Catheterization and cardiovascular diagnosis最新文献

One hundred-twelve intracoronary stents (83 Palmaz-Schatz, 25 biliary, and 4 Gianturco-Roubin) were placed in 87 (51.7% male) patients aged > or = 70 years (70-93; mean 76.1) during a 1-year period. All stents were deployed using high-pressure inflation (mean 17.4 +/- 2 atm) without intravascular ultrasound. All patients received antiplatelet therapy with aspirin and ticlopidine. Seven patients additionally received warfarin at the physician's discretion. No patient was excluded from analysis regardless of presentation (40% acute myocardial infarction and 12.6% bailout) or complication. There were four deaths and two target vessel reinterventions in-hospital. One reintervention (a bailout) developed a non-Q-wave myocardial infarction. Bleeding, vascular complications, and length of stay were all greater for the warfarin group. The event-free survival rate was 83.9%, at an average of 8.6 months follow-up. A wide range of elderly patients can thus undergo stenting without intravascular ultrasound, usually without warfarin, yielding results comparable to those with more standard therapy in select populations.

Increased basal epicardial tone may attenuate the coronary flow reserve (CFR) by causing vasodilatation of resistance vessels. We examined the effect of basal epicardial tone on the endothelium-independent CFR measurements in subjects with nonobstructive coronary disease. Patients underwent evaluation of endothelium-independent CFR using adenosine (18-36 microg) and endothelium-dependent CFR using acetylcholine (10(-6) M-10(-4) M), both administered intracoronary. CFR to adenosine, presented as the ratio of Doppler flow velocities post- and pre-adenosine, was measured at baseline and after intracoronary nitroglycerin (200 microg). Nitroglycerin increased the coronary artery diameter by 19.7 +/- 2.5%, and decreased the coronary vascular resistance from 3.0 +/- 0.2 mm Hg/ml/min to 1.8 +/- 0.1 mm Hg/ml/min (p < 0.0001). The response to adenosine at baseline and after nitroglycerin was similar (CFR ratio of 2.52 +/- 0.09 and 2.57 +/- 0.10, respectively, p = NS). The effect of nitroglycerin on the response to adenosine did not correlate with coronary endothelial function (r2 = 0.06, p = 0.13). The basal epicardial tone does not affect CFR measurements in patients with angina and nonobstructive coronary disease.

The purpose of this study was to assess safety and feasibility of intracoronary delivery of reviparin using a porous balloon following percutaneous transluminal coronary angioplasty. The 2.7 mm porous balloon used in this study had 35 holes arranged in a spiral pattern. Eighteen patients (male n = 10, female n = 8, age 63 +/- 9 years) undergoing successful PTCA in coronary arteries with a vessel diameter of 2.5 to 3.0 mm determined by online QCA (LAD = 11, RCX = 3, RCA = 4) were included. They received a bolus of 7,000 anti-Xa-IU reviparin followed by local delivery of 1,500 anti-Xa-IU in 4 ml with an injection pressure of 2 atm. The patients received additionally 10500 anti-Xa-units intravenously during the following 24 hours and a daily dose of 7000 anti-Xa-units reviparin subcutaneously for the following 28 days. Angiograms were obtained before and after PTCA, directly after local delivery, at 24 hours postintervention and after 6 months. The primary success rate was 100%. Quantitative coronary angiography showed a minimum luminal diameter of 0.42 +/- 0.14 mm before PTCA, 1.87 +/- 0.45 after PTCA, 1.67 +/- 0.43 after LDD, 1.63 +/- 0.46 after 24 hours, and 1.06 +/- 0.6 after 6 months. Angiographic follow-up was obtained in all patients. No major complications occurred during the 6-month follow-up period. The angiographic restenosis rate was 28% (5/18) at follow-up. This study demonstrates safety and feasibility of local intracoronary delivery of reviparin with a porous balloon following PTCA even in smaller diameter coronary arteries.

The primary objective of the Diabetes Atherosclerosis Intervention Study (DAIS) is to determine by quantitative coronary angiography whether long-term correction of the dyslipoproteinemia of diabetes with micronized fenofibrate results in evidence of decreased progression or regression of angiographically measured obstructive coronary atherosclerosis. The purpose of this communication is to describe the angiographic methodology for the DAIS project, and to present data documenting the reproducibility of measurements that will determine the primary outcome of DAIS. Four hundred eighteen subjects between the ages of 40 and 65 were entered from 11 centers in Canada, France, Finland, and Sweden, with 305 males and 113 females. Thirty-two percent of subjects had undergone a previous coronary artery intervention, either PTCA or bypass grafting. Subjects underwent coronary arteriography at baseline according to a strictly defined protocol. The coronary tree was divided into AHA segments and quantitative analysis of segments was performed using the cardiovascular measurement system described by Reiber. Geometric parameters including mean lumen diameter, minimum lumen diameter, maximum lumen diameter, and segment length were determined. In 15 studies, measurements were carried out on the same frame by two observers, and at least 1 week apart by the same observer. In 13 studies, measurements were performed by the same observer on two separate injections of the same coronary artery. The mean of the standard deviation of the differences of measurements of all segments for the primary study analyst was 0.029 mm, with a mean of correlation coefficients of 1.00. Between two observers, the mean of the standard deviations of segmental mean lumen diameters was 0.347 mm with a mean of coefficients of variation of 0.78. The mean of standard deviations for measurements of segmental mean lumen diameter from two separate coronary injections was 0.122, with a mean of correlation coefficients of 0.94. The mean of correlation coefficients for minimum lumen diameter were 0.98 for intraobserver variability, 0.77 for inter-observer variability, and 0.96 for inter-angiogram variability. For segment length the corresponding values were 0.99, 0.79, and 0.94. These data demonstrate that a high level of reproducibility and precision may be achieved in a multicenter study in assessment of the coronary tree in carefully performed studies using this methodology. We anticipate the results will provide a statistically powerful conclusion with new and unique data to answer the question of the effect of long-term correction of dyslipoproteinemia on coronary atherosclerosis in type II diabetic patients with dyslipoproteinemia.

This study was designed to characterize hemostatic activation (using fibrinopeptide A (FPA), a marker of thrombin activity, and beta-thromboglobulin (BTG), a marker of platelet activation) sequentially in the coronary and peripheral circulation in patients during percutaneous coronary intervention (PCI) and several hours after PCI and discontinuation of heparin therapy. Heparin administered during PCI is known to nonuniformly suppress thrombin activity in the coronary. Persistent elevations of FPA in coronary sinus (CS) blood during PCI have been associated with subsequent ischemic events. As a related consideration, rebound thrombin activity has been demonstrated in peripheral blood samples several hours after cessation of heparin therapy in patients with acute coronary syndromes. Accordingly, we hypothesized that increased thrombin activity occurs in the coronary circulation after PCI and is induced by cessation of intravenous heparin to facilitate vascular sheath removal. Such a rebound prothrombotic effect, may contribute to suboptimal outcomes after PCI. In 21 patients undergoing PCI, heparin-bonded catheters were employed to obtain sequential CS and femoral vein (FV) blood samples for measurement in the coronary and peripheral circulation of plasma FPA, a marker of thrombin activity in vivo, and BTG released by platelets during degranulation. Following heparin administration samples were obtained immediately prior to (base) and during (start and end) PCI. Late samples were obtained several hours after PCI (284 +/- 46 min, mean +/- SD) following the cessation of heparin and prior to planned vascular sheath removal. Mean FPA concentration in CS blood was low at baseline (3.82 +/- 2.09 ng/ml) and did not increase during PCI. Mean FPA concentration in CS blood increased significantly several hours after cessation of heparin (3.42 +/- 2.36 vs. 7.82 +/- 9.98, end vs. late, P < 0.001). In contrast, mean FPA concentration in FV blood was highest at baseline following vascular sheath insertion, decreased during PCI (69%, P < 0.05, base vs. end), and trended upward after PCI and cessation of heparin. Mean FPA values were higher at all times in FV compared with CS blood samples and were not concordant after PCI. Elevation of coronary circulation FPA after PCI was maximal in patients with myocardial infarction within 7 days (13.7 +/- 12.4 vs. 5.6 +/- 7.9 ng/ml, P = 0.08), but was not influenced by heparin treatment prior to PCI, a history of unstable angina, or coronary stent placement during PCI (9 of 21 patients). BTG values showed less variation than did FPA values, and cessation of heparin after PCI was not associated with an increase in BTG in CS or FV blood samples. An increase in thrombin activity occurs in the coronary circulation after PCI following discontinuation of heparin. The extent of increased thrombin activity was greatest in patients with recent myocardial infarction and was not exacerbated by coronary stent placement during PCI

Intra-aortic balloon pump entrapment is a rare complication that may necessitate major abdominal surgery that is potentially life threatening in the critically ill patients who require balloon counterpulsation. We report successful removal of a ruptured and entrapped intra-aortic balloon pump catheter after use of streptokinase solution to clear clots from the device. We suggest this procedure as a safer, nonsurgical method that may eliminate the need for abdominal surgery.

Secondary to the low attrition rate of internal mammary artery grafts, limited data are available on the clinical and angiographic outcome of patients who have undergone balloon angioplasty of an internal mammary artery stenosis. This study examined a consecutive series of 68 patients who underwent balloon angioplasty of an internal mammary artery graft over a 9-year period. Procedural success was achieved in 60 of 68 (88%) patients. The primary reason for procedural failure was extreme vessel tortuosity. There were no major in-hospital complications. Angiographic follow-up was obtained in 78% of the patients with an angiographic restenosis rate of 19%. The overall event-free survival in patients with an initially successful procedure was 92%. In conclusion, internal mammary artery balloon angioplasty has both an excellent initial success rate as well as a low incidence of restenosis and repeat target lesion revascularization.

Our purpose was to study the effectiveness of thrombolytic therapy in treating acute, subacute, and chronic arterial occlusions in a multicenter retrospective study. Intraarterial urokinase infusion was performed in 235 patients for occluded native arteries. There were 70 (30%) with acute and 26 (5%) with subacute occlusions, and 141 (59%) with chronic symptoms for longer than 3 mo. Complete thrombolysis was achieved in 60 (86%) of the acute, 20 (77%) of the subacute, and 106 (75%) of the chronic occlusions. Adjunctive interventional procedures were performed as needed. Long-term follow-up revealed a primary patency of 87%, 85%, and 76% for the acute, subacute, and chronic occlusion groups, respectively. We conclude that the rate of complete thrombolysis of chronic occlusions proved slightly more efficient for acute and virtually the same for subacute occlusions. Long-term follow-up demonstrated a higher failure rate with chronic than with acute occlusions, probably due to worsened peripheral vascular runoff.