

RESULTS

The three-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction were significantly lower in the DES group (6.3%, 3.6%, 5.4%) compared with the BMS group (16.2%, 11.5%, 14.9%; P < 0.05). No significant differences were found in the three-year cumulative rate for target lesion revascularization (6.3% vs. 4.6%, P = 0.61) or stent thrombosis (3.6% vs. 2.3%, P = 0.70). Likewise, there were no statistically significant differences in the cumulative rate for intracranial hemorrhage, or major and minor hemorrhage at three years.

CONCLUSIONS

DES-based PCI was associated with a significant reduction in the three-year cumulative rate of all-cause mortality, cardiovascular death, and myocardial infarction compared with BMS, without increased risk of TLR, stent thrombosis, or bleeding complications at three years in this group of Chinese geriatric patients.

Dietary glycemic load, glycemic index, and carbohydrates on the risk of primary liver cancer among Chinese women and men

BACKGROUND

Dietary glycemic index (GI) and glycemic load (GL) typically have a positive relationship with obesity and diabetes, which are risk factors for liver cancer. However, studies on their association with liver cancer have yielded inconsistent results. Therefore, we assessed the association of GI, GL, and carbohydrates with liver cancer risk.

PATIENTS AND METHODS

A total of 72 966 women and 60 207 men from the Shanghai Women's Health Study (SWHS) and the Shanghai Men's Health Study (SMHS) were included for analysis. Food frequency questionnaire (FFQ) data were used to calculate daily dietary GI, GL, and carbohydrate intake. These values were energy adjusted and categorized into quintiles. The hazard ratios (HRs) and 95% confidence intervals (CI) were calculated with adjustment for potential confounders.

RESULTS

After a median follow-up time of 11.2 years for the SWHS and 5.3 years for the SMHS, 139 and 208 incident liver cancer cases were identified in the SWHS and SMHS, respectively. In multivariable Cox regression models, no statistically significant trends by quintile of GI, GL, or carbohydrate intake were observed. Stratification by chronic liver disease/hepatitis, diabetes, or body mass index (BMI) did not alter the findings.

CONCLUSIONS

There is little evidence that dietary GI, GL, or carbohydrates affect the incidence of liver cancer in this Asian population.

Meat-cooking mutagens and risk of renal cell carcinoma

BACKGROUND

High-temperature cooked meat contains two families of carcinogens, heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs). Given the kidneys' role in metabolism and urinary excretion of these compounds, we investigated meat-derived mutagens, as well as meat intake and cooking methods, in a population-based case-control study conducted in metropolitan Detroit and Chicago.

METHODS

Newly diagnosed, histologically confirmed adenocarcinoma of the renal parenchyma (renal cell carcinoma (RCC)) cases (n=1192) were frequency matched on age, sex, and race to controls (n=1175). The interviewer-administered Diet History Questionnaire (DHQ) included queries for meat-cooking methods and doneness with photographic aids. Levels of meat mutagens were estimated using the DHQ in conjunction with the CHARRED database.

RESULTS

The risk of RCC increased with intake of barbecued meat (P(trend)=0.04) and the PAH, benzo(a)pyrene (BaP) (multivariable-adjusted odds ratio and 95% confidence interval, highest vs lowest quartile: 1.50 (1.14, 1.95), P(trend)=0.001). With increasing BaP intake, the risk of RCC was more than twofold in African Americans and current smokers (P(interaction)<0.05). We found no association for HCAs or overall meat intake.

CONCLUSION

BaP intake, a PAH in barbecued meat, was positively associated with RCC. These biologically plausible findings advocate further epidemiological investigation into dietary intake of BaP and risk of RCC.

Angiographic and long-term clinical outcome of the sleeve technique in treating in-stent restenotic bifurcation lesions: a preliminary experience

BACKGROUND

No data has been published on the management of in-stent restenotic bifurcation lesions. The aim of this small case series was to examine the angiographic and long-term clinical outcomes of using sleeve technique to treat this lesion subset.

METHODS

Six consecutive and symptomatic patients with MEDINA classification 1,1,1 in-stent restenotic bifurcation lesion were treated with drug-eluting stents using sleeve technique. Dual antiplatelet therapy was prescribed for an average of 13.5 ± 2.3 months.

RESULTS

Most of the lesions (87%) were located at LAD/diagonal branch bifurcation. Kissing balloon inflation was performed successfully in all the patients. Follow-up angiography at nine months revealed a late loss of 0.35 ± 0.26 mm and 0.56 ± 0.56 mm in MV and SB, respectively. Angiographic restenosis was developed in 2 patients (33%), which were all located at the SB ostium. No in-hospital MACE was observed. One-year MACE was 17%, attributed by 1 patient with restenosis who needed revascularization. The mean follow up period was 50 ± 18 months, no stent thrombosis was detected.

CONCLUSIONS

The use of sleeve technique to treat in-stent restenotic bifurcation lesions is associated with good acute procedural result, a fairly low one-year MACE and long-term clinical safety.

A biomarker survey of urinary deoxynivalenol in China: the Shanghai Women's Health Study

Deoxynivalenol (DON) is a trichothecene mycotoxin found on wheat, maize and barley. In ecological surveys in China, DON and other trichothecenes have been implicated in acute poisoning episodes and linked with the incidence of esophageal cancer. In order to better understand exposure patterns, this pilot survey provided a combined measure of urinary un-metabolised or free DON (fD) and its glucuronide metabolite (DG) in a subset of 60 samples taken from the Shanghai Women's Health Study cohort, China. Samples were collected in 1997/1998 from women age 40-70 years. Urinary fD+DG combined was detected in 58/60 (96.7%) samples (mean 5.9 ng DON/mg creatinine; range nd-30.5); a similar frequency, and a mean level approximately half, of that previously observed for women in the UK. Wheat consumption was approximately 25% of that consumed by western diets; thus DON contamination of wheat may be higher in Shanghai than the UK. The de-epoxy metabolite of DON, a detoxification product observed in animals, was not detected, suggesting that humans may be particularly sensitive to DON due to a more restricted detoxification capacity.

Paclitaxel-eluting stents for chronically occluded saphenous vein grafts (EOS) study

OBJECTIVES

The aim of this study was to report the feasibility, short- and medium-term results of percutaneous coronary intervention (PCI) on saphenous vein graft (SVG) chronic total occlusions (CTO) using paclitaxel-eluting stents (PES).

BACKGROUND

In postbypass patients, PCI on SVG CTO, rather than native vessel CTO, is another treatment option. However, the acute procedural and medium-term outcomes are unknown.

METHODS

Twenty-two consecutive, symptomatic postbypass patients underwent PCI on SVG CTO; angiographic success was seen in 16 patients (73%). The successful cases were evaluated at 1 year; restudy angiography was performed at 11 +/- 5 months in 15 patients (94%).

RESULTS

The patients had a mean age of 73 years with predominance of male (68%); the mean SVG age was 14 years. On average, patients received 3.4 PESs per lesion; the stent size was 3.5 +/- 0.4 mm with a total stent length of 98 +/- 34 mm. The use of embolic protection devices and glycoprotein IIb/ IIIa inhibitors was observed in 6 (38%) and 5 (31%) patients, respectively. The in-hospital major adverse cardiac event (MACE) was 13%, accountable by 2 patients with postprocedure myocardial infarction. At follow-up, 6 patients had angiographic restenosis (40%); there was 1 noncardiac death and 3 target vessel revascularizations. The 1-year MACE was 25%; the graft survival free of occlusion and revascularization was 56%.

CONCLUSIONS

PCI on SVG CTO is a feasible approach with a fairly high success and low in-hospital complication. However, it is associated with a relatively high angiographic restenosis and MACE at 1 year.

Long-term clinical outcomes of drug-eluting stents vs bare-metal stents in Chinese patients

BACKGROUND

There is limited data on the magnitude of the problem of drug-eluting stent (DES) thrombosis in the Asian population.

HYPOTHESIS

We evaluated the long-term clinical outcomes of DES vs bare metal stents (BMS) in Chinese patients.

METHODS

From January 2002 to October 2005, 1236 consecutive patients underwent percutaneous coronary intervention with DES or BMS coronary stent implantation at our institution. We analyzed major clinical end points like all-cause mortality, cardiovascular death, myocardial infarction, target lesion revascularization (TLR), and stent thrombosis.

RESULTS

The 3-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction were significantly lower in the DES group (3.4%, 0.9%, 3.6%) when compared with the BMS group (7.5%, 4.4%, 6.2%; P < .05). No significant differences were found in the 3-year cumulative rates for TLR or stent thrombosis when comparing the DES group (8.3%, 1.63%) vs the BMS group (9.6%, 1.6%; P > .05). However, after 1 year, there were 8 episodes of stent thrombosis in the DES group vs 1 episode of stent thrombosis in the BMS group (P = .04).

CONCLUSION

Drug-eluting stents are associated with a significant reduction in the 3-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction when compared to BMS. However, there were no significant differences in the cumulative rates of TLR or stent thrombosis at 3 years. Stent thrombosis after 1 year was more common in the DES group, but this did not translate to increased mortality. The suggestion that DES might confer a mortality benefit should be interpreted with caution as there could be several confounding factors that were not identified in our study.

Manual aspiration prior to stenting does not reduce the incidence of filter no reflow in saphenous vein graft lesions protected by FilterWire EX/EZ

BACKGROUND

The beneficial role of manual thrombus aspiration in thrombus-containing lesions has been proven in acute myocardial infarction but data is lacking in saphenous vein graft lesions.

METHODS

From January 2004 to December 2008, 74 consecutive post-bypass patients underwent percutaneous coronary interventions to 76 saphenous vein graft lesions under the protection of FilterWire EX/EZ. Among them, the latest 25 consecutive patients with 25 lesions were treated with manual aspiration before stenting. The incidence of filter no reflow was compared between patients with and without manual aspiration pretreatment.

RESULTS

No major difference in demography, clinical, lesion, and procedure characteristics, and in-hospital outcome has been observed between the two patient groups. Most importantly, the incidence of filter no reflow has not been reduced (32.0% versus 19.6%, P = 0.26) by manual aspiration, even among thrombus-containing lesions (63.2% versus 64.7%, P = 1.00). The absence of diabetes mellitus is found to be the independent predictor for the occurrence of filter no reflow.

CONCLUSIONS

Adjunctive manual thrombus aspiration fails to reduce the filter no reflow, and probably has no additional benefit in saphenous vein graft lesions already protected by FilterWire EX/EZ.

Angioplasty on an Infarct-related Anomalous Right Coronary Artery Arising from Posterior Coronary Sinus

Introduction: The objective of this case report was to illustrate the diagnostic and intervention approach of anomalous right coronary artery (RCA). Clinical Picture: A 60-year-old man presented with acute inferior myocardial infarction. Cardiac catheterisation revealed an anomalous RCA arising from the posterior coronary sinus as the infarct-related artery. Treatment: Ad hoc percutaneous coronary intervention with stent implantation was performed using a few technical modifications. Outcome: Good angiographic result was achieved within 90 minutes, with 260 mL of contrast used. Conclusion: A high index of suspicion and logical diagnostic and intervention approach are required for the proper management of anomalous RCA. Key words: Acute myocardial infarction, Congenital coronary anomalies, Coronary interventions

Angioplasty on an infarct-related anomalous right coronary artery arising from posterior coronary sinus

INTRODUCTION

The objective of this case report was to illustrate the diagnostic and intervention approach of anomalous right coronary artery (RCA).

CLINICAL PICTURE

A 60-year-old man presented with acute inferior myocardial infarction. Cardiac catheterisation revealed an anomalous RCA arising from the posterior coronary sinus as the infarct-related artery.

TREATMENT

Ad hoc percutaneous coronary intervention with stent implantation was performed using a few technical modifications.

OUTCOME

Good angiographic result was achieved within 90 minutes, with 260 mL of contrast used.

CONCLUSION

A high index of suspicion and logical diagnostic and intervention approach are required for the proper management of anomalous RCA.

TP53, EGFR, and KRAS mutations in relation to VHL inactivation and lifestyle risk factors in renal-cell carcinoma from central and eastern Europe

Renal-cell carcinomas (RCC) are frequent in central and eastern Europe and the reasons remain unclear. Molecular mechanisms, except for VHL, have not been much investigated. We analysed 361 RCCs (334 clear-cell carcinomas) from a multi-centre case-control study for mutations in TP53 (exons 5-9 in the whole series and exons 4 and 10 in a pilot subset of 60 tumours) and a pilot 50 tumours for mutations in EGFR (exons 18-21) or KRAS (codon 12) in relation to VHL status. TP53 mutations were detected in 4% of clear-cell cases, independently of VHL mutations. In non-clear-cell carcinomas, they were detected in 11% of VHL-wild-type tumours and in 0% of tumours with VHL functional mutations. No mutations were found in EGFR or KRAS. We conclude that mutations in TP53, KRAS, or EGFR are not major contributors to the RCC development even in the absence of VHL inactivation. The prevalence of TP53 mutations in relation to VHL status may differ between clear-cell and other renal carcinomas.

Paclitaxel-Eluting Stents for Chronically Occluded Saphenous Vein Grafts (EOS) Study

Objectives:The aim of this study was to report the feasibility, short- and medium-term results of percutaneous coronary intervention (PCI) on saphenous vein graft (SVG) chronic total occlusions (CTO) using paclitaxel-eluting stents (PES). Background:In postbypass patients, PCI on SVG CTO, rather than native vessel CTO, is another treatment option. However, the acute procedural and medium-term outcomes are unknown. Methods:Twenty-two consecutive, symptomatic postbypass patients underwent PCI on SVG CTO; angiographic success was seen in 16 patients (73%). The successful cases were evaluated at 1 year; restudy angiography was performed at 11 +/- 5 months in 15 patients (94%). Results:The patients had a mean age of 73 years with predominance of male (68%); the mean SVG age was 14 years. On average, patients received 3.4 PESs per lesion; the stent size was 3.5 +/- 0.4 mm with a total stent length of 98 +/- 34 mm. The use of embolic protection devices and glycoprotein IIb/ IIIa inhibitors was observed in 6 (38%) and 5 (31%) patients, respectively. The in-hospital major adverse cardiac event (MACE) was 13%, accountable by 2 patients with postprocedure myocardial infarction. At follow-up, 6 patients had angiographic restenosis (40%); there was 1 noncardiac death and 3 target vessel revascularizations. The 1-year MACE was 25%; the graft survival free of occlusion and revascularization was 56%. Conclusions:PCI on SVG CTO is a feasible approach with a fairly high success and low in-hospital complication. However, it is associated with a relatively high angiographic restenosis and MACE at 1 year. (J Interven Cardiol 2010;**:1-6).

Isolated left ventricular non-compaction: an unusual indication for heart transplantation

We report a patient with isolated left ventricular non-compaction diagnosed by echocardiography and cardiac magnetic resonance imaging. She developed refractory congestive heart failure and subsequently underwent successful heart transplantation. This type of cardiomyopathy is thought to be caused by the arrest of normal embryogenesis of the endocardium and myocardium. The spectrum of clinical, radiological, and pathological abnormalities is discussed.

Long-term clinical and angiographic outcomes of the sleeve technique on non-left-main coronary bifurcation lesions

AIMS

The purpose of this study was to examine the long-term results of the sleeve technique, which is a modification of the crush technique and capable of increasing the success of final kissing balloon inflation (FKB) in the treatment of non-left-main coronary bifurcation lesions.

METHODS AND RESULTS

Forty-five patients with 45 non-left-main coronary bifurcation stenoses were treated with drug-eluting stents (DES) using the sleeve technique and prospectively evaluated. Follow-up angiography was performed on 41 patients (91%) at nine months. The mean age of patient was 65 years with predominance of male (73%); FKB was successfully performed in all patients. Post-procedure myocardial infarction was observed in four patients, leading to an in-hospital major adverse cardiac event (MACE) rate of 9%. At angiographic follow-up, the late loss in the main vessel and side-branch was 0.18+/-0.26 mm and 0.29+/-0.27 mm, respectively. Binary angiographic restenosis was seen in two patients (4.7%) at main vessel and one patient (2.4%) at side-branch. At 1-year follow-up, there were two non-cardiac deaths and three patients needed revascularisation.

CONCLUSIONS

The use of the sleeve technique and DES in the treatment of non-left-main coronary bifurcation lesions is associated with a low angiographic restenosis, particularly at side branch ostium, and long-term safety.

Amiodarone-induced thyrotoxicosis is a predictor of adverse cardiovascular outcome

BACKGROUND

Amiodarone-induced thyrotoxicosis (AIT) is a clinical condition that is notoriously difficult to manage; the relative risk of adverse cardiovascular events in these patients compared with euthyroid patients is largely unknown.

OBJECTIVE

We compared the clinical characteristics and major adverse cardiovascular events (MACE) in AIT and euthyroid patients.

METHOD

Patients at a tertiary referral center who had been prescribed amiodarone for at least 3 months were retrospectively analyzed. Baseline clinical characteristics, laboratory parameters, and outcome events were evaluated. MACE was defined as cardiovascular mortality, myocardial infarction, stroke and heart failure, or ventricular arrhythmias that required hospitalization.

RESULTS

A total of 354 patients (61.8 +/- 14.1 yr; 64.7% male) with a mean follow-up of 48.6 +/- 26.7 months were studied. AIT, euthyroid status, and amiodarone-induced hypothyroidism were identified in 57 (16.1%), 224 (63.3%), and 73 (20.6%) patients, respectively. No differences in baseline clinical characteristics were observed between AIT and euthyroid patients. Nonetheless AIT patients demonstrated a higher MACE rate (31.6 vs. 10.7%, P < 0.01), mostly driven by a higher rate of ventricular arrhythmias that required admission (7.0 vs. 1.3%, P = 0.03). Cox-regression multivariate analysis revealed that AIT (hazard ratio 2.68; confidence interval 1.53-4.68; P < 0.01) and left ventricular ejection fraction less than 45% (hazard ratio 2.52; confidence interval 1.43-4.42; P < 0.01) were independent predictors of MACE.

CONCLUSION

In patients prescribed long-term amiodarone therapy, occurrence of AIT is associated with a 2.7-fold increased risk of MACE. Regular and close biochemical surveillance is thus advisable to identify and treat this high-risk group of patients.

Iatrogenic Tako-Tsubo cardiomyopathy

We report a rare case of Tako-Tsubo cardiomyopathy developed after excision of left atrial myxoma and adrenaline infusion given for blood pressure augmentation in a 56-year-old lady. Although the risk for developing Tako-Tsubo cardiomyopathy associated with adrenaline use has not been established, caution is still warranted.

Cardiac amyloidosis — Experience in a tertiary cardiac referral centre

Amyloidosis is an uncommon systemic disease characterized by deposition of insoluble fibrillar protein in different organs and the prognosis is poor if the heart is involved. Experience with management of cardiac amyloidosis is difficult because of its rare occurrence, late presentation and ineffective treatment. Since 1995, we have encountered and prospectively followed up 16 cases of cardiac amyloidosis in our cardiac centre. We believe this is the largest series of cardiac amyloidosis reported in Chinese patients. The 1-year, 3-year and 5-year survival rates were 40%, 25% and 17%, respectively. The major cause of death was cardiac-related. Those patients with overt heart failure or with untreated amyloidosis had a dismal prognosis (mean survival of 2.2 months and 3.5 months, respectively). Those who received specific treatment for the underlying amyloidosis had a better outcome with an average survival of 33.4 months.

Effects of chronic sildenafil in patients with Eisenmenger syndrome versus idiopathic pulmonary arterial hypertension

BACKGROUND

To test the hypothesis that chronic sildenafil treatment has similar functional and hemodynamic effects in patients with severe pulmonary arterial hypertension due to Eisenmenger syndrome as those due to idiopathic pulmonary arterial hypertension without intracardiac shunts.

METHODS

A prospective open-label study was carried out to compare the effects of sildenafil on the pulmonary hemodynamics between two groups of patients with severe pulmonary hypertension and similar baseline functional capacity--Eisenmenger syndrome (ES group) (n=7) versus idiopathic pulmonary arterial hypertension (IPAH group) (n=6).

RESULTS

After 6 months of sildenafil, there was a significant improvement in the functional capacity, the arterial saturation and the pulmonary hemodynamics in the ES group, as shown by significant reduction in the systolic and mean pulmonary artery pressures and the pulmonary vascular resistance.

CONCLUSION

Sildenafil increases pulmonary blood flow and improves cyanosis in patients with Eisenmenger syndrome. Efficacy of sildenafil as treatment for idiopathic pulmonary arterial hypertension may be extended to patients with Eisenmenger syndrome.

Clinical use of clopidogrel in acute coronary syndrome

Several therapeutic approaches have been developed to improve the outcome among patients with acute coronary syndrome (ACS). However, treatment with antithrombotic therapies such as oral glycoprotein IIb/IIIa inhibitors has been limited by the lack of efficacy and excess bleeding complications. As the publication of the landmark study Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE), the clinical benefit of early and intermediate-term use of combined antiplatelet agents--clopidogrel plus aspirin--in non-ST-segment elevation myocardial infarction (NSTEMI) patients became evident. Pretreatment and intermediate-term therapy with clopidogrel in NSTEMI ACS patients undergoing percutaneous coronary intervention (PCI) was further supported by the PCI-CURE trial. Recently, the results of two major trials Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28, Clopidogrel and Metoprolol in Myocardial Infarction Trial established the pivotal role of clopidogrel in the other spectrum of ACS-STEMI. Coupled with the results from previous multicentre trials, these two studies provide a guide for the early and long-term use of clopidogrel in the whole spectrum of ACS. A review summarising the results of the recent clinical trials and a discussion on its implications for the clinical management of ACS is presented.

Stenting of Unprotected Distal Left Main Coronary Artery Bifurcation Stenoses Using Modified Crush Technique with Double Kissing Balloon Inflation (Sleeve Technique): Immediate Procedure Result and Early Clinical Outcome

BACKGROUND

Sleeve technique is a modified version of the crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter.

OBJECTIVE

This study sought to look at the feasibility, safety, and early clinical outcome of sleeve technique in stenting of unprotected distal left main coronary artery (LMCA) bifurcation stenoses.

METHODS

From August 2005 to April 2006, 12 consecutive patients with symptomatic distal LMCA bifurcation stenoses of diameter narrowing > or =50%, who refused coronary artery bypass graft surgery, were treated with two-stent strategy using the sleeve technique.

RESULTS

Eleven patients (91.7%) were male, with a mean age of 64.4 +/- 9.3 years. Intravenous abciximab was given to 10 patients (83.3%). The baseline reference vessel diameters of the main vessel and side branch were 3.32 +/- 0.44 and 3.00 +/- 0.58 mm, respectively. After intervention, the minimal luminal diameter was increased from 0.99 +/- 0.46 to 3.26 +/- 0.28 mm and 1.43 +/- 0.71 to 2.93 +/- 0.45 mm in the main vessel and side branch, respectively. The intervention procedure was successful in all patients with 100% final kissing balloon inflation rate. The average procedure time was 58.6 +/- 20.5 minutes. Two patients had a small non-Q myocardial infarction postprocedure. The resultant major adverse cardiac event rate was 16.7% at 30 days after the procedure.

CONCLUSIONS

Sleeve technique is a safe and feasible approach in the stenting of distal LMCA bifurcation stenoses.

Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): Immediate procedure result and short-term clinical outcomes

BACKGROUND

Sleeve technique is a modified version of crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter.

OBJECTIVES

The aim of this study was to examine the feasibility, safety, and early clinical outcomes of sleeve technique in stenting different types (de novo, in-stent restenotic or in-stent bifurcation) of coronary bifurcation lesions at different locations.

METHODS

From August 2005 to May 2006, 41 consecutive patients with symptomatic, nonleft-main coronary bifurcation stenoses of diameter narrowing >or=50% were treated with two-stent strategy, using sleeve technique.

RESULTS

The mean age was 63.6 +/- 11.6 years with male predominance (70.7%). High prevalence of diabetes mellitus (31.7%), total occlusion (22.0%), and multi-vessel disease (65.9%) was observed in this cohort. Intravenous abciximab was given in 35 (85.4%) patients. Final kissing balloon inflation was successfully performed in all patients. The minimal luminal diameter in main vessel and side branch was increased from 0.97 +/- 0.53 mm and 0.81 +/- 0.45 mm to 2.76 +/- 0.34 mm and 2.22 +/- 0.35 mm, respectively. The mean procedure time was only 66.6 +/- 24.6 min. There was one (2.4%) case of subacute stent thrombosis presented as non-Q-wave myocardial infarction at day 3 postprocedure. The resultant in-hospital and 30-day major adverse cardiac event rate were both 2.4%.

CONCLUSIONS

Sleeve technique is a feasible and efficient approach in stenting of coronary bifurcation stenoses.

Treatment of a double-bifurcation lesion with sirolimus-eluting stents using the "sleeve technique"

We describe a diabetic patient with a very long lesion in a small and diffusely diseased left anterior descending artery that had 2 sizable and diseased diagonal branches (double-bifurcation lesion). The authors successfully used sirolimus-eluting stents and the sleeve technique to reconstruct the vessel and its 2 bifurcations. The sleeve technique is a modified version of the crush technique. It involves stent placement in the side branch ostium, balloon-crush of the proximal protruding stent segment against the main vessel wall, and reconstruction of the side branch ostium by kissing balloon inflation, followed by stenting of the main vessel and reconstruction of the bifurcation again by a second kissing balloon inflation.

In-stent restenosis in idiopathic isolated ostial left main coronary artery stenosis

Idiopathic isolated ostial left main artery stenosis is a rare disease with uncertain etiology, clinical course and prognosis. We described a young woman with no cardiovascular risk factors, who developed the disease 3 years ago with a bare-metal stent implanted in the left main artery ostium. She presented again with severe angina of rapid onset. Coronary angiography revealed ostial left main artery in-stent restenosis. A drug-eluting stent was successfully deployed over the previous stent with good angiographic result. The etiology and management of this disorder were briefly discussed.

Export aspiration catheter-enhanced FilterWire delivery: an innovative strategy for treatment of saphenous vein graft disease

We report a series of 4 cases of percutaneous saphenous vein graft intervention on thrombus-containing occlusive lesions. After passing a 0.014-inch flexible coronary wire, primary thrombosuction was performed using an Export aspiration catheter (EAC). After removing the premounted delivery sheath, a 300-cm long FilterWire EZ was loaded into the aspiration lumen of the EAC. The EAC-FilterWire assembly was then advanced across the lesion. The filter sac was deployed after withdrawing the EAC. The coronary wire was removed, and angioplasty and stenting were performed in the usual manner over the FilterWire. Filter no-reflow developed in 2 cases, which was promptly reversed by repeated manual thrombosuction using the EAC. Finally, normal coronary blood flow was restored after filter retrieval. Visible thrombi or debris were detectable in 2 patients. This interventional strategy increases the efficiency of FilterWire delivery and also gives both active and passive embolic protection without causing any adverse clinical events. It may play a positive role in saphenous vein graft intervention and primary angioplasty in the future.

Polymorphisms in Th1-type cell-mediated response genes and risk of gastric cancer

Helicobacter pylori infection, the dominant risk factor for gastric cancers, has been shown to elicit T helper type 1 (Th1) polarized immunological responses. We conducted a population-based study of 305 gastric cancer cases and 427 age- and gender-matched controls in Warsaw, Poland, to evaluate the association with several variants in genes responsible for Th1-cell-mediated response. Genotyping was performed on genomic DNA by TaqMan(TM) assays to determine TNFA (-308 G>A, -417 G>A, -555 G>A, -1036 C>T, -1042 C>A, -1210 T>C), IL1A (-889 C>T), IFNGR2 (Ex7-128 T>C, Ex2-34 C>G and Ex2-16 A>G) and IL12A (IVS2-798 T>A, IVS2-701 C>A and Ex7+277 G>A) polymorphisms. We used unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for sex, age, education and smoking status. Out of six single nucleotide polymorphisms (SNPs) tested in TNFA, gastric cancer risk was significantly associated with the TNFA (-308 G>A) polymorphism, with ORs of 1.4 (95% CI: 1.0-2.0) for the G/A and 2.5 (95% CI: 1.3-4.9) for the A/A genotype carriers, when compared with the more frequent genotype (G/G) (P-trend < 0.001). Among the three tested SNPs in the IFNGR2 gene, only the Ex7-128C>T polymorphism was associated with increased risk, with ORs of 1.5 (95% CI: 1.0-2.3) for T/C and 1.7 (95% CI: 1.1-2.7) for C/C carriers when compared with T/T carriers (P-trend = 0.01). Subjects carrying both IFNGR2 Ex7-128 C/C and TNFA -308 A/A genotypes had the highest risk (OR = 5.5, 95% CI: 1.5-19.4), although the interaction was not statistically significant. IL1A (-889 C>T) and the three examined IL12A variants were unrelated to gastric cancer risk. Our findings suggest that two Th1-related polymorphisms (TNFA -308 A>G and IFNGR2 Ex7-128 C>T) may increase the risk of gastric cancer.

Treatment and outcome of biopsy-proven fulminant myocarditis in adults

Fulminant myocarditis may be rapidly fatal with severe haemodynamic compromise in previously healthy patients. We reviewed our experience with eight cases of biopsy-proven fulminant myocarditis (seven cases with lymphocytic myocarditis and one with eosinophilic myocarditis). Immunosuppression was given in seven out of eight cases. Mechanical circulatory support was required in 50% of the patients. Time from onset of illness to recovery of ventricular function varied from 12 to 17 days. All except one patient were alive at a mean follow-up of 4.4 years after the acute illness. Patients with acute fulminant myocarditis should be treated aggressively with immunosuppression and, if necessary, mechanical circulatory support during the first 2 to 3 weeks of the illness because of the reversible nature of this illness and good long-term prognosis.

Non-infectious aortitis: an important cause of severe aortic regurgitation

From 1995 to 2004, 13 patients with severe aortic regurgitation due to non-infectious aortitis underwent aortic valve surgery at our center. Twenty-eight operations (18 aortic valve replacements and 10 Bentall procedures including 1 aortic root replacement with a homograft) were performed due to a high incidence of prosthetic valve or valved conduit dehiscence (54%). Steroid therapy reduced the incidence of re-operation for anastomotic dehiscence within one year from 90% to 18%. Strategies to prevent dehiscence of the prosthetic aortic valve, which include institution of immunosuppression, replacement of the diseased aorta, and monitoring inflammatory indices, are discussed.

First human experience with angiopeptin-eluting stent: a quantitative coronary angiography and three-dimensional intravascular ultrasound study

Angiopeptin has been shown to reduce in-stent restenosis in various animal models. Meanwhile, BiodivYsio DD phosphorylcholine (PC)-coated stent provides a platform for local delivery of antiproliferative agents to the coronary artery. We studied the feasibility, safety, and impact on tissue growth of angiopeptin-eluting BiodivYsio DD PC-coated stents in human native de novo coronary lesions. We enrolled 14 patients (16 lesions) who underwent intravascular ultrasound (IVUS)-guided angiopeptin-eluting stent implantation in native coronary arteries between 3.0 and 4.0 mm in diameter with lesion length<or=18 mm. We successfully implanted 13 stents loaded with 22 microg of angiopeptin and three stents with 126 microg of angiopeptin. No major adverse cardiac events or target vessel failure occurred at 1-year clinical follow-up. All patients underwent 6-month angiographic and volumetric IVUS follow-up. In-stent late loss was 0.46+/-0.32 mm in the low-dose group and 0.26+/-0.14 mm in the high-dose group. Binary restenosis rate was 0%. Follow-up percentage neointimal hyperplasia by IVUS was 18.4%+/-22.5% for the low-dose group and 10.2%+/-5.8% for the high-dose group, respectively. There were no edge effect and late stent malapposition. Angiopeptin-eluting BiodivYsio DD PC stent appears feasible and safe in treating native de novo coronary lesions with modest degree of neointimal hyperplasia.

Cardiac sarcoidosis: a potentially fatal but treatable form of infiltrative heart disease

Cardiac sarcoidosis is a rare but important differential diagnosis in patients who present with progressive heart failure and arrhythmia. It may be diagnosed on endomyocardial biopsy. An excellent response can be achieved with steroid therapy in the early acute inflammatory stage. Progression of the disease may lead to end-stage heart failure that requires implantation of a permanent pacemaker, implantable cardioverter-defibrillator, or mechanical circulatory support as a bridge to heart transplantation. We present three Hong Kong Chinese patients with cardiac sarcoidosis.

Modified crush technique with double kissing balloon inflation (sleeve technique): A novel technique for coronary bifurcation lesions

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.

Combined atrial septostomy and oral sildenafil for severe right ventricular failure due to primary pulmonary hypertension

Management of primary pulmonary hypertension is usually difficult because the disease is uncommon and the aetiology of the disease is not well understood. The disease is potentially lethal because it can lead to failure of the right ventricle, low cardiac output, and ensuing multiple organ failure. We report the successful treatment of a case of low-output syndrome due to primary pulmonary hypertension using combined drug therapy and atrial septostomy. Latest developments in the treatment of this disease are also discussed.

Transcatheter closure of patent ductus arteriosus in Chinese adults: immediate and long-term results

BACKGROUND

Transcatheter closure of patent ductus arteriosus (PDA) has been established as a safe and effective treatment for pediatric patients. However, long-term experience in adults remains limited. Therefore, our purpose is to report our experience with this approach in Chinese adults.

METHODS

Twenty-five patients (mean age, 34 years) who underwent transcatheter closure of PDA in a tertiary cardiology center in Hong Kong were recruited.

RESULTS

The mean PDA diameter measured by angiogram was 3.1 mm (range, 1.3 6.6 mm) and the mean pulmonary-to-systemic shunt was 1.65 (range, 1.3 1.8). All procedures were performed under local anesthesia. The average procedure and fluoroscopy times were 54 14 minutes and 14 4 minutes, respectively. The mean period of hospitalization was 4 days (range, 3 5 days). Immediate, one-month and late success rates were 96%, 92% and 84%, respectively.

CONCLUSIONS

Percutaneous closure of PDA in adults is a safe and feasible procedure. It should be a reasonable alternative for adult patients who are either not fit for open-chest surgery or who prefer a less invasive approach.