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[Robotic-enhanced percutaneous coronary revascularization].
Weisz, Giora
Percutaneous revascularization (PCI) has made significant technological progress in the last four decades. Despite advances in the safety and efficacy of the coronary revascularization, interventional cardiologists have to cope with occupational hazards including exposure to radiation, cataract, and orthopedic problems. Robotic systems that enable distant navigation were developed to address the risks and challenges that are associated with percutaneous revascularization. The PRECISE multi-center study with robotic-enhanced PCI demonstrated technical success of 98.7% and clinical success of 97.5%. The use of the robotic-enhanced PCI system reduced operator radiation exposure by 95%. Patient benefits include precise segment measurements, improved stability of the intracoronary devices, and reduction of contrast media volume. Robotic-enhanced PCI is a promising advancement in interventional cardiology. PMID:25654916
Better Outcome for Women Compared With Men Undergoing Coronary Revascularization A Report From the Bypass Angioplasty Revascularization Investigation (BARI)
Alice K. Jacobs; Sheryl F. Kelsey; Maria Mori Brooks; David P. Faxon; Bernard R. Chaitman; Vera Bittner; Michael B. Mock; Bonnie H. Weiner; Larry Dean; Carla Winston; Laura Drew; George Sopko
Background—Numerous studies have shown that women undergoing coronary revascularization procedures do so at a higher risk for an adverse outcome compared with men. However, the impact of advances in technology and improvements in techniques on in-hospital and long-term outcome after revascularization in women is unclear. Methods and Results—We evaluated 1829 patients with symptomatic multivessel coronary disease randomized to CABG or
Total arterial coronary revascularization—patient selection, stenoses, conduits, targets
Graft patency determines prognosis in coronary artery bypass grafting (CABG). Numerous reports over the past 20 years have documented superior patencies and prognosis when multiple arterial grafts are used, yet less than 10% of CABG have multiple arterial grafts. Several conduits have been proposed, with varying degrees of success. Saphenous vein grafts (SVG) begin to fail with intimal hypertrophy and then atheroma after 5 years, with patency rates of 50% to 60% at 10 years, and <30% at 15 years. In contrast, left internal thoracic artery (LITA) patency is >95% at 10 years and >90% at 20 years. The radial artery is extremely versatile and can reach all territories, but is muscular and vulnerable to spasm and competitive flow. Similarly, the right gastroepiploic artery is also muscular, and is best suited to the posterior descending coronary artery, especially in reoperations and is also affected by competitive flow. In addition, bilateral internal thoracic artery grafting (BITA) grafts and total arterial revascularization (TACR) can be performed with identical perioperative mortality (1%) and perioperative morbidity to LITA + SVG. Importantly, survival is superior—85% to 90% at 10 years versus 75% to 80% respectively. BITA/TACR patients also suffer fewer late cardiac events and reoperations, with superior results for older patients, those requiring urgent surgery, diabetics, patients with renal dysfunction and in reoperations. Contraindications to BITA include obesity, insulin dependent diabetics, and severe chronic obstructive airways disease. As such, arterial grafts have better patencies and clinical results. BITA/TACR is often underutilized, but can be achieved in the majority of patients. Opportunities exist to enhance BITA/TACR use in CABG to the potential benefit of our patients. PMID:23977629
Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease.
Harskamp, Ralf E; Zheng, Zhe; Alexander, John H; Williams, Judson B; Xian, Ying; Halkos, Michael E; Brennan, J Matthew; de Winter, Robbert J; Smith, Peter K; Lopes, Renato D
Hybrid coronary revascularization (HCR) combines bypass grafting of the left anterior descending (LAD) coronary artery with percutaneous coronary intervention (PCI) of non-LAD vessels. HCR has been performed as an alternative to CABG or multi-vessel PCI in thousands of patients since the late 1990s. In this review article, we provide an overview on patient selection, procedural sequence and timing, use of surgical techniques and anti-platelet agents. Additionally, patient recovery, satisfaction, costs and clinical outcomes of individual studies after HCR are evaluated. Future directions are also discussed, including the need for adequately powered randomized trials. PMID:24446561
[Coronary revascularization in acute coronary syndrome: which technique? which patients? how and when?].
Casella, Gianni; Di Pasquale, Giuseppe
During the last decades, the prognosis of non-ST-elevation acute coronary syndromes has greatly improved. This improvement mainly depends on a better understanding of their pathophysiological background that allowed a remarkable evolution of their diagnostic and therapeutic management. Likewise, invasive strategies have evolved accordingly. Initially, patients with non-ST-elevation acute coronary syndromes had a very conservative approach and coronary revascularization was strongly discouraged during the acute phase. Afterward, as pharmacological therapies and revascularization techniques improved, interventional strategies gradually switched to a careful "delayed invasive approach". Recently, several studies, taking full advantage from the most effective treatments, have demonstrated that an early aggressive strategy (coronary revascularization within 48 hours of symptom onset) could reduce the incidence of cardiac events in patients with non-ST-elevation acute coronary syndromes at medium-to-high risk. These findings made this "early aggressive" strategy very attractive. However, in the real world such a strategy is rarely an option due to several logistical constraints and very often the selection of the therapeutic strategy depends more on resource availability than on patients' risk profile. Therefore, Italian cardiologists should pursue integrated healthcare models in order to overcome such limitations. They should develop critical pathways able to target adequately the patient risk and improve interventional networks where even subjects admitted to peripheral hospitals could benefit from a timely revascularization procedure according to their risk profile. This could reduce treatment disparities and could counteract the vicious circle that tends to privilege interventions in low-risk subjects instead of high-risk patients, like the elderly, women or diabetics. PMID:15945317
On-pump versus off-pump coronary revascularization: evaluation of renal function
Raimondo Ascione; Clinton T Lloyd; Malcom J Underwood; Walter J Gomes; Gianni D Angelini
Background. Coronary revascularization with cardiopulmonary bypass has the potential risk of renal dysfunction related to the nonphysiologic nature of cardiopulmonary bypass. Recently, there has been a revival of interest in performing myocardial revascularization on the beating heart and we investigated whether this prevents renal compromise.Methods. A prospective, randomized, controlled trial was performed in 50 patients (45 males, mean age 61
Coronary revascularization in lung transplant recipients with concomitant coronary artery disease.
Castleberry, A W; Martin, J T; Osho, A A; Hartwig, M G; Hashmi, Z A; Zanotti, G; Shaw, L K; Williams, J B; Lin, S S; Davis, R D
Coronary artery disease (CAD) is not uncommon among lung transplant candidates. Several small, single-center series have suggested that short-term outcomes are acceptable in selected patients who undergo coronary revascularization prior to, or concomitant with, lung transplantation. Our objective was to evaluate perioperative and intermediate-term outcomes in this patient population at our institution. We performed a retrospective, observational cohort analysis of 898 lung transplant recipients between 1997 and 2010. Pediatric, multivisceral, lobar or repeat transplantations were excluded, resulting in 791 patients for comparative analysis, of which 49 (median age 62, 79.6% bilateral transplant) underwent concurrent coronary artery bypass and 38 (median age 64, 63.2% bilateral transplant) received preoperative percutaneous coronary intervention (PCI). Perioperative mortality, overall unadjusted survival and adjusted hazard ratio for cumulative risk of death were similar among both revascularization groups as well as controls. The rate of postoperative major adverse cardiac events was also similar among groups; however, concurrent coronary artery bypass was associated with longer postoperative length of stay, more time in the intensive care unit and more postoperative days requiring ventilator support. These results suggest that patients with CAD need not be excluded from lung transplantation. Preferential consideration should be given to preoperative PCI when feasible. PMID:24102830
Risk Factors for Rehospitalization for Acute Coronary Syndromes and Unplanned Revascularization Following Acute Myocardial Infarction
Arnold, Suzanne V.; Smolderen, Kim G.; Kennedy, Kevin F.; Li, Yan; Shore, Supriya; Stolker, Joshua M.; Wang, Tracy Y.; Jones, Philip G.; Zhao, Zhenxiang; Spertus, John A.
Background Rehospitalizations for acute coronary syndromes (ACS) and coronary revascularization after an acute myocardial infarction (AMI) are not only common and costly but can also impact patients' quality of life. In contrast to mortality and all?cause readmissions, little insight is available into risk factors associated with ACS and revascularization after AMI. Methods and Results In a multicenter AMI registry, we examined the rates and predictors of rehospitalizations for ACS and revascularization within the year after AMI among 3283 patients. Staged revascularization procedures were excluded. Kaplan–Meier estimated rates of rehospitalization due to ACS and revascularization were 6.8% and 4.1%, respectively. In hierarchical, multivariable models, the strongest predictors of rehospitalization for ACS were coronary artery bypass graft prior to AMI hospitalization (hazard ratio [HR] 2.12, 95% CI 1.45 to 3.10), female sex (HR 1.67, 95% CI 1.23 to 2.25), and in?hospital PCI (HR 1.85, 95% CI 1.28 to 2.69). The strongest predictors of subsequent revascularization were multivessel disease (HR 2.89, 95% CI 1.90 to 4.39) and in?hospital percutaneous coronary intervention with a bare metal stent (HR 2.08, 95% CI 1.19 to 3.63). The Global Registry of Acute Coronary Events mortality risk score was not associated with the risk of rehospitalization for ACS or revascularization. Conclusions Unique characteristics are associated with admissions for ACS and revascularization, as compared with survival. These multivariable risk predictors may help identify patients at high risk for ACS and revascularization, in whom intensification of secondary prevention therapies or closer post?AMI follow?up may be warranted. PMID:25666368
Validation of the SYNTAX Revascularization Index to Quantify Reasonable Level of Incomplete Revascularization After Percutaneous Coronary Intervention.
Généreux, Philippe; Campos, Carlos M; Farooq, Vasim; Bourantas, Christos V; Mohr, Friedrich W; Colombo, Antonio; Morel, Marie-Angčle; Feldman, Ted E; Holmes, David R; Mack, Michael J; Morice, Marie-Claude; Kappetein, A Pieter; Palmerini, Tullio; Stone, Gregg W; Serruys, Patrick W
Incomplete revascularization is common after percutaneous coronary intervention (PCI). Whether a "reasonable" degree of incomplete revascularization is associated with a similar favorable long-term prognosis compared with complete revascularization remains unknown. We sought to quantify the proportion of coronary artery disease burden treated by PCI and evaluate its impact on outcomes using a new prognostic instrument-the Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) Revascularization Index (SRI). The baseline SYNTAX score (bSS), the residual SYNTAX score, and the delta SYNTAX score (?SS) were determined from 888 angiograms of patients enrolled in the prospective SYNTAX trial. The SRI was then calculated for each patient using the following formula: SRI = (?SS/bSS]) × 100. Outcomes were examined according to the proportion of revascularized myocardium (SRI = 100% [complete revascularization], 50% to <100%, and <50%). The Youden index for the SRI was computed to identify the best cutoff for 5-year all-cause mortality. The mean bSS was 28.4 ± 11.5, and after PCI, the mean ?SS was 23.8 ± 10.9 and the mean residual SYNTAX score was 4.5 ± 6.9. The mean SRI was 85.3 ± 21.2% and was 100% in 385 patients (43.5%), <100% to 50% in 454 patients (51.1%), and <50% in 48 patients (5.4%). Five-year adverse outcomes, including death, were inversely proportional to the SRI. An SRI cutoff of <70% (present in 142 patients [16.0%] after PCI) had the best prognostic accuracy for prediction of death and, by multivariable analysis, was an independent predictor of 5-year mortality (hazard ratio [HR] 4.13, 95% confidence interval [CI] 2.79 to 6.11, p <0.0001). In conclusion, the SRI is a newly described method for quantifying the proportion of coronary artery disease burden treated by PCI. The SRI is a useful tool in assessing the degree of revascularization after PCI, with SRI ?70% representing a "reasonable" goal for patients with complex coronary artery disease. PMID:25983123
The innovation of composite core dual coil coronary guide-wire technology: A didactic coronary chronic total occlusion revascularization case report.
Tomasello, Salvatore Davide; Giudice, Pietro; Attisano, Tiziana; Boukhris, Marouane; Galassi, Alfredo R
The treatment of coronary chronic total occlusions (CTO) continues to solicit technical innovations. As success primarily depends on crossing the lesion with a wire, all aspects regarding tip shape retention, torque precision, and penetration ability of the guide-wire have greatly influenced new techniques and strategies. The world of interventional cardiology has to look carefully at these developments, and to use them accordingly to improve the success rate in ordinary percutaneous coronary interventions. We present a didactical case report of a CTO revascularization treated with a new 'dual core' technology guide-wire. PMID:25278725
Percutaneous coronary revascularization in patients with formerly "refractory angina pectoris in end-stage coronary artery disease" – Not "end-stage" after all
Jax, Thomas W; Peters, Ansgar J; Khattab, Ahmed A; Heintzen, Matthias P; Schoebel, Frank-Chris
Background Patients with refractory angina pectoris in end-stage coronary artery disease represent a severe condition with a higher reduction of life-expectancy and quality of life as compared to patients with stable coronary artery disease. It was the purpose of this study to invasively re-evaluate highly symptomatic patients with formerly diagnosed refractory angina pectoris in end-stage coronary artery disease for feasible options of myocardial revascularization. Methods Thirty-four Patients formerly characterized as having end stage coronary artery disease with refractory angina pectoris were retrospectively followed for coronary interventions. Results Of those 34 patients 21 (61.8%) were eventually revascularized with percutaneous interventional revascularization (PCI). Due to complex coronary morphology (angulation, chronic total occlusion) PCI demanded an above-average amount of time (66 ± 42 minutes, range 25–206 minutes) and materials (contrast media 247 ± 209 ml, range 50–750 ml; PCI guiding wires 2.0 ± 1.4, range 1–6 wires). Of PCI patients 7 (33.3%) showed a new lesion as a sign of progression of atherosclerosis. Clinical success rate with a reduction to angina class II or lower was 71.4% at 30 days. Surgery was performed in a total of8 (23.5%) patients with a clinical success rate of 62.5%. Based on an intention-to-treat 2 patients of originally 8 (25%) demonstrated clinical success. Mortality during follow-up (1–18 months) was 4.8% in patients who underwent PCI, 25% in patients treated surgically and 25% in those only treated medically. Conclusion The majority of patients with end-stage coronary artery disease can be treated effectively with conventional invasive treatment modalities. Therefore even though it is challenging and demanding PCI should be considered as a first choice before experimental interventions are considered. PMID:19715566
Mid-term Outcomes of Total Arterial Revascularization Versus Conventional Coronary Surgery in Isolated Three-Vessel Coronary Disease
Chung, Jin Woo; Kim, Joon Bum; Jung, Sung Ho; Choo, Suk Jung; Song, Hyun; Chung, Cheol Hyun
Whether arterial conduits are superior to venous grafts in coronary artery bypassing has been debated. The aim of this study was to investigate clinical outcomes after total arterial revascularization versus conventional coronary bypassing using both arterial and venous conduits in isolated three-vessel coronary disease. Between 2003 and 2005, 503 patients who underwent isolated coronary artery bypass grafting for three-vessel coronary disease were enrolled. A total of 117 patients underwent total arterial revascularization (Artery group) whereas 386 patients were treated with arterial and venous conduits (Vein group). Major adverse outcomes (death, myocardial infarction, stroke and repeat revascularization) were compared. Clinical follow-up was complete in all patients with a mean duration of 6.1 ± 0.9 yr. After adjustment for differences in baseline risk factors, risks of death (hazard ratio [HR] 0.96; 95% confidence interval [CI] 0.51-1.82, P = 0.90), myocardial infarction (HR 0.20, 95% CI 0.02-2.63, P = 0.22), stroke (HR 1.29, 95% CI 0.35-4.72, P = 0.70), repeat revascularization (HR 0.64, 95% CI 0.26-1.55, P = 0.32) and the composite outcomes (HR 0.83, 95% CI 0.50-1.36, P = 0.45) were similar between two groups. Since the use of veins does not increase the risks of adverse outcomes compared with total arterial revascularization, a selection of the conduit should be more liberal. PMID:22969251
Physicians' perceptions of the effect of nonclinical factors on coronary revascularization.
Barnhart, J Marie; Monrad, E Scott; Cohen, Hillel W
The main objective of this study was to determine if physicians perceive that extracardiac or nonclinical factors such as patients' financial status, lifestyle, or trust in the physician impact coronary revascularization decisions. A self-administered questionnaire was developed and mailed to a random sample of 1200 family physicians, internists, cardiologists, and cardiothoracic surgeons who were active members of well-respected medical organizations in the United States. Survey questions were rated on a 4- and 5-point Likert scale to determine whether physicians perceive that nonclinical factors impede or facilitate coronary revascularization, respectively. The survey response rate was 70%. Family physicians were most likely to perceive that unhealthy lifestyle (51%), financial barriers (48%), and lack of social support (31%) probably or definitely precluded revascularization. White physicians (52%) were more likely to perceive that distrust in the physician affected revascularization, compared with black (33%), Hispanic (38%) and Asian (40%) physicians. Mean responses regarding how often (1 = rarely to 5 = most of the time) nonclinical factors facilitate revascularization revealed that women and Hispanic physicians were more likely to perceive male patients had easier access to the procedure (mean response, 2.8 for women versus 2.1 for men; 2.8 for Hispanics versus 2.4 for blacks and 2.1 for whites). Physicians perceived that nonclinical factors influence decision making for coronary revascularization. What needs to be further explored is whether such factors affect actual patient outcomes or contribute to disparities in the utilization of cardiac interventions. PMID:14503928
Prognostic Value of Anatomical Dominance of Coronary Circulation in Patients with Surgical Myocardial Revascularization
Omerbasic, Edin; Hasanovic, Aida; Omerbasic, Amir; Pandur, Sanko
Introduction: This study evaluated the frequency of domination of the coronary arteries types in patients treated by surgical myocardial revascularization. The aim of the study was to determine whether the left coronary circulation dominance is a prognostic factor for poorer outcome in patients undergoing coronary artery bypass surgery. Material and methods: A total sample consisted of 100 patients with coronary artery disease that were treated with coronary artery bypass grafting at the Clinic for Cardiac Surgery, Clinical Center of the University of Sarajevo. To all patients on the basis of preoperative coronary angiography was determined the dominance of the coronary arteries. Patients included in the study were divided into two groups, with the left and right with coronary dominance. Results: Left coronary dominance in a sample of patients was present in 21/100 (21%), right in 69/100 (69%) and balanced in 10/100 (10%) cases. Female gender was significantly more frequent in patients with left coronary dominance and proved to be a stronger predictor of poorer outcome, especially in combination with left main stenosis of the left coronary artery and left coronary dominance. Inability of revascularization of the r. interventricularis posterior (RIVP) was statistically significantly higher in case of left dominance 9/21 (42.9%), compared to the right 16/79 (20.3%), p=0.033. Lethal outcome was more common in case of left dominance in relation to the right (9.4% vs 0.9%). The incidence of surgical complications, respiratory, neurological and renal complications was not significantly different between groups, while the length of hospital stay was significantly higher in the group of patients with left dominance, p = 0.003. Conclusion: Left coronary dominance is an important risk factor for patients undergoing surgical myocardial revascularization. PMID:25870467
Projected long-term costs of coronary stenting in multivessel coronary disease based on the experience of the Bypass Angioplasty Revascularization Investigation (BARI)
Cynthia A. Yock; Derek B. Boothroyd; Douglas K. Owens; Carla Winston; Mark A. Hlatky
Background Stents are now used in the majority of percutaneous coronary revascularization procedures. It is not clear whether the higher initial cost of stenting is later repaid by reducing costly complications and repeat revascularization procedures, especially for patients with multivessel disease. Methods To project the long-term costs of using coronary stents, angioplasty, or bypass surgery to treat patients with multivessel
Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization
Boukhris, Marouane; Tomasello, Salvatore Davide; Azzarelli, Salvatore; Elhadj, Zied Ibn; Marzŕ, Francesco; Galassi, Alfredo Ruggero
In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.
Successful emergency surgery on triple-vessel spontaneous coronary artery dissection
Adrian Ooi; Michael Lavrsen; James Monro; Stephen M Langley
Although there is increasing number of reported spontaneous coronary artery dissection (SCAD) recently, this is the first successful operative case of myocardial revascularization on triple-vessel SCAD. Emergency coronary artery bypass grafting was performed on a 42-year-old female presented with acute myocardial infarction, who had failed thrombolysis with on-going angina and acute heart failure.
Glucose-insulin-potassium therapy in the era of coronary revascularization.
Leos, Cara L; Griego, Jennifer E; Anderson, Joe R
Glucose-insulin-potassium (GIK) utilization in the treatment of acute myocardial infarction (AMI) has been studied since the early 1960s with varying results. It is well established that ischemic myocardial cells convert from aerobic metabolism of glucose to toxic anaerobic free fatty acid (FFA) metabolism for the production of energy. It has been hypothesized that administration of GIK during coronary revascularization would decrease the degree of myocardial damage. Earlier clinical trials, before the revascularization era, demonstrated a potential role for GIK therapy to reduce the mortality and morbidity associated with AMI. In recent years, GIK therapy has been incorporated into current revascularization methods without clear evidence as to its efficacy. Based on the most current studies, it has been determined that GIK therapy is not beneficial in patients with AMI, regardless of revascularization status, and therefore should not be used. PMID:16106190
The art of arterial revascularization—total arterial revascularization in patients with triple vessel coronary artery disease
Hayward, Philip A.
The use of the left internal thoracic artery to graft the left anterior descending artery has been widely accepted as the gold standard for surgical treatment of coronary disease for over 40 years. However the use of multiple other arterial grafts to support this has not been accepted readily, in spite of evidence of superiority over saphenous vein grafts, probably because of perceptions of technical complexity, time constraints for conduit harvesting and increased peri-operative complications. As a result, even today most patients with multivessel coronary artery disease do not receive the potential benefits of extensive or total arterial revascularization. We discuss here the use of contemporary techniques and grafts configurations to simplify this, and the safety and benefit data underpinning this practice. Current patency data confirm that a left internal thoracic artery graft performs well beyond 20 years, with over 80% freedom from failure, but accumulating data suggest that the right internal thoracic artery behaves in the same way. Radial artery grafts are being studied in several randomized trials, but observational studies already suggest a performance which compares favourably with saphenous vein. Total arterial revascularization is achievable in most patients with a small but acceptable increase in risk of sternal complications when certain defined subgroups are excluded. PMID:23977634
The art of arterial revascularization-total arterial revascularization in patients with triple vessel coronary artery disease.
Buxton, Brian F; Hayward, Philip A
The use of the left internal thoracic artery to graft the left anterior descending artery has been widely accepted as the gold standard for surgical treatment of coronary disease for over 40 years. However the use of multiple other arterial grafts to support this has not been accepted readily, in spite of evidence of superiority over saphenous vein grafts, probably because of perceptions of technical complexity, time constraints for conduit harvesting and increased peri-operative complications. As a result, even today most patients with multivessel coronary artery disease do not receive the potential benefits of extensive or total arterial revascularization. We discuss here the use of contemporary techniques and grafts configurations to simplify this, and the safety and benefit data underpinning this practice. Current patency data confirm that a left internal thoracic artery graft performs well beyond 20 years, with over 80% freedom from failure, but accumulating data suggest that the right internal thoracic artery behaves in the same way. Radial artery grafts are being studied in several randomized trials, but observational studies already suggest a performance which compares favourably with saphenous vein. Total arterial revascularization is achievable in most patients with a small but acceptable increase in risk of sternal complications when certain defined subgroups are excluded. PMID:23977634
Congenital atresia of the left coronary artery--myocardial revascularization in two children.
Gebauer, Roman; Cerny, Stepan; Vojtovic, Pavel; Tax, Petr
Two patients with congenital atresia of the left coronary artery ostium underwent myocardial revascularization at the age of three years and three months, respectively. The patients were admitted to the hospital with a clinical history of sudden chest pain or short apnea not necessitating resuscitation. Non-invasive examinations and hemodynamic studies revealed dysfunction of the left ventricle and ostial atresia of the left coronary artery. Surgical revascularization-bypass grafts were performed using the left internal mammary artery and saphenous vein graft in the first case and the left internal mammary artery in the second child. Both patients survived surgery and good patency of the grafts was confirmed by coronary angiograms during hospital stay. These cases are interesting because of their rarity and diagnostic and therapeutic difficulties. PMID:18728035
Detection of Gender Differences in Incomplete Revascularization after Coronary Artery Bypass Surgery Varies with Classification Technique
Oertelt-Prigione, Sabine; Kaltenbach, Martin; Hetzer, Roland; Regitz-Zagrosek, Vera; Baretti, Rufus
Background. Incomplete revascularization negatively affects survival after coronary artery bypass surgery (CABG). Since gender and classification technique might impact outcome and reporting, we investigated their effect on revascularization patterns and mortality. Methods. A cohort of bypass patients (N = 1545, 23% women) was enrolled prospectively. The degree of revascularization was determined as mathematical difference between affected vessels upon diagnosis and number of grafts or the surgeon's rating on the case file. Results. Although men displayed more triple-vessel disease, they obtained complete revascularization more frequently than women (85% versus 77%, P < 0.001). The two calculation methods identified analogous percentages of incompletely revascularized patients, yet there was only a 50% overlap between the two groups. Mathematically, more women, older patients, and patients with NYHA class III/IV appeared incompletely revascularized, while the surgeons identified more patients undergoing technically challenging procedures. Regardless of the definition, incompleteness was a significant risk factor for mortality in both genders (mathematical calculation: HR 2.62, 95% CI 1.76–3.89, P < 0.001; surgeon: HR 2.04, 95% CI 1.35–3.89, P = 0.001). Conclusions. Given the differences in identification patterns, we advise that the mathematical calculation be performed after-procedure in all patients regardless of the surgeons' rating to uncover additional subjects at increased risk. PMID:23936769
Temporal Trends in Mortality after Coronary Artery Revascularization in Patients with End-Stage Renal Disease
Krishnaswami, Ashok; Leong, Thomas K; Hlatky, Mark A; Chang, Tara I; Go, Alan S
Background: Recent studies that have assessed the comparative effectiveness between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with end-stage renal disease (ESRD) that have included analyses of temporal trends in mortality have noted mixed results. Methods: We conducted an observational longitudinal cohort study of all adults with ESRD undergoing CABG or PCI within Kaiser Permanente Northern California. The primary predictor, index period of revascularization, was categorized into 3 periods: 1996–1999 (reference), 2000–2003, and 2004–2008, with the primary outcome being 3-year all-cause mortality. A multivariable Cox regression model with the assumption of independent censoring was used to determine the adjusted relative risk of the primary predictor. Results: Among 1015 ESRD patients, 3-year mortality showed no significant change in the 2000–2003 period but was lower during the 2004–2008 period with an adjusted hazard ratio of 0.66 (95% confidence interval: 0.49–0.88; trend test p = 0.01). No change in 30-day mortality was noted. Further adjustment for receipt of medications at baseline and after revascularization did not materially affect risk estimates. No significant interactions were observed between the type of revascularization (CABG or PCI) and the period of the index revascularization. Conclusions: Among a high-risk cohort of patients with ESRD and coronary artery disease within Kaiser Permanente Northern California who were referred for coronary revascularization by either CABG or PCI, the relative risk of mortality in the 2004–2008 period decreased by 34% compared with the 1996–1999 period, with the benefit primarily in the decrease in late mortality. PMID:25102514
Changing treatment patterns for coronary artery revascularization in Canada: the projected impact of drug eluting stents
Halpern, Michael T; Lacey, Michael; Clark, Mary Ann; Valentin, Miguel A
Background To evaluate current treatment patterns for coronary artery revascularization in Canada and explore the potential impact of drug eluting stents (DES) on these treatment patterns. Methods Eleven cardiologists at multiple Canadian academic centers completed a questionnaire on coronary artery revascularization rates and treatment patterns. Results Participating physicians indicated slightly higher rates of PTCA, CABG, and stent implantation than reported in CCN publications. Participants estimated that 24% of all patients currently receiving bare metal stents (BMS) would receive DES in the first year following DES approval in Canada, although there was a large range of estimates around this value (5% to 65%). By the fifth year following DES approval, it was estimated that 85% of BMS patients would instead receive DES. Among diabetic patients, estimates ranged from 43% in the first year following approval to 91% in the fifth year. For all patients currently receiving CABG, mean use of DES instead was estimated at 12% in the first year to 42% at five years; rates among diabetic patients currently undergoing CABG were 17% in the first year to 49% in the fifth year. Conclusions These results suggest a continued increase in revascularization procedures in Canada. Based on the panel's responses, it is likely that a trend away from CABG towards PTCA will continue in Canada, and will be augmented by the availability of DES as a treatment option. The availability of DES as a treatment option in Canada may change the threshold at which revascularization procedures are considered. PMID:15596004
A randomized comparison of a sirolimus eluting stent with a standard stent for coronary revascularization
M. C. Morice; P. W. Serruys; E. J. Sousa; F. Molnar; J. E. Sousa; J. Fajadet; E. Ban Hayashi; M. A. Perin; A. Colombo; G. Schuler; P. Barragan
BACKGROUND: The need for repeated treatment of restenosis of a treated vessel remains the main limitation of percutaneous coronary revascularization. Because sirolimus (rapamycin) inhibits the proliferation of lymphocytes and smooth-muscle cells, we compared a sirolimus-eluting stent with a standard uncoated stent in patients with angina pectoris. METHODS: We performed a randomized, double-blind trial to compare the two types of stents
Coronary Artery Revascularization Evaluation—A Multicenter Registry With Seven Years of Follow?Up
Kurlansky, Paul; Herbert, Morley; Prince, Syma; Mack, Michael J.
Background Data from randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) may not accurately reflect current clinical practice, in which there is off?label usage of drug?eluting stents (DES). We undertook a prospective registry of coronary revascularization by CABG on? and off?pump and PCI with bare?metal stents (BMSs), DESs, or percutaneous transluminal coronary angioplasty (PTCA) to determine clinical outcomes. Methods and Results All patients undergoing isolated coronary revascularization in 8 community?based hospitals were enrolled. Final follow?up was obtained after 5 years by patient and/or physician contact and the Social Security Death Index. ST?elevation myocardial infarction and salvage patients were excluded. Five or more years of follow?up was obtained on 81.5% (3156) of the eligible patients—968 CABG patients (82.0%) and 2188 PCI patients (81.3%). Overall follow?up was 63.5±27.9 months (median, 79.7 months). The incidence of initial major adverse cardiac events (MACEs) at follow?up for CABG versus PCI was 29.2% versus 41.8% (P<0.001). Analysis of stent subgroups showed more events with BMSs (equivalent to PTCA alone) compared with DESs. All stents had more events than on? or off?pump CABG groups. Using propensity score–matched groups, the odds ratio for CABG to PCI was 0.69 (95% confidence interval [CI], 0.56 to 0.85; P<0.001) for mortality and 0.58 (95% CI, 0.45 to 0.75; P<0.001) for any MACE. Conclusions In the current era of DES and off?pump surgery, in a community hospital setting, comparable patients undergoing coronary revascularization appear to benefit from improved long?term survival and reduced MACE with CABG versus PCI. PMID:23598273
Inflammatory response after coronary revascularization with or without cardiopulmonary bypass
Raimondo Ascione; Clinton T Lloyd; Malcolm J Underwood; Attilio A Lotto; Antonis A Pitsis; Gianni D Angelini
Background. We sought to investigate the effect of multiple coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (CPB) on the perioperative inflammatory response.Methods. Sixty patients undergoing CABG were randomly assigned to one of two groups: (A) on pump with conventional CPB and cardioplegic arrest, and (B) off pump on the beating heart. Serum samples were collected for estimation
Successful emergency surgery on triple-vessel spontaneous coronary artery dissection
Adrian Ooi; Michael Lavrsen; James Monro; Stephen M. Langley
Although there is increasing number of reported spontaneous coronary artery dissection (SCAD) recently, this is the first successful operative case of myocardial revascularization on triple-vessel SCAD. Emergency coronary artery bypass grafting was performed on a 42-year-old female presented with acute myocardial infarction, who had failed thrombolysis with on-going angina and acute heart failure. q 2004 Elsevier B.V. All rights reserved.
Anatomic versus physiologic assessment of coronary artery disease. Role of coronary flow reserve, fractional flow reserve, and positron emission tomography imaging in revascularization decision-making.
Gould, K Lance; Johnson, Nils P; Bateman, Timothy M; Beanlands, Rob S; Bengel, Frank M; Bober, Robert; Camici, Paolo G; Cerqueira, Manuel D; Chow, Benjamin J W; Di Carli, Marcelo F; Dorbala, Sharmila; Gewirtz, Henry; Gropler, Robert J; Kaufmann, Philipp A; Knaapen, Paul; Knuuti, Juhani; Merhige, Michael E; Rentrop, K Peter; Ruddy, Terrence D; Schelbert, Heinrich R; Schindler, Thomas H; Schwaiger, Markus; Sdringola, Stefano; Vitarello, John; Williams, Kim A; Gordon, Donald; Dilsizian, Vasken; Narula, Jagat
Angiographic severity of coronary artery stenosis has historically been the primary guide to revascularization or medical management of coronary artery disease. However, physiologic severity defined by coronary pressure and/or flow has resurged into clinical prominence as a potential, fundamental change from anatomically to physiologically guided management. This review addresses clinical coronary physiology-pressure and flow-as clinical tools for treating patients. We clarify the basic concepts that hold true for whatever technology measures coronary physiology directly and reliably, here focusing on positron emission tomography and its interplay with intracoronary measurements. PMID:23954338
Completeness of revascularization for multivessel coronary artery disease and its effect on one-year outcome: a report from the NHLBI Dynamic Registry.
Srinivas, Vankeepuram S; Selzer, Faith; Wilensky, Robert L; Holmes, David R; Cohen, Howard A; Monrad, E Scott; Jacobs, Alice K; Kelsey, Sheryl F; Williams, David O; Kip, Kevin E
When percutaneous coronary intervention (PCI) is performed in patients with multivessel coronary disease, a targeted revascularization (TR) of diseased vessels is performed more often than complete revascularization (CR). We compared baseline characteristics and 1-year outcomes of patients undergoing TR by operator choice (n = 1,091), TR because CR was unachievable (n = 375), and CR (n = 315) in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry. Patients receiving TR because CR was unachievable were older, had more comorbidities, worse ejection fraction, less often received 2b/3a inhibitors and stents, and less frequently achieved complete angiographic success than either patients receiving TR by choice or CR. Despite these considerable differences, cumulative rates of 1-year mortality, the need for repeat PCI, or coronary bypass surgery were similar in patients who received CR, TR by choice, or TR because CR was unachievable. In multivariable models, after adjustment for clinical characteristics and propensity to receive CR, the hazard ratio for CR versus TR was 1.10 (95% CI: 0.58-2.10) for 1-year mortality; 0.89 (0.60-1.32) for repeat PCI, and 0.92 (0.66-1.29) for repeat PCI or coronary bypass surgery. In conclusion, despite the presence of more unfavorable characteristics, patients undergoing TR demonstrate 1-year outcomes equivalent to those having CR, supporting its continued use in selected patients. PMID:17880334
Coronary artery bypass grafting or percutaneous revascularization in acute myocardial infarction?
Perrier, Stéphanie; Kindo, Michel; Gerelli, Sébastien; Mazzucotelli, Jean-Philippe
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was as follows: is coronary artery bypass graft (CABG) surgery superior to percutaneous coronary intervention (PCI) in terms of in-hospital mortality and morbidity and long-term outcomes in patients with acute myocardial infarction (MI)? A total of 104 papers were returned using the selected search. Of these, six represented the best evidence to answer the clinical question. The selection criteria were comparative studies with only PCI and CABG groups in patients with acute MI. Case reports, reviews, recommendations and studies on a specific population or out of the context of acute MI were excluded. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Almost all PCI patients received stents. One study used drug-eluting stents (DES). Two randomized studies showed similar short- and mid-term morbidities and mortalities in patients with acute MI in the PCI and CABG groups but higher repeat revascularization rates after PCI. Three observational studies found comparable survival, but one of them found more periprocedural events with CABG and the other two found more recurrent ischaemia requiring repeat revascularization in the PCI group. In one cohort study, CABG appeared to be an independent risk factor for death in N-STEMI according to the European Society/American College of Cardiology 2000 definition. The results are strongly influenced by the definition of acute MI. In an institution offering the two techniques with an equivalent accessibility, the principal advantage of PCI is a lower incidence of periprocedural and short-term morbidities. CABG, on the other hand, offers a better durability with less mid-term repeat revascularization required, especially when compared with PCI with DES implantation. Choice had to weight up coronary artery anatomy, number and localization of coronary artery stenosis and accessibility of both PCI and CABG treatments. Medical and surgical discussion within the Heart Team is required to make the best medical decision for each patient. PMID:23962854
Revascularization procedures in patients with transplant coronary artery disease 1 Presented at the 9th Annual Meeting of the European Association for Cardiothoracic Surgery, Paris, France, 24–27 September 1995. 1
V. S Patel; B Radovancevic; W Springer; O. H Frazier; E Massin; J Benrey; K Kadipasaoglu; D. A Cooley
Objective: To assess the efficacy of revascularization in cardiac transplant patients who developed de novo coronary artery disease. Methods: Eighteen patients underwent one or more of four methods of revascularization: percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revacularization (TMLR). Eleven PTCA procedures were performed in 10 patients 55.3±6.6
Short term outcomes of total arterial coronary revascularization in patients above 65 years: a propensity score analysis
Background Despite the advantages of bilateral mammary coronary revascularization, many surgeons are still restricting this technique to the young patients. The objective of this study is to demonstrate the safety and potential advantages of bilateral mammary coronary revascularization in patients older than 65 years. Methods Group I included 415 patients older than 65 years with exclusively bilateral mammary revascularization. Using a propensity score we selected 389 patients (group II) in whom coronary bypass operations were performed using the left internal mammary artery and the great saphenous vein. Results The incidence of postoperative stroke was higher in group II (1.5% vs. 0%, P = 0.0111). The amount of postoperative blood loss was higher in group I (908 ± 757 ml vs. 800 ± 713 ml, P = 0.0405). There were no other postoperative differences between both groups. Conclusion Bilateral internal mammary artery revascularization can be safely performed in patients older than 65 years. T-graft configuration without aortic anastomosis is particularly beneficial in this age group since it avoids aortic manipulation, which is an important risk factor for postoperative stroke. PMID:20398421
Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with conventional off-pump coronary artery bypass
Kon, Zachary N.; Brown, Emile N.; Tran, Richard; Joshi, Ashish; Reicher, Barry; Grant, Michael C.; Kallam, Seeta; Burris, Nicholas; Connerney, Ingrid; Zimrin, David; Poston, Robert S.
Objectives Less-invasive options are available for surgical treatment of multivessel coronary artery disease. We hypothesized that stenting combined with grafting of the left anterior descending artery with the left internal thoracic artery through a minithoracotomy (hybrid procedure) would provide the best outcome. Methods Patients with equivalent numbers of coronary lesions (2.8 ± 0.4) underwent either hybrid (n = 15) or off-pump coronary artery bypass through a sternotomy (n = 30). Early and 1-year outcomes were compared. Blood drawn from the aorta and coronary sinus immediately postoperatively was analyzed for activation of coagulation (prothrombin fragment 1.2 and activated Factor XII), myocardial injury (myoglobin), and inflammation (interleukin 8) by using an enzyme-linked immunosorbent assay. Target-vessel patency was determined by means of computed tomographic angiographic analysis. Results The hybrid procedure was associated with significantly shorter lengths of intubation and stays in the intensive care unit and hospital and perioperative morbidity (P < .05). Intraoperative costs were increased but postoperative costs were reduced for the hybrid procedure compared with off-pump coronary artery bypass through a sternotomy. As a result, overall total costs were not significantly different between the groups. After adjusting for potential confounders, assignment to the hybrid group was an independent predictor of shortened time to return to work (t = ?2.12, P = .04). Patient satisfaction after the hybrid procedure, as judged on a 6-point scale, was greater versus that after off-pump coronary artery bypass through a sternotomy. Finally, the hybrid procedure showed significantly reduced transcardiac gradients of markers of coagulation, myocardial injury, and inflammation and a trend toward significant improvement in target-vessel patency. Conclusions Perhaps because of reduced myocardial injury, inflammation, and activation of coagulation, patients undergoing the hybrid procedure had better perioperative outcomes and satisfaction, with excellent patency at 1 year's follow-up. These promising preliminary findings warrant further investigation of this procedure. PMID:18242270
Prognostic significance of glomerular filtration rate estimated by the Japanese equation among patients who underwent complete coronary revascularization
Takatoshi Kasai; Katsumi Miyauchi; Kan Kajimoto; Naozumi Kubota; Tomotaka Dohi; Ryo Tsuruta; Manabu Ogita; Takayuki Yokoyama; Atsushi Amano; Hiroyuki Daida
An equation that accurately estimates the glomerular filtration rate (GFR) in the Japanese population has been proposed; however, the prognostic significance of estimated GFR (eGFR) defined according to this equation has not been reported. In addition, the prognostic significance of eGFR during long-term follow-up after complete coronary revascularization remains unclear. We assessed the prognostic significance of eGFR values, estimated by
Impact of Critical Limb Ischemia on Long-Term Cardiac Mortality in Diabetic Patients Undergoing Percutaneous Coronary Revascularization
Liistro, Francesco; Angioli, Paolo; Grotti, Simone; Brandini, Rossella; Porto, Italo; Ricci, Lucia; Tacconi, Danilo; Ducci, Kenneth; Falsini, Giovanni; Bellandi, Guido; Bolognese, Leonardo
OBJECTIVE Development of critical limb ischemia (CLI) has been reported as an independent predictor of cardiac mortality in diabetic patients. We aimed to determine whether CLI, managed in a structured setting of close collaboration between different vascular specialists and treated with early endovascular intervention, has any impact on long-term cardiac mortality of diabetic patients initially presenting with symptomatic coronary artery disease (CAD). RESEARCH DESIGN AND METHODS We designed a prospective observational study of 764 consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in whom development of CLI was assessed by a dedicated diabetic foot clinic. Cardiac mortality at 4-year follow-up was the primary end point of the study. RESULTS Among the 764 patients, 111 (14%) developed CLI (PCI-CLI group) and underwent revascularization of 145 limbs, with procedural success in 140 (96%). PCI-CLI patients at baseline had lower left ventricular ejection fraction (51 ± 11% vs. 53 ± 10%, P = 0.008), higher prevalence of dialysis (7% vs. 0.3%, P < 0.0001), and longer diabetes duration (13 ± 8 vs. 11 ± 7 years, P = 0.02) compared with PCI-only patients. At 4-year follow-up, cardiac mortality occurred in 10 (9%) PCI-CLI patients vs. 42 (6%) PCI-only patients (P = 0.2). Time-dependent Cox regression model for cardiac death revealed that CLI was not associated with an increased risk of cardiac mortality (hazard ratio 1.08 [95% CI 0.89–3.85]; P = 0.1). CONCLUSIONS The development of promptly assessed and aggressively treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially presenting with symptomatic CAD. PMID:23340882
Interventional Revascularization of Coronary Artery Lesions in Diabetic Patients; In-hospital and One Year Follow up
Zibaeenezhad, Mohammad Javad; Aslani, Amir; Moniri, Alireza; Kheiri, Mohammad Ali; Heydari, Seyed Taghi; Amanat, Ahmad; Daneshvar, Zahra
Background Diabetes mellitus is a life threatening disease accompanied by several micro- and macro vascular complications. Several modalities are available for interventional revascularization of coronary artery lesions, but their efficacy in diabetic patients is studied only in few patients. Materials and Method This study evaluated major in- hospital complications and clinical outcome after one year in 200 consecutive patients who underwent percutaneous Coronary Intervention from 2007 to 2009. Results Our findings showed comparable single and 2 vessel stenting, regarding major adverse cardiovascular event in diabetic and nondiabetic patients. In connection with long term and in hospital outcome, no statistically significant difference was found between one and two vessel stenting when drug eluting stent was used in diabetic patients. Conclusion The use of drug eluting stent in single or two vessel disease of diabetic patients is technically satisfactory and clinically safe and can substitute for coronary artery bypass grafting. PMID:24757604
Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: A prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting
J. D. Puskas; W. H. Williams; P. G. Duke; J. R. Staples; K. E. Glas; J. J. Marshall; M. Leimbach; P. Huber; S. Garas; B. H. Sammons; S. A. McCall; R. J. Petersen; D. E. Bailey; H. Chu; E. M. Mahoney; W. S. Weintraub; R. A. Guyton
Objective: Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting.Methods: Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic,
Hypothesis of Long-Term Outcome after Coronary Revascularization in Japanese Patients Compared to Multiethnic Groups in the US
Inohara, Taku; Kohsaka, Shun; Goto, Masashi; Furukawa, Yutaka; Fukushima, Masanori; Sakata, Ryuzo; Elayda, MacArthur; Wilson, James M.; Kimura, Takeshi
Background Ethnicity has a significant impact on coronary artery disease (CAD). This study investigated the long-term outcomes of Japanese patients undergoing revascularization compared with US patients belonging to multiple ethnic groups. Methods and Results We evaluated clinical outcomes, based on ethnicity, of patients included in the Coronary Revascularization Demonstrating Outcome (CREDO-Kyoto) and the Texas (US) Heart Institute Research Database (THIRDBase) registries. For the analysis, we included 8871 patients from the CREDO-Kyoto registry (median follow-up period [FU], 3.5 years; interquartile range [IQR], 2.6–4.3) and 6717 patients from the THIRDBase registry (FU, 5.2 years; IQR, 3.8–6.5) who underwent percutaneous coronary intervention or bypass surgery. Cox proportional hazard models were constructed to compare the adjusted long-term outcomes for each ethnic group. A total of 8871 Japanese, 5170 Caucasians, 648 African-Americans, 817 Hispanics, and 82 Asian-Americans were identified. When adjusted, Japanese patients had significantly better outcomes than US patients, classified by ethnicity (Caucasians: hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.35–1.79; Hispanics: HR, 1.53; 95% CI, 1.22–1.93; African-Americans: HR, 2.03; 95% CI, 1.62–2.56), except for Asian-Americans (HR, 0.84; 95% CI. 0.38–1.89) who had outcomes similar to Japanese patients. Conclusion Our findings indicate better survival outcomes in re-vascularized Japanese CAD patients compared to major ethnic groups in the US, including Caucasian, Hispanic, and African-American CAD patients. The characteristics and outcomes of Japanese CAD patients were similar to those of Asian-Americans, despite the sample size limitations in the US dataset. PMID:26023784
Comparison of Five-Year Outcome of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Triple-Vessel Coronary Artery Disease (from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2).
Shiomi, Hiroki; Morimoto, Takeshi; Furukawa, Yutaka; Nakagawa, Yoshihisa; Tazaki, Junichi; Sakata, Ryuzo; Okabayashi, Hitoshi; Hanyu, Michiya; Shimamoto, Mitsuomi; Nishiwaki, Noboru; Komiya, Tatsuhiko; Kimura, Takeshi
Studies evaluating long-term (?5 years) outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents compared with coronary artery bypass grafting (CABG) in patients with triple-vessel coronary artery disease (TVD) are still limited. We identified 2,978 patients with TVD (PCI: n = 1,824, CABG: n = 1,154) of 15,939 patients with first coronary revascularization enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2. The primary outcome measure in the present analysis was a composite of death, myocardial infarction (MI), and stroke. Median follow-up duration for the surviving patients was 1,973 days (interquartile range 1,700 to 2,244). The cumulative 5-year incidence of death/MI/stroke was significantly higher in the PCI group than in the CABG group (28.2% vs 24.0%, log-rank p = 0.006). After adjusting for confounders, the excess risk of PCI relative to CABG for death/MI/stroke remained significant (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.13 to 1.68, p = 0.002). The excess risks of PCI relative to CABG for all-cause death, MI, and any coronary revascularization were also significant (HR 1.38, 95% CI 1.10 to 1.74, p = 0.006; HR 2.81, 95% CI 1.69 to 4.66, p <0.001; and HR 4.10, 95% CI 3.32 to 5.06, p <0.001, respectively). The risk for stroke was not significantly different between the PCI and CABG groups (HR 0.88, 95% CI 0.61 to 1.26, p = 0.48). There were no interactions for the primary outcome measure between the mode of revascularization (PCI or CABG) and the subgroup factors such as age, diabetes, and Synergy Between PCI With Taxus and Cardiac Surgery score. In conclusion, CABG compared with PCI was associated with better long-term outcome in patients with TVD. PMID:25956622
The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: focus on rehabilitation and exercise and surgical coronary revascularization.
Moe, Gordon W; Ezekowitz, Justin A; O'Meara, Eileen; Howlett, Jonathan G; Fremes, Steve E; Al-Hesayen, Abdul; Heckman, George A; Ducharme, Anique; Estrella-Holder, Estrellita; Grzeslo, Adam; Harkness, Karen; Lepage, Serge; McDonald, Michael; McKelvie, Robert S; Nigam, Anil; Rajda, Miroslaw; Rao, Vivek; Swiggum, Elizabeth; Virani, Sean; Van Le, Vy; Zieroth, Shelley; Arnold, J Malcolm O; Ashton, Tom; D'Astous, Michel; Dorian, Paul; Giannetti, Nadia; Haddad, Haissam; Isaac, Debra L; Kouz, Simon; Leblanc, Marie-Hélčne; Liu, Peter; Ross, Heather J; Sussex, Bruce; White, Michel
The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure. PMID:24480445
Evaluation of the Effect of Concurrent Chronic Total Occlusion and Successful Staged Revascularization on Long-Term Mortality in Patients with ST-Elevation Myocardial Infarction
Shi, Guoxiang; He, Pengcheng; Liu, Yuanhui; Lin, Yaowang; Yang, Xing; Chen, Jiyuan; Zhou, Yingling; Tan, Ning
Aims. To investigate the impact of chronic total occlusion (CTO) in non-infarct-related artery (IRA) on the long-term prognosis and evaluate the clinical significance of staged revascularization in patients with ST-segment elevation myocardial infarction (STEMI). Methods. 1266 STEMI patients with primary percutaneous coronary intervention (PCI) were categorized as single-vessel disease (SVD), multivessel disease (MVD) without and with CTO. We study the clinical outcomes of patients after primary PCI in the following 3 years. Additionally, patients with CTO received staged revascularization, and major adverse cardiac events (MACE) during 3-year follow-up were recorded. Results. Presence of CTO was a predictor of both early mortality [hazard ratio (HR) 3.4, 95% confidence interval (CI) 2.4–4.5, P < 0.01] and late mortality (HR 1.9, 95% CI 1.4–3.6, P < 0.01), whereas MVD without CTO was only a predictor of early mortality (HR 1.7, 95% CI 1.3–2.3, P < 0.05). In CTO group, 100 patients had successful CTO recanalization, and 48 patients failed. During 3-year follow-up, patients with failed procedure had higher cardiac mortality (22.9% versus 9.0%, P = 0.020) and lower MACE-free survival (50.0% versus 72.0%, P = 0.009) compared to patients with successful procedure. Conclusion. The presence of CTO and not MVD alone is associated with long-term mortality. Successful revascularization of CTO in the non-IRA is associated with improved clinical outcomes in patients with STEMI undergoing primary PCI. PMID:24790581
Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle
Go Watanabe; Takuro Misaki; Keijyu Kotoh; Kyousuke Kawakami; Akio Yamashita; Katsushi Ueyama
Background. Single-vessel coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality rate. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass
An update on coronary artery chronic total occlusions.
Brayton, Kimberly; Mohammad, Atif; Brilakis, Emmanouil S; Banerjee, Subhash
A coronary artery chronic total occlusion (CTO) represents a coronary artery that has been occluded for a long period of time, typically months. Coronary artery CTOs are common and occur in approximately one-third of patients referred for coronary angiography. Revascularization of CTO is technically challenging and has historically been associated with lower procedural success rates and higher complication rates. Technical success of CTO revascularization has significantly improved given remarkable advances in interventional cardiology over the past 3 decades. However, the decision to perform CTO revascularization remains a dilemma, given the lack of robust clinical evidence to support its use. PMID:22406899
The changing mortality of myocardial revascularization: Coronary artery bypass and angioplasty
Keith S. Naunheim; Andrew C. Fiore; J. Jeffrey Wadley; Kirk R. Kanter; Lawrence R. McBride; D. Glenn Pennington; Hendrick B. Barner; Ubeydullah Deligonul; Morton J. Kern; Michel Vandormael; Vallee L. Willman; George C. Kaiser
The risk factors and outcome for the first 150 consecutive patients undergoing coronary artery bypass grafting (CABG) in 1985 (CABG '85) were compared with those of the first 150 patients undergoing CABG in 1975 (CABG '75) and those of the first 150 patients to have percutaneous transluminal coronary angioplasty (PTCA) in 1985 (PTCA '85). The CABG '85 patients had a
Five-year outcomes of percutaneous versus surgical coronary revascularization in patients with diabetes mellitus (from the CREDO-Kyoto PCI/CABG Registry Cohort-2).
Marui, Akira; Kimura, Takeshi; Nishiwaki, Noboru; Mitsudo, Kazuaki; Komiya, Tatsuhiko; Hanyu, Michiya; Shiomi, Hiroki; Tanaka, Shiro; Sakata, Ryuzo
We investigated the impact of diabetes mellitus on long-term outcomes of percutaneous coronary intervention (PCI) in the drug-eluting stent era versus coronary artery bypass grafting (CABG) in a real-world population with advanced coronary disease. We identified 3,982 patients with 3-vessel and/or left main disease of 15,939 patients with first coronary revascularization enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (patients without diabetes: n = 1,984 [PCI: n = 1,123 and CABG: n = 861], and patients with diabetes: n = 1,998 [PCI: n = 1,065 and CABG: n = 933]). Cumulative 5-year incidence of all-cause death after PCI was significantly higher than after CABG both in patients without and with diabetes (19.8% vs 16.2%, p = 0.01, and 22.9% vs 19.0%, p = 0.046, respectively). After adjusting confounders, the excess mortality risk of PCI relative to CABG was no longer significant (hazard ratio [HR] 1.16; 95% confidence interval [CI] 0.88 to 1.54; p = 0.29) in patients without diabetes, whereas it remained significant (HR 1.31; 95% CI 1.01 to 1.70; p = 0.04) in patients with diabetes. The excess adjusted risks of PCI relative to CABG for cardiac death, myocardial infarction (MI), and any coronary revascularization were significant in both patients without (HR 1.59, 95% CI 1.01 to 2.51, p = 0.047; HR 2.16, 95% CI 1.20 to 3.87, p = 0.01; and HR 3.30, 95% CI 2.55 to 4.25, p <0.001, respectively) and with diabetes (HR 1.45, 95% CI 1.00 to 2.51, p = 0.047; HR 2.31, 95% CI 1.31 to 4.08, p = 0.004; and HR 3.70, 95% CI 2.91 to 4.69, p <0.001, respectively). There was no interaction between diabetic status and the effect of PCI relative to CABG for all-cause death, cardiac death, MI, and any revascularization. In conclusion, in both patients without and with diabetes with 3-vessel and/or left main disease, CABG compared with PCI was associated with better 5-year outcomes in terms of cardiac death, MI, and any coronary revascularization. There was no difference in the direction and magnitude of treatment effect of CABG relative to PCI regardless of diabetic status. PMID:25733384
Percutaneous treatment of coronary subclavian steal syndrome.
Mulvihill, Niall T; Loutfi, Mohamed; Salengro, Emmanuel; Boccalatte, Marco; Laborde, Jean-Claude; Fajadet, Jean; Marco, Jean
Coronary subclavian steal syndrome arises when a stenosis of the subclavian artery results in reduced antegrade or retrograde flow in an internal mammary artery with resultant coronary ischemia. This occurs in patients who have previously undergone surgical coronary revascularization utilizing an internal mammary artery graft. This syndrome can be successfully treated percutaneously with excellent immediate and long-term results. PMID:12840236
Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting
Hubacek, Jaroslav; Kalla, Sunil; Galbraith, P Diane; Graham, Michelle M; Knudtson, Merril L; Ghali, William A
BACKGROUND The best therapeutic strategy for patients with double-vessel coronary artery disease and proximal left anterior descending artery involvement (2VD + pLAD) is not clear. OBJECTIVES To compare the survival experience of a cohort of cardiac catheterization patients with 2VD + pLAD based on chosen therapeutic strategy (medical management versus percutaneous coronary intervention [PCI] versus coronary artery bypass graft surgery [CABG]). METHODS The authors identified and studied a total of 603 patients with 2VD + pLAD from all patients who underwent diagnostic coronary angiography in Alberta between January 1997 and May 1999. The primary end point was five-year survival from index catheterization for each of the treatment groups and from time of revascularization when the two revascularization strategies were compared. RESULTS Risk-adjusted hazard ratios (HR) comparing cumulative five-year survival rates of patients treated medically, or with PCI or CABG indicated a survival benefit for patients treated with CABG (HR 0.24, 95% CI 0.11 to 0.54; P<0.001) and PCI (HR 0.43, 95% CI 0.24 to 0.77; P=0.003) compared with medical management. Meanwhile, a risk-adjusted comparison of revascularization strategies suggested a possible trend toward higher mortality for PCI-treated patients versus CABG-treated patients (HR 1.56, 95% CI 0.65 to 3.72; P=0.125). CONCLUSIONS The results of this registry-based observational study suggest a survival benefit from revascularization compared with medical management in patients with 2VD + pLAD. Furthermore, the authors found a trend toward better survival in CABG-treated patients compared with PCI-treated patients. PMID:18273485
Clinical Significance of A Single Multi-Slice CT Assessment in Patients with Coronary Chronic Total Occlusion Lesions Prior to Revascularization
Qu, Xinkai; Fang, Weiyi; Gong, Kaizheng; Ye, Jianding; Guan, Shaofeng; Li, Ruogu; Xu, Yingjia; Shen, Yan; Zhang, Min; Liu, Hua; Xie, Wenhui
Accurate assessment of coronary chronic total occlusion (CTO) lesion is essential to design an appropriate procedural strategy before revascularization. The present study aims to evaluate the significance of a single multislice computed tomography (MSCT) examination in patients with CTO lesion. We retrospectively analyzed the clinical data of 23 CTO lesions in twenty patients underwent computed tomography coronary angiography (CTCA) and SPECT. The CTCA was more powerful and sensitive to determine the CTO lesion length (100% v.s 47.8%) and to identify the length and location of calcification in occluded vessels compared with the coronary angiography (CAG). The LVEF measured by MSCT was comparable to that from the gated SPECT. Myocardial perfusion imaging showed that the location of the early defect region identified by MSCT was corresponded to the nuclide filling defect on the stressed 201thallium-SPECT imaging. The late hyperenhancement on MSCT was presented as incomplete nuclide filling on the 99mTc-MIBI imaging. The results suggested that a single MSCT examination in previous myocardial infarction without revascularization facilitates to provide some valuable information on the nature of the occluded lesion, myocardial perfusion and globe cardiac function, which would be helpful to design appropriate revascularization strategy in these subjects. PMID:24905494
Diabetes mellitus: a prothrombotic state Implications for outcomes after coronary revascularization
Cola, Clarissa; Brugaletta, Salvatore; Yuste, Victoria Martín; Campos, Bieito; Angiolillo, Dominick J; Sabaté, Manel
Coronary stent thrombosis is a serious problem in the drug-eluting stent era. Despite aggressive antiplatelet therapy during and after percutaneous coronary intervention (PCI), the incidence of sub-acute stent thrombosis remains approximately 0.5%–2%, which may represent a catastrophic clinical situation. Both procedural factors and discontinuation of antiplatelet therapy are normally associated with this event. We report on simultaneous stent thromboses of two drug-eluting stents implanted in two different vessels, which resulted in a life-threatening clinical condition. Possible contributing factors that led to synergistic thrombotic effects are discussed. PMID:19436654
Factors Related to the Selection of Surgical versus Percutaneous Revascularization in Diabetic Patients with Multivessel Coronary Artery Disease in the BARI 2D Trial
Kim, Lauren J.; King, Spencer B.; Kent, Kenneth; Brooks, Maria Mori; Kip, Kevin E.; Abbott, J. Dawn; Jacobs, Alice K.; Rihal, Charanjit; Hueb, Whady A.; Alderman, Edwin; Sing, Ivan R. Pena; Attubato, Michael J.; Feit, Frederick
Objectives We evaluated demographic, clinical and angiographic factors influencing the selection of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (CAD) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Background Factors guiding selection of mode of revascularization for patients with DM and multivessel CAD are not clearly defined. Methods In BARI 2D, the selected revascularization strategy, CABG or PCI, was based on physician discretion, declared independent of randomization to either immediate or deferred revascularization if clinically warranted. We analyzed factors favoring selection of CABG versus PCI in 1593 diabetic patients with multivessel CAD enrolled between 2001 and 2005. Results Selection of CABG over PCI was declared in 44% of patients and was driven by angiographic factors including: triple vessel disease (OR=4.43), left anterior descending (LAD) stenosis ?70% (OR=2.86), proximal LAD stenosis ?50% (OR=1.78), total occlusion (OR=2.35), and multiple class C lesions (OR=2.06), (all p< 0.005). Non-angiographic predictors of CABG included: age ? 65 years (OR=1.43, p=0.011), and non-US region (OR=2.89, p=0.017). Absence of prior PCI (OR=0.45, p<0.001), and the availability of drug-eluting stents (DES) conferred a lower probability of choosing CABG (OR=0.60, p=0.003). Conclusions The majority of diabetic patients with multivessel disease were selected for PCI rather than CABG. Preference for CABG over PCI was largely based on angiographic features related to the extent, location, and nature of CAD, as well as geographic, demographic and clinical factors. PMID:19463459
Successful Coronary Stent Retrieval From a Pedal Artery
Mariano, Enrica, E-mail: email@example.com; Versaci, Francesco [Tor Vergata University, Department of Cardiology (Italy); Gandini, Roberto; Simonetti, Giovanni; Di Vito, Livio [Tor Vergata University, Department of Radiology (Italy); Romeo, Francesco [Tor Vergata University, Department of Cardiology (Italy)
The purpose of this article is to report complications from a coronary drug-eluting stent lost in the peripheral circulation. We report the case of successful retrieval of a sirolimus coronary stent from a pedal artery in a young patient who underwent coronary angiography for previous anterior myocardial infarction. Recognition of stent embolization requires adequate removal of the device to avoid unwelcome clinical sequelae.
National trends in utilization and outcomes of coronary revascularization procedures among people with and without type 2 diabetes in Spain (2001–2011)
Background Diabetes is associated with a high risk of death due to coronary artery disease (CAD). People with diabetes suffering from CAD are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of coronary revascularization procedures in diabetic and non-diabetic patients in Spain between 2001 and 2011. Methods We identified all patients who had undergone coronary revascularization procedures, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. The incidence of discharges attributed to coronary revascularization procedures were calculated stratified by diabetes status. We calculated length of stay and in-hospital mortality (IHM). We apply joinpoint log-linear regression to identify the years in which changes in tendency occurred in the use of PCI and CABG in diabetic and non-diabetic patients. Multivariate analysis was adjusted by age, sex, year and comorbidity (Charlson comorbidity index). Results From 2001 to 2011, 434,108 PCIs and 79,986 CABGs were performed. According to the results of the joinpoint analysis, we found that sex and age-adjusted use of PCI increased by 31.4% per year from 2001 to 2003, by 15.9% per year from 2003 to 2006 and by 3.8% per year from 2006 to 2011 in patients with diabetes. IHM among patients with diabetes who underwent a PCI did not change significantly over the entire study period (OR 0.99; 95% CI 0.97-1.00). Among patients with diabetes who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 10.4% per year from 2001 to 2003, and then decreased by 1.1% through 2011. Diabetic patients who underwent a CABG had a 0.67 (95% CI 0.63-0.71) times lower probability of dying during hospitalization than those without diabetes. Conclusions The annual percent change in PCI procedures increased in diabetic and non-diabetic patients. Higher comorbidity and the female gender are associated with a higher IHM in PCI procedures. In diabetic and non-diabetic patients, we found a decrease in the use of CABG procedures. IHM was higher in patients without diabetes than in those with diabetes. PMID:24383412
Myocardial revascularization in patients with end-stage renal disease: Comparison of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting
K. Ivens; F. Gradaus; P. Heering; F. C. Schoebel; M. Klein; H. D. Schulte; B. E. Strauer; B. Grabensee
Background: Ischemic heart disease is the major cause of death inpatients with end-stage renal disease. The high prevalence of coronary\\u000a artery disease results in a rising number of dialysis patients requiring myocardial revascularisation. Objective: The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions\\u000a and cardiovascular death following percutaneous coronary angioplasty (PTCA)
Relation of clinical success in coronary brachytherapy to dose.
Singh, Harsimran S; Yue, Ning; Azimi, Nassir; Nath, Ravinder; Roberts, Kenneth B; Pfau, Steven
Intravascular brachytherapy is the primary treatment for coronary in-stent restenosis. Variations in dose in the treated artery may represent a potential cause of treatment failure. We compared dose distributions in patients who had developed recurrent restenosis (treatment failure) with those in patients who remained event free at 9 months (treatment success). We followed 140 patients who were receiving brachytherapy for in-stent restenosis with 4 radiation delivery devices to identify treatment failures and successes. Through a nested case-control construct, treatment failures (n = 14) were compared 1:2 with treatment successes (n = 28) matched by radiation delivery system and in-stent restenosis lesion pattern. The dose absorbed by 90% of the artery encompassed by the external elastic membrane (D(90)EEM) was calculated by applying intravascular ultrasound at 2-mm intervals along the treated lesion. Dose calculations were performed using dose kernel integration techniques generated from Monte Carlo simulations. The mean minimum D(90)EEM in treatment failures was 7.46 +/- 1.98 Gy, and that in treatment successes was 8.87 +/- 1.13 Gy (p = 0.007). Using a minimum dose threshold of 8.4 Gy, a minimum D(90)EEM
ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography.
Patel, Manesh R; Dehmer, Gregory J; Hirshfeld, John W; Smith, Peter K; Spertus, John A; Masoudi, Frederick A; Dehmer, Gregory J; Patel, Manesh R; Smith, Peter K; Chambers, Charles E; Ferguson, T Bruce; Garcia, Mario J; Grover, Frederick L; Holmes, David R; Klein, Lloyd W; Limacher, Marian C; Mack, Michael J; Malenka, David J; Park, Myung H; Ragosta, Michael; Ritchie, James L; Rose, Geoffrey A; Rosenberg, Alan B; Russo, Andrea M; Shemin, Richard J; Weintraub, William S; Wolk, Michael J; Bailey, Steven R; Douglas, Pamela S; Hendel, Robert C; Kramer, Christopher M; Min, James K; Patel, Manesh R; Shaw, Leslee; Stainback, Raymond F; Allen, Joseph M
The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research. PMID:22424518
Rosiglitazone and Outcomes for Patients with Diabetes and Coronary Artery Disease in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial
Bach, Richard G.; Brooks, Maria Mori; Lombardero, Manuel; Genuth, Saul; Donner, Thomas W.; Garber, Alan; Kennedy, Laurence; Monrad, E. Scott; Pop-Busui, Rodica; Kelsey, Sheryl F.; Frye, Robert L.
Background Rosiglitazone improves glycemic control for patients with type 2 diabetes, but there remains controversy regarding an observed association with cardiovascular hazard. The cardiovascular effects of rosiglitazone for patients with coronary artery disease (CAD) remain unknown. Methods and Results To examine any association between rosiglitazone use and cardiovascular events among patients with diabetes and CAD, we analyzed events among 2368 patients with type 2 diabetes and CAD in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Total mortality, composite death, myocardial infarction (MI), and stroke, and individual incidence of death, MI, stroke, congestive heart failure (CHF) and fractures, were compared during 4.5 yrs of follow-up among patients treated with rosiglitazone vs. patients not receiving a thiazolidinedione using Cox proportional hazards and Kaplan-Meier analyses including propensity matching. After multivariable adjustment, among patients treated with rosiglitazone, mortality was similar (HR 0.83; 95% CI, 0.58 to 1.18) while there was a lower adjusted incidence of composite death, MI, and stroke (hazard ratio (HR) 0.72; 95% confidence interval (CI), 0.55 to 0.93) and stroke (HR 0.36, 95% CI 0.16 to 0.86), and a higher incidence of fractures (HR 1.62, 95% CI 1.05 to 2.51); the incidence of MI (HR 0.77; 95% CI, 0.54 to 1.10) and CHF (HR 1.22, 95%CI, 0.84 to 1.82) were not significantly different. Among propensity matched patients rates of major ischemic cardiovascular events and CHF were not significantly different. Conclusions Among patients with type 2 diabetes and CAD in the BARI 2D trial, neither on-treatment nor propensity matched analysis supported an association of rosiglitazone treatment with an increase in major ischemic cardiovascular events. PMID:23857320
Long-Term Outcomes After Coronary Stent Implantation in Patients Presenting With Versus Without Acute Myocardial Infarction (an Observation from Coronary Revascularization Demonstrating Outcome Study-Kyoto Registry Cohort-2).
Yamaji, Kyohei; Natsuaki, Masahiro; Morimoto, Takeshi; Ono, Koh; Furukawa, Yutaka; Nakagawa, Yoshihisa; Kadota, Kazushige; Ando, Kenji; Shirai, Shinichi; Watanabe, Hirotoshi; Shiomi, Hiroki; Kimura, Takeshi
It has not been adequately addressed yet how long the excess cardiovascular event risk persists after acute myocardial infarction (AMI) compared with stable coronary artery disease. Of 10,470 consecutive patients who underwent percutaneous coronary intervention either with sirolimus-eluting stent (SES) only or with bare-metal stent (BMS) only in the Coronary Revascularization Demonstrating Outcome Study-Kyoto Registry Cohort-2, 3,710 (SES: n = 820 and BMS: n = 2,890) and 6,760 patients (SES: n = 4,258 and BMS: n = 2,502) presented with AMI (AMI group) and without AMI (non-AMI group), respectively. During the median 5-year follow-up, the excess adjusted risk of the AMI group relative to the non-AMI group for the primary outcome measure (cardiac death or myocardial infarction) was significant (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.30 to 1.80, p <0.001). However, the excess event risk was limited to the early period within 3 months. Late adjusted risk beyond 3 months was similar between the AMI and non-AMI groups (HR 1.16, 95% CI 0.95 to 1.41, p = 0.15). The higher risk of the AMI group relative to the non-AMI group for stent thrombosis (ST) was significant within 3 months (HR 3.38, 95% CI 2.04 to 5.60, p <0.001), whereas the risk for ST was not different between the 2 groups beyond 3 months (HR 1.11, 95% CI 0.65 to 1.90, p = 0.70). There were no interactions between the types of stents implanted and the risk of the AMI group relative to the non-AMI groups for all the outcome measures including ST. In conclusion, patients with AMI compared with those without AMI were associated with similar late cardiovascular event risk beyond 3 months after percutaneous coronary intervention despite their higher early risk within 3 months. PMID:26068701
A unique and unexplained ricochet leak post PCI – Successfully treated with intra-coronary glue
Goel, Pravin K.; Syal, Sanjeev K.
We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate. PMID:24581110
A unique and unexplained ricochet leak post PCI - successfully treated with intra-coronary glue.
Goel, Pravin K; Syal, Sanjeev K
We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate. PMID:24581110
Coronary-to-Bronchial Artery Communication: Report of Two Patients Successfully Treated by Embolization
Jarry, Genevieve [Department of Cardiology, University of Amiens, Rene Laennec Avenue, F-80054 Amiens (France); Bruaire, Jean-Pierre [Department of Cardiology, Coutances Hospital, Rue de la Gare, F-50200 Coutances (France); Commeau, Philippe [Department of Cardiology, Centre Hospitalier Prive St. Martin, 18 rue des Roqueronts, F-14050 Caen (France); Hermida, Jean-Sylvain; Leborgne, Laurent [Department of Cardiology, University of Amiens, Rene Laennec Avenue, F-80054 Amiens (France); Auquier, Marie-Anne [Department of Radiology, University of Amiens, Rene Laennec Avenue, F-80054 Amiens (France); Delonca, Jean; Quiret, Jean-Claude [Department of Cardiology, University of Amiens, Rene Laennec Avenue, F-80054 Amiens (France); Remond, Alexandre [Department of Radiology, University of Amiens, Rene Laennec Avenue, F-80054 Amiens (France)
We report two cases of coronary-to-bronchial artery communication responsible for coronary steal. In both cases the anastomosis originated from the proximal circumflex artery and developed because of bronchiectasis. In both cases closure of the anastomosis was achieved successfully by embolization. To date, the patients remained free from symptoms.
The Population-Based Risk of Need for Coronary Revascularization According to the Presence of Type 2 Diabetes Mellitus and History of Coronary Heart Disease in the Korean Population
Jung, Chang Hee; Seo, Gi Hyeon; Suh, Sunghwan; Bae, Ji Cheol; Kim, Mee Kyoung; Hwang, You-Cheol; Kim, Jae Hyeon; Lee, Byung-Wan
Background Whether diabetic patients without a history of coronary heart disease (CHD) have the same risk of CHD events as non-diabetic patients with a history of CHD remains controversial. This study aimed to determine whether type 2 diabetes mellitus (T2DM) is a coronary heart disease (CHD) equivalent in the need for coronary revascularization procedures (RVs) in the Korean population. Methodology/Principal Findings We followed 2,168,698 subjects who had oral anti-diabetic drugs (OADs)-taking T2DM in 2008 and/or CHD in 2007–2008 (i.e., recent CHD). We used systematic datasets from the nationwide claims database of the Health Insurance Review and Assessment service of Korea, which is representative of the whole population of Korea, from January 2007 to December 2012. The primary study endpoint was the development of need for RVs (i.e., incident CHD) after January 2009 among three groups based on their status of T2DM and recent CHD, i.e., T2DM only, recent CHD only, and both T2DM and recent CHD. After adjustment for age and sex, patients with recent CHD only had 2.14 times the risk of incident CHD (95% CI, 2.11–2.18, P<0.001) compared with patients with T2DM only. Patients with both T2DM and recent CHD demonstrated approximately 2-fold increased risk of incident CHD compared with subjects with recent CHD only (95% CI, 1.75-1.82), while 4-fold increased risk compared with subjects with T2DM only (95% CI, 3.71-3.87). The risk of incident CHD also differed according to sex and age. Conclusions/Significance This analysis of data from the nationwide claims database revealed that T2DM did not have a recent CHD equivalent risk in the Korean population. These results suggest that an appropriate strategy for the CHD risk stratification in diabetic patients should be adopted to manage this population. PMID:26053222
Differences in per capita rates of revascularization and in choice of revascularization procedure for eleven states
Hannan, Edward L; Wu, Chuntao; Chassin, Mark R
Background A few studies have investigated differences in elective procedure rates across small and medium sized referral regions. The purposes of this study are to investigate differences in revascularizations across 11 entire states and to investigate differences in choice of revascularization procedure (percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) surgery). Methods Age-sex adjusted rates per 100,000 population who were 20 or older were calculated for PCI, CABG surgery, and total revascularization for each state. Also, the risk-adjusted proportion of revascularized patients who underwent PCI was calculated for each state and differences were compared. Results We found variations in procedures performed per capita of 1.83-fold for PCI, 1.54-fold for CABG surgery, and 1.54-fold for total revascularization. For patients undergoing revascularization of two or more vessels, the age/sex adjusted maximum rate of 224 per 100,000 population over 20 years old in Florida was 53% higher than the minimum rate of 146 in Colorado. Higher catheterization rates per 1,000 Medicare enrollees and higher percent of white patients were significant predictors of higher revascularization rates, and density of specialists was a significant predictor of catheterization rate. The risk-adjusted percentage of revascularized patients with two or more arteries attempted who underwent PCI ranged from 10.4% in Oregon to 29.0% in Iowa. Conclusion There are reasonably large differences among states in total revascularization rates and in type of revascularization among revascularization. These differences appear to be related to practice pattern differences. Future effort should be devoted to understanding the reason for these differences and the impact on patients' health and survival. PMID:16542441
Association Between Visit-to-Visit Variability in Blood Pressure and Cardiovascular Events in Hypertensive Patients After Successful Percutaneous Coronary Intervention
Gondo, Kouki; Miura, Shin-ichiro; Suematsu, Yasunori; Shiga, Yuhei; Kuwano, Takashi; Sugihara, Makoto; Ike, Amane; Iwata, Atsushi; Motozato, Kota; Kusumoto, Takaaki; Nishikawa, Hiroaki; Saku, Keijiro
Background Visit-to-visit variability (VVV) in blood pressure (BP) in addition to high BP has been shown to be a strong predictor of coronary events and stroke. Therefore, we investigated the associations between VVV in BP or BP levels and cardiovascular events after successful percutaneous coronary intervention (PCI). Methods We enrolled 176 hypertensive patients who had undergone successful PCI and who had four clinic visits to measure BP until follow-up coronary angiography (CAG) at 6 - 9 months after PCI. The patients were divided into those with acute coronary syndrome (ACS group; n = 50) and those with stable angina pectoris (SAP group; n = 126). We determined VVV in BP expressed as the standard deviation (SD) of average BP, average, and the maximum and minimum BP during the follow-up period. Major adverse cardiovascular events (MACEs) (myocardial infarction (MI), target lesion revascularization (TLR) and all-cause death) were also analyzed. Results There were no significant differences in VVV in BP, average BP or maximum or minimum BP between the patients with and without MACE in all patients, the ACS and SAP groups. Interestingly, in the ACS group, VVV in SBP and maximum SBP in patients with MI were significantly higher than those in patients without MI. The cut-off levels for VVV in BP and maximum SBP that gave the greatest sensitivity and specificity for MI in the ACS group were 15.1 and 138 mm Hg, respectively. Conclusion Higher VVV in SBP and maximum SBP in patients with ACS after successful PCI were associated with the onset of MI. PMID:26015820
Coronary artery surgery: now and in the next decade.
Ennker, J C; Ennker, I C
In coronary artery surgery the superiority of the internal mammary artery graft in 10-year survival was documented in 1986. In 1999 it was demonstrated that death, reoperation and percutaneous transluminary coronary angioplasty were more frequent in patients undergoing single rather than bilateral internal mammary artery grafting. Today coronary artery bypass grafting surgery is challenged by the success story of modern interventional cardiology. The Syntax Study, however, clearly underlined the better outcome for patients with triple-vessel and/or left main disease undergoing coronary artery bypass grafting in terms of repeat revascularization. Another point of ongoing discussion is the comparison between on-pump and off-pump coronary artery revascularization techniques. Even if mixed results exists in the literature, in experienced hands the combination of aortic no-touch and total arterial revascularization, probably leads to the superiority in off pump coronary artery bypass grafting in terms of significantly decreased rates of mortality, stroke, major adverse cardiac and cerebral vascular events. Coronary artery surgery in the next decade will be influenced by the further progression of minimally invasive surgical principles and by a variety of other factors. The role of robotics and hybrid surgery has yet to be defined. Alternatives within surgery will not only need to move to a less disruptive strategy (e.g. from on-pump to off-pump bypass) but also have to secure sustained innovation, as we can be sure that the current coronary artery bypass grafting activity will change substantially. PMID:23439278
Successful embolization of iatrogenic ruptured coronary artery using Onyx: a new technique.
Asouhidou, I; Katsaridis, V
Iatrogenic perforation of coronary artery is rare during percutaneous coronary intervention (PCI); however the complications are life-threatening. Patients in this clinical setting may be treated either by stent placement, closure of the perforation with fibrin glue or coils, or with emergency bypass surgery. Onyx, a new material that has been used successfully in cerebral arteries, represents a new and safe alternative. The advantage of Onyx is that it is easily injected through a microcatheter and it allows for a longer injection time having also the ability to reach difficult anatomical locations. We present the first case of successful embolization of a right coronary artery perforation during coronary angiography using Onyx. PMID:25110834
Successful treatment of coronary artery perforation during angioplasty using a new membrane-coated stent.
Casella, G; Werner, F; Klauss, V; Mudra, H
We report a case of successful treatment of coronary artery perforation and cardiac tamponade, which developed during percutaneous transluminal coronary angioplasty, with a PTFE-coated stent. Intravascular ultrasound was first used to overcome the shortcomings of conventional angiography and overlapping of a conventional stent was not as effective as coated-stent placement in sealing a further leakage. Thus, PTFE-coated stents may be an effective alternative to emergency surgery or autologous venous covered stenting and should be considered when coronary artery perforation occurs. PMID:10745446
Transmyocardial laser as an adjunct to minimally invasive CABG for complete myocardial revascularization
Naresh Trehan; Yugal Mishra; Yatin Mehta; Dhan Raj Jangid
Background. To achieve complete myocardial revascularization in patients with diffuse coronary artery disease and patients at high risk if they undergo cardiopulmonary bypass such as severe systemic disease or diffuse arteriosclerosis of the aorta, we have adopted the technique of combining direct coronary artery bypass grafting without cardiopulmonary bypass with transmyocardial laser revascularization.Methods. From April 1995 to September 1997 this
Successful angioplasty of three cases of coronary artery dissections using hydrophilic wires
Menon, Rajeev; Kapadia, Anuj
Three cases of successful angioplasty of high-grade coronary dissections using hydrophilic wires were reported. Our first case had edge dissection after a stent deployed in the left anterior descending artery, after which we found it impossible to track the second stent over the regular wires, and which was successful when we tried with a stiffer hydrophilic wire. The second had spontaneous coronary artery dissections (SCAD), and the third case was a complicated plaque with multiple stenotic and ectatic segments along with dissection and successful angioplasty carried out using the same wires and without additional hardware. These wires also provided adequate support in tracking the required balloons and stents PMID:25489325
Functional Testing Underlying Coronary Revascularisation
Multivessel Coronary Artery Disease; Vessel Disease; Stable Angina; Unstable Angina or Stabilized Non-ST Elevated Myocardial Infarction; Patients With ST-elevated Myocardial Infarction; Revascularization of Culprit Coronary Artery
Revascularization surgery for penile calciphylaxis.
Akai, Atsushi; Okamoto, Hiroyuki; Shigematsu, Kunihiro; Miyata, Tetsuro; Watanabe, Toshiaki
Calciphylaxis, a systemic disorder seen in 1%-4% of patients with end-stage renal disease, is a cause of penile ischemic gangrene. We present a case of successful revascularization surgery for penile calciphylaxis. An arterial bypass to the deep dorsal penile vein relieved the rest pain and stopped expansion of the gangrenous lesion. PMID:23571078
Transmyocardial Laser Revascularization
... bypass surgery, there is a procedure called transmyocardial laser revascularization, also called TMLR or TMR. TMLR cannot ... reduce the pain of angina. What is Transmyocardial Laser Revascularization (TMLR)? TMLR is a type of surgery ...
Percutaneous coronary intervention in the Occluded Artery Trial: Procedural success, hazard, and outcomes over 5 years
Buller, Christopher E.; Rankin, Jamie M.; Carere, Ronald G.; Buszman, Pawel E.; Pfisterer, Matthias E.; Dzavik, Vladimir; Thomas, Boban; Forman, Sandra; Ruzyllo, Witold; Mancini, G.B. John; Michalis, Lampros K.; Abreu, Pedro F.; Lamas, Gervasio A.; Hochman, Judith S.
Background The Occluded Artery Trial (OAT) was a 2,201-patient randomized clinical trial comparing routine stent-based percutaneous coronary intervention (PCI) versus optimal medical therapy alone in stable myocardial infarction (MI) survivors with persistent infarct-related artery occlusion identified day 3 to 28 post MI. Intent-to-treat analysis showed no difference between strategies with respect to the incidence of new class IV congestive heart failure, MI, or death. The influence of PCI failure, procedural hazard, and crossover on trial results has not been reported. Methods Study angiograms were analyzed and adjudicated centrally. Factors associated with PCI failure were examined. Time-to-event analysis using the OAT primary outcome was performed by PCI success status. Landmark analysis (up to and beyond 30 days) partitioned early hazard versus late outcome according to treatment received. Results Percutaneous coronary intervention was adjudicated successful in >87%. Percutaneous coronary intervention failure rates were similar in US and non-US sites, and did not significantly influence outcome at 60 months (hazard ratio for success vs fail 0.79, 99% CI 0.45–1.40, P = .29). Partitioning of early procedural hazard revealed no late benefit for PCI (hazard ratio for PCI success vs medical therapy alone 1.06, 99% CI 0.75–1.50, P = .66). Conclusions Percutaneous coronary intervention failure and complication rates in the OAT were low. Neither PCI failure nor early procedural hazard substantively influenced the primary trial results. PMID:19699864
Transmyocardial revascularization devices: technology update.
Kindzelski, Bogdan A; Zhou, Yifu; Horvath, Keith A
Transmyocardial laser revascularization (TMR) emerged as treatment modality for patients with diffuse coronary artery disease not amendable to percutaneous or surgical revascularization. The procedure entails the creation of laser channels within ischemic myocardium in an effort to better perfuse these areas. Currently, two laser devices are approved by the US Food and Drug Administration for TMR - holmium:yttrium-aluminum-garnet and CO2. The two devices differ in regard to energy outputs, wavelengths, ability to synchronize with the heart cycle, and laser-tissue interactions. These differences have led to studies showing different efficacies between the two laser devices. Over 50,000 procedures have been performed worldwide using TMR. Improvements in angina stages, quality of life, and perfusion of the myocardium have been demonstrated with TMR. Although several mechanisms for these improvements have been suggested, evidence points to new blood vessel formation, or angiogenesis, within the treated myocardium, as the major contributory factor. TMR has been used as sole therapy and in combination with coronary artery bypass grafting. Clinical studies have demonstrated that TMR is both safe and effective in angina relief long term. The objective of this review is to present the two approved laser devices and evidence for the safety and efficacy of TMR, along with future directions with this technology. PMID:25565905
Transmyocardial revascularization devices: technology update
Kindzelski, Bogdan A; Zhou, Yifu; Horvath, Keith A
Transmyocardial laser revascularization (TMR) emerged as treatment modality for patients with diffuse coronary artery disease not amendable to percutaneous or surgical revascularization. The procedure entails the creation of laser channels within ischemic myocardium in an effort to better perfuse these areas. Currently, two laser devices are approved by the US Food and Drug Administration for TMR – holmium:yttrium–aluminum–garnet and CO2. The two devices differ in regard to energy outputs, wavelengths, ability to synchronize with the heart cycle, and laser–tissue interactions. These differences have led to studies showing different efficacies between the two laser devices. Over 50,000 procedures have been performed worldwide using TMR. Improvements in angina stages, quality of life, and perfusion of the myocardium have been demonstrated with TMR. Although several mechanisms for these improvements have been suggested, evidence points to new blood vessel formation, or angiogenesis, within the treated myocardium, as the major contributory factor. TMR has been used as sole therapy and in combination with coronary artery bypass grafting. Clinical studies have demonstrated that TMR is both safe and effective in angina relief long term. The objective of this review is to present the two approved laser devices and evidence for the safety and efficacy of TMR, along with future directions with this technology. PMID:25565905
Successfully treated bilateral renal artery stenosis in a patient with coronary artery disease
Gunduz, Yasemin; Akdemir, Ramazan; Sahinkus, Salih; Vatan, Mehmet Bulent
Renal artery stenosis (RAS) is the most common cause of secondary hypertension and accounts for approximately 1–3% of all causes of hypertension. Over 90% of RASs are caused by atherosclerosis; atherosclerotic RAS is increasingly common in aging populations, particularly elderly people with diabetes, hyperlipidaemia, aortoiliac occlusive disease, coronary artery disease or hypertension. Three therapeutic options are currently available for patients with renovascular hypertension: medical antihypertensive therapy, surgical revascularisation and transluminal angioplasty including stent implantation. We present in this report a male patient with bilateral severe ostial stenosis and coronary artery disease, and who was successfully treated with renal stent implantation in one session. PMID:23737568
Optimal treatment of multivessel complex coronary artery disease
The aim of the present study was to investigate major cardiac events and the similarities and differences of medical costs among patients with multivessel complex coronary artery disease (MCCAD) during the three-year follow-up. The MCCAD patients had undergone single complete revascularization (CR), fractionated revascularization (FR) or partial revascularization (PR) and the present study aimed to screen the optimal treatment program. A total of 2,309 MCCAD patients who had been treated at a single center in the last decade, among which 1,020 cases underwent single CR, 856 cases successively underwent FR and 433 cases only underwent PR, were followed-up for three years. Major cardiac events, including all-cause mortality, myocardial infarction, severe heart failure, rehospitalization and revascularization (coronary artery bypass grafting and coronary stent reimplantation), were set as the end points. In addition, the three-year medical costs associated with heart disease were analyzed. The three-year cardiac event rate in the CR group (17%) was significantly lower compared with the other two groups and the average three-year medical costs in the CR group (62,100 RMB) were significantly lower than those in the other two groups. Therefore, under permissive conditions, single CR is the optimal and most economical treatment strategy for patients with MCCAD. PMID:24926344
[Is aortocoronary bypass indicated in patients with lesions of the common trunk of the left coronary artery incapable of complete revascularization?].
Barboso, G; Saccani, S; Busi, M; Fesani, F
Obstructive lesions of the left common coronary trunk need surgery if our operability criteria: possibility of at least making a by-pass on the left descending anterior coronary branch and a not seriously compromised miocardial contractility exist. Of the 25 patients operated, there was a mortality of 8% and 3 intra-and post-operatory infarcts; two other patients died after some time (one for extracardiac causes). Other infarcts were not observed. 48% of the patients had incomplete riva-scolarization which after some time had an effect on the objective state of the patients but not on their survival. The authors conclude their studies by affirming that total surgical correction is indicated even on non susceptible patients on the basis of coronarography. PMID:6971115
Angiographic patterns of in-stent restenosis and implications on subsequent revascularization
Annapoorna Kini; Jonathan D. Marmur; George Dangas; Sanjay Choudhary; Samin K. Sharma
Stent implantation has become the mainstay of percutaneous revascularization for most coronary lesions; in-stent restenosis (ISR) can occur in 6%-40% of stent procedures and the subsequent response to repeat intervention can possibly be predicted by the angiographic patterns of ISR. This study evaluated the incidence and predictors of angiographic patterns of ISR and its impact on subsequent target lesion revascularization
Review of current concepts of revascularization/revitalization.
Bezgin, Tu?ba; Sönmez, Hayriye
This review focuses on the current concepts on revascularization/revitalization therapy. Revascularization/revitalization procedures performed under current protocols have reportedly achieved successful clinical and radiographical outcomes for immature permanent teeth with non-vital pulps; however, randomized prospective studies are needed to develop evidence-based methodologies for regenerative endodontic treatment. PMID:25950886
Comparison of six risk scores in patients with triple vessel coronary artery disease undergoing PCI: competing factors influence mortality, myocardial infarction and target lesion revascularization
Kovacic, Jason C.; Limaye, Atul M.; Sartori, Samantha; Lee, Paul; Patel, Roshan; Chandela, Sweta; Trost, Biana; Roy, Swathi; Harari, Rafael; Narechania, Birju; Karajgikar, Rucha; Kim, Michael C.; Krishnan, Prakash; Moreno, Pedro; Baber, Usman; Mehran, Roxana; Dangas, George; Kini, Annapoorna S.; Sharma, Samin K.
Objectives To compare the discriminatory value of differing risk scores for predicting clinical outcomes following PCI in routine practice. Background Various risk scores predict outcomes after PCI. However, these scores consider markedly different factors, from purely anatomical (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], NY State Risk Score [NYSRS]). Methods Patients with triple vessel and/or LM disease with 12 month follow-up were studied from a single center PCI registry. Exclusion criteria included STEMI presentation, prior revascularization and shock. Clinical events at 12 months were compared to baseline risk scores, according to score tertiles and area under receiver-operating-characteristic curves (AUC). Results We identified 584 eligible patients (69.8±12.3yrs, 405 males). All scores were predictive of mortality, with the SRS being least predictive (AUC=0.66). The most accurate scores for mortality were the CSS and ACEF (AUC=0.76 for both: p=0.019 and 0.08 vs. SRS, respectively). For TLR, while the SRS trended toward being positively predictive (p=0.075), several scores trended towards a negative association, which reached significance for the NCDR (p=0.045). The SRS and CSS were the only scores predictive of MI (both p<0.05). No score was particularly accurate for predicting MACE (death+MI+TLR), with AUCs ranging from 0.53 (NCDR) to 0.63 (SRS). Conclusions Competing factors influence mortality, MI and TLR after PCI. An increasing burden of comorbidities is associated with mortality, whereas anatomical complexity predicts MI. By combining these outcomes to predict MACE, all scores show reduced utility. PMID:23703934
Improved late survival with arterial revascularization
Schaff, Hartzell V.; Dearani, Joseph A.; Daly, Richard C.
New coronary artery revascularization strategies are developing: improved quantification of coronary artery disease by the SYNTAX score, new-generation drug-eluting stents and increased use of stents for multivessel disease, ongoing evaluation of stents for left main disease, new strategies for minimally invasive coronary artery bypass grafting (CABG) including the use of robotic-assisted CABG, hybrid procedures, and off pump CABG. In comparisons of all these strategies, the impact on survival is arguably the most important parameter. It has long been accepted that using the left internal mammary artery (LIMA) to bypass the left anterior descending coronary artery (LAD) is the gold standard and may confer the survival advantage reported for CABG compared with percutaneous coronary intervention in the literature. The survival advantage of using additional arterial conduits as compared to the conventional use of LIMA with saphenous veins only has long been debated. Our study, which involved a large cohort of 8,622 patients with multivessel disease, followed over a long period of time, has shown that in primary isolated CABG surgery performed more than 15 years ago with the use of LIMA to the LAD, bypassing the non-LAD targets with at least 1 additional arterial graft, either the right internal mammary artery and/or the radial artery, was an independent predictor of increased survival during the following 15 years. The results were confirmed with both a propensity-matched analysis that included 1,153 patients in each group and a multivariate analysis that was able to control for all differences between the groups because of the power of the large cohort in this series. The significant survival advantage of coronary artery bypass surgery with the use of multiple arterial grafting cannot be ignored in patients with multivessel coronary artery disease as various revascularization strategies are considered. PMID:23977624
Risk-Benefit Trade-offs in Revascularization Choices
Federspiel, Jerome J.; Stearns, Sally C.; van Domburg, Ron T.; Sheridan, Brett C.; Lund, Jennifer L.; Serruys, Patrick W.
Aims When patients choose percutaneous coronary intervention (PCI) over coronary artery bypass grafting (CABG), they accept an increased long-term risk of repeat revascularization in exchange for short term morbidity benefits. This paper quantifies the risk-benefit trade-off faced by patients with multiple vessel coronary artery disease. Methods and Results Data from the Arterial Revascularization Therapies Study are used to generate risk-benefit acceptability curves for PCI versus CABG. Risks are measured by the long-term likelihood of repeat revascularization while benefits are measured by short term reductions in pain or improvements in health-related quality of life (HRQL). PCI patients faced a risk of 0.81 additional revascularization events over three years in exchange for being pain-free at one month. A patient would need to be willing to tolerate a risk of 1.06 additional revascularization events at three years, in exchange for being pain free at one month to be 95% confident that choosing PCI over CABG is risk-effective for him/her. Conclusions The risk-benefit framework outlined in this study provides information to enable physicians to help their patients weigh directly each procedure's risks and benefits. While trade-offs are typically measured in quality-adjusted life years, using pain reduction to reflect benefits may provide a more tangible framework for patients. PMID:21330240
All internal thoracic artery composite graft revascularization.
Izumoto, Hiroshi; Ishihara, Kazuaki; Kawase, Tetsunori; Nakajima, Takayuki; Satoh, Hiroshi; Kawazoe, Kohei
The aim of this study was to determine the most efficient design of composite grafts and clarify the technical feasibility rate of composite grafting using internal thoracic artery exclusively in patients undergoing triple-vessel revascularization. Retrospective analysis of 104 consecutive patients was carried out. An in situ left internal thoracic artery graft for the left anterior descending artery area, with attachment of the right internal thoracic artery to the side of the left internal thoracic artery to revascularize the circumflex and right coronary vessels, was the most efficient graft design. The technical feasibility rate was 80% (83/104 patients). The mean number of distal anastomoses for the entire group was 3.8+/-0.8 per patient. Intraoperative left internal thoracic artery flow rate was 91.6+/-37.8 mL.min-1. With more experience, it is thought that the technical feasibility rate could be increased. PMID:16304225
Revascularization in severe left ventricular dysfunction.
Velazquez, Eric J; Bonow, Robert O
The highest-risk patients with heart failure with reduced ejection fraction are those with ischemic cardiomyopathy and severe left ventricular systolic dysfunction (ejection fraction?35%). The cornerstone of treatment is guideline-driven medical therapy for all patients and implantable device therapy for appropriately selected patients. Surgical revascularization offers the potential for improved survival and quality of life, particularly in patients with more extensive multivessel disease and the greatest degree of left ventricular systolic dysfunction and remodeling. These are also the patients at greatest short-term risk of mortality with coronary artery bypass graft surgery. The short-term risks of surgery need to be balanced against the potential for long-term benefit. This review discusses the evolving data on the role of surgical revascularization, surgical ventricular reconstruction, and mitral valve surgery in this high-risk patient population. PMID:25677320
Successful catheter ablation of a left anterior accessory pathway from the non-coronary cusp of the aortic valve.
Laranjo, Sérgio; Oliveira, Mário; Trigo, Conceiçăo
Left anterior accessory pathways are considered to be rare findings. Catheter ablation of accessory pathways in this location remains a challenging target, and few reports about successful ablation of these accessory pathways are available. We describe our experience regarding a case of a manifest left anterior accessory pathway ablation using radiofrequency energy at the junction of the left coronary cusp with the non-coronary cusp. PMID:25249369
Anomalous origin of the left anterior descending coronary artery from the pulmonary trunk: recognition in life and successful surgical treatment.
el Habbal, M M; de Leval, M; Somerville, J
An anomalous origin of the left anterior descending coronary artery from the pulmonary trunk with the right and left circumflex arteries arising from the aorta is very rare and the diagnosis made only at necropsy. An anomalous coronary artery was suspected owing to unexplained cardiomegaly in a 17 month old girl and the anatomy was defined by angiography. The anomalous vessel was successfully reimplanted into the aorta. Images Fig 2 PMID:2970270
Long-term clinical events following creatine kinase–myocardial band isoenzyme elevation after successful coronary stenting
Jorge F Saucedo; Roxana Mehran; George Dangas; Mun K Hong; Alexandra Lansky; Kenneth M Kent; Lowell F Satler; Augusto D Pichard; Gregg W Stone; Martin B Leon
OBJECTIVEWe sought to evaluate the impact of intermediate creatine kinase–myocardial band isoenzyme (CK-MB) elevation on late clinical outcomes in patients undergoing successful stent implantation in native coronary arteries.BACKGROUNDElevations of CK-MB after percutaneous coronary interventions are frequent. An association between high level of CK-MB elevation (>5 times normal) and late mortality after balloon and new device angioplasty has been reported previously.
Unprotected Left Main Percutaneous Coronary Intervention in a 108-Year-Old Patient
Rahman, Afzalur
With the increase in life expectancy, the proportion of very elderly people is increasing. Coronary artery disease (CAD) is an important cause of mortality and morbidity in this age group, for which myocardial revascularization is often indicated. Percutaneous coronary intervention (PCI) in the very elderly bears the inherent risks of complications and mortality, but the potential benefits may outweigh these risks. A number of observational studies, registries, and few randomized controlled trials have shown the safety and feasibility of PCI in octogenarians and nonagenarians. However, PCI is only rarely done in centenarians; so, the outcome of percutaneous coronary revascularization in this age group is largely unknown. PCI in a centenarian with complex CAD is described here; the patient presented with unstable angina despite optimum medical therapy, and surgery was declined. Good angiographic success was followed by non-cardiac complications, which were managed with a multidisciplinary approach. PMID:24653741
Partial sternotomy coronary surgery with triple-vessel disease in dextrocardia and situs inversus totalis.
Su, Pi Xiong; Gu, Song; Liu, Yan; Gao, Jie
Dextrocardia associated with situs inversus totalis is a rare congenital condition. A small number of cases with these conditions have been reported who underwent myocardial revascularization via the on-pump or off-pump techniques. Among them, only 1 patient with dextrocardia and situs inversus totalis was reported to have the procedure performed with minimally invasive coronary surgery via a right anterior small thoracotomy. However, the case was a single-vessel disease and only one graft was achieved. We describe the case of a 65-year old female patient with triple-vessel obstructive coronary diseases who was successfully revascularized with three grafts using a minimally invasive technique. This was achieved via partial sternotomy and employing off-pump coronary artery bypass grafting. PMID:23559364
Early occlusion of the non-infarct-related coronary artery following successful primary percutaneous coronary intervention in ST-elevation myocardial infarction
Pr?gowski, Jerzy; Bekta, Pawe?; Chmielak, Zbigniew; Witkowski, Adam
We present a clinical case of early occlusion of the non-infarct-related artery (non-IRA) in a patient with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Several hours after successful percutaneous treatment of the occluded right coronary artery the patient developed a second myocardial infarction, which was caused by acute occlusion of the left anterior descending artery, which had a significant lesion in the proximal segment. The lesion was diagnosed during the first catheterization, but was left untreated. We discuss the potential advantages and risks associated with the ad-hoc multivessel PCI strategy in STEMI.
Transthoracic coronary flow reserve and dobutamine derived myocardial function: a 6-month evaluation after successful coronary angioplasty
Silvana Cicala; Maurizio Galderisi; Pasquale Guarini; Arcangelo D'Errico; Pasquale Innelli; Moira Pardo; Giancarlo Scognamiglio; Oreste de Divitiis
After percutaneous transluminal coronary angioplasty (PTCA), stress-echocardiography and gated single photon emission computerized tomography (g-SPECT) are usually performed but both tools have technical limitations. The present study evaluated results of PTCA of left anterior descending artery (LAD) six months after PTCA, by combining transthoracic Doppler coronary flow reserve (CFR) and color Tissue Doppler (C-TD) dobutamine stress. Six months after PTCA
Total arterial revascularization with internal mammary artery or radial artery pi graft configuration.
Deng, Yongzhi; Sun, Zongquan; Paterson, Hugh S
To investigate the clinical use of pi graft in total arterial revascularization and its outcomes, a retrospective analysis of 23 patients out of 1000 patients undergoing total arterial coronary bypass surgery with a pi graft between September 1994 and December 2004 was performed. In the selected patients for the management of triple vessel disease with middle diagonal/intermediate ramus disease such that a skip with the left internal mammary artery (LIMA) or radial artery (RA), the main stem of pi graft, to the left anterior descending coronary artery (LAD) will not work and the right internal mammary artery (RIMA) or right gastroepiploic artery (RGEA) cannot pick up the diagonal/intermediate ramus, hence the LAD and diagonal/intermediate ramus were grafted with a mini Y graft using the distal segment of LIMA, RIMA, RA or RGEA, together with the bilateral internal mammary artery (BIMA) or LIMA-RA T graft to compose pi graft. Twenty-three patients (18 males, 5 females) underwent the pi graft procedure. There were no deaths or episodes of myocardial infarction, stroke, and deep sternal wound infection. One patient required reopening for controlling bleeding. Until the end of 2004, during a mean follow-up of 81.0 +/- 28.4 months, no angina needing re-intervention or operative therapy or coronary related death occurred. In conclusion, in patients with specific coronary artery anatomy/stenosis, the BIMA (sometimes LIMA with RA or RGEA) pi graft can be successfully performed for total arterial revascularization with good midterm outcomes. PMID:16463678
Effect of transmyocardial laser revascularization on chronic ischemic hearts in sheepq
Shigeyuki Ozaki; Bart Meyns; Rozalia Racza; Eric Verbeken; Veerle Leunens; Pascal Dohmen; Willem Flameng
Background: We investigated the effect of transmyocardial laser revascularization (TMR) on myocardial function and regional blood flow in an animal model of ischemic heart disease. Methods: Chronic ischemia was induced in 11 sheep by the application of coronary stenosis on the left anterior descending (LAD) and circumflex coronary artery (LCX). Ten weeks later, in six of them, transmyocardial channels were
Effect of transmyocardial laser revascularization on chronic ischemic hearts in sheep
Shigeyuki Ozaki; Bart Meyns; Rozalia Racz; Eric Verbeken; Veerle Leunens; Pascal Dohmen; Willem Flameng
Background: We investigated the effect of transmyocardial laser revascularization (TMR) on myocardial function and regional blood flow in an animal model of ischemic heart disease. Methods: Chronic ischemia was induced in 11 sheep by the application of coronary stenosis on the left anterior descending (LAD) and circumflex coronary artery (LCX). Ten weeks later, in six of them, transmyocardial channels were
Outcomes of Patients With Chronic Renal Insufficiency in the Bypass Angioplasty Revascularization Investigation
L. A. Szczech; P. J. Best; E. Crowley; M. M. Brooks; P. B. Berger; V. Bittner; B. J. Gersh; R. Jones; R. M. Califf; H. H. Ting; P. J. Whitlow; K. M. Detre; D. Holmes
Background—Although severe chronic kidney disease (CKD) is an independent predictor of mortality among patients with coronary artery disease, the impact of mild CKD on morbidity and mortality has not been fully defined. Methods and Results—Morbidity and mortality for the 3608 patients with multivessel coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation randomized trial and registry were compared on
Coronary flow reserve evaluation: basics, techniques and clinical applications.
De Rosa, R; Piccolo, R; Cassese, S; Petretta, A; D'Andrea, C; D'Anna, C; Piscione, F; Chiariello, M
Coronary flow reserve is a useful physiologic parameter providing information on coronary stenoses severity. To date, the gold standard to evaluate coronary flow reserve consists of fractional flow reserve (FFR) measurement, assessed with a pressure-wire. The FFR has a high lesion specificity, due to insensitivity to patient hemodynamic status and to coronary microvascular resistance; it shows low inter- and intraindividual variability and a well-defined, bound cut-off range values (0.75-0.80). Several reports confirmed that FFR has high reproducibility and feasibility in patients with either single- or multi-vessel coronary artery disease, or with both stable and instable coronary artery disease and that is significantly associated with patient outcome. More recently, the FFR has been used as a sensitive marker of successful percutaneous coronary intervention, since postprocedural FFR value strongly predicts patients event-free survival rate after angioplasty. Moreover, it has been demonstrated that abnormal FFR ratios can be also associated with diffused atherosclerotic coronary artery disease in the absence of unique angiographically detectable stenoses requiring revascularization. There are strong evidences supporting that the FFR provides crucial functional information that could be related with morphological endovascular ultrasound findings, with the possibility to achieve same information in a cheaper, easier and more available manner. This review will focus on the current available literature regarding coronary flow reserve quantification and its clinical validation, suggesting and highlighting its current and future clinical applications. PMID:19946255
Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy
Koul, Sasha; Roijer, Anders; Holmqvist, Jasminka; Keussen, Inger; Cwikiel, Wojciech; Öhlin, Bertil; Erlinge, David
Patent foramen ovale (PFO) is present in approximately 25% of the general population. PFO is characterized by intermittent shunting of blood from the right to the left atrium, especially in the context of increased right-sided filling pressures, with risk of paradoxical embolism. We describe a 69-year-old woman presenting with acute chest pain, severe dyspnoea, and acute inferolateral ST-segment elevation on the electrocardiogram. The patient was diagnosed with myocardial infarction and failure of the right cardiac ventricle, which was considered to be secondary to extensive pulmonary embolism leading to increased filling pressures and paradoxical coronary embolism. The patient underwent emergent percutaneous interventions with coronary thrombus extraction and pulmonary thrombus fragmentation and local thrombolysis. The patient was free of symptoms at follow up 6 months later and echocardiography showed substantially improved right ventricular function. We discuss issues related to the diagnosis, treatment, and secondary prevention for patients with concomitant pulmonary and coronary arterial thrombosis. PMID:24222822
Transthoracic coronary flow reserve and dobutamine derived myocardial function: a 6-month evaluation after successful coronary angioplasty
Cicala, Silvana; Galderisi, Maurizio; Guarini, Pasquale; D'Errico, Arcangelo; Innelli, Pasquale; Pardo, Moira; Scognamiglio, Giancarlo; de Divitiis, Oreste
After percutaneous transluminal coronary angioplasty (PTCA), stress-echocardiography and gated single photon emission computerized tomography (g-SPECT) are usually performed but both tools have technical limitations. The present study evaluated results of PTCA of left anterior descending artery (LAD) six months after PTCA, by combining transthoracic Doppler coronary flow reserve (CFR) and color Tissue Doppler (C-TD) dobutamine stress. Six months after PTCA of LAD, 24 men, free of angiographic evidence of restenosis, underwent standard Doppler-echocardiography, transthoracic CFR of distal LAD (hyperemic to basal diastolic coronary flow ratio) and C-TD at rest and during dobutamine stress to quantify myocardial systolic (Sm) and diastolic (Em and Am, Em/Am ratio) peak velocities in middle posterior septum. Patients with myocardial infarction, coronary stenosis of non-LAD territory and heart failure were excluded. According to dipyridamole g-SPECT, 13 patients had normal perfusion and 11 with perfusion defects. The 2 groups were comparable for age, wall motion score index (WMSI) and C-TD at rest. However, patients with perfusion defects had lower CFR (2.11 ± 0.4 versus 2.87 ± 0.6, p < 0.002) and septal Sm at high-dose dobutamine (p < 0.01), with higher WMSI (p < 0.05) and stress-echo positivity of LAD territory in 5/11 patients. In the overall population, CFR was related negatively to high-dobutamine WMSI (r = -0.50, p < 0.01) and positively to high-dobutamine Sm of middle septum (r = 0.55, p < 0.005). In conclusion, even in absence of epicardial coronary restenosis, stress perfusion imaging reflects a physiologic impairment in coronary microcirculation function whose magnitude is associated with the degree of regional functional impairment detectable by C-TD. PMID:15581428
Successful use of the Impella Recover LP 5.0 device for circulatory support during off-pump coronary artery bypass grafting
Pepino, Paolo; Coronella, Germano; Oliviero, Piermario; Monaco, Mario; Schiavone, Vincenzo; Finizio, Filippo; Biondi-Zoccai, Giuseppe; Frati, Giacomo; Giordano, Arturo
INTRODUCTION Surgical coronary revascularization is being performed with ever increasing frequency in patients at high surgical risk. Off-pump coronary artery bypass grafting (OPCABG) is particularly appealing in such subjects, but may limit the options for concomitant mechanical circulatory support. PRESENTATION OF CASE We hereby report an original case of mechanical circulatory support with the Impella Recover LP 5.0 device during OPCABG in a 61-year-old gentleman with multiple comorbidities and severe left ventricular systolic dysfunction. Specifically, the soft tipped device did not impede surgical manipulation of the heart during the surgical procedure, providing uninterrupted circulatory support to the patient. DISCUSSION This clinical vignette supports the feasibility, safety and efficacy of the Impella Recover LP 5.0 device in patients undergoing OPCABG. CONCLUSION Pending further studies, use of the Impella Recover LP 5.0 device can be envisioned safely for OPCABG. PMID:25305600
Sudden cardiac death after coronary artery bypass grafting is not predicted by signal-averaged ECG
Christoph Scharf; Hermann Redecker; Firat Duru; Reto Candinas; Hans Peter Brunner-La Rocca; Andreas Gerber; Osmund Bertel; Marko I Turina; Wolfgang Kiowski
Background. Sudden cardiac death (SCD) is a major cause of death despite successful revascularization in patients with coronary artery disease. The signal-averaged ECG (SAECG) is a sensitive predictor of SCD and could be used in the screening strategy to select patients for prophylactic cardioverter implantation.Methods. The SAECG was recorded in 561 patients (mean age: 60 ± 8.8 years) within 10
Microvascular function/dysfunction downstream a coronary stenosis.
Guarini, Giacinta; Capozza, Paola Giuseppina; Huqi, Alda; Morrone, Doralisa; Chilian, William M; Marzilli, Mario
For decades coronary macrovascular atherosclerosis has been considered the principal manifestation of coronary heart disease, with most of our effort dedicated to identifying and removal of coronary stenosis. However, growing body of literature indicates that coronary microcirculation also contributes substantially to the pathophysiology of cardiovascular disease. An understanding of mechanisms regulating microvascular function is of critical importance in understanding its role in disease, especially because these regulatory mechanisms vary substantially across species, vascular bed and due to comorbidities. Indeed, the most obvious consequence of coronary stenosis is that it may limit blood supply to the dependent myocardium to the point of causing ischaemia during exercise or even at rest. However, this flow limiting effect is not only due to the passive hydraulic effect of a narrowed conduit, but also to active responses in the coronary microcirculation triggered by the presence of an epicardial stenosis. To understand this problem it is important to review the inter-related mechanisms that regulate flow to the left ventricular wall and modulate transmural distribution of flow. These regulatory mechanisms operate hierarchically and are heterogeneously distributed along the coronary vascular tree. It is also important to discuss the effect of myocardial performance in modulating both blood flow demands and coronary resistance. Some of the interactions between coronary stenosis and microcirculation are transient, like those documented in acute coronary syndromes or during percutaneous interventions. However, microcirculatory remodeling may be triggered by a chronic coronary stenosis, leading to a sustained impairment of blood supply even after successful removal of the epicardial stenosis. A deeper understanding of these phenomena may explain paradoxical findings in patients undergoing coronary revascularization, particularly when functional tests are used in their assessment. These aspects are discussed in detail in this review. PMID:23173585
Current status and future directions in computer-enhanced video- and robotic-assisted coronary bypass surgery.
Boyd, W Douglas; Kodera, Kojiro; Stahl, Kenneth D; Rayman, Reiza
Since 1997, both the Cleveland Clinic and London Health Sciences Centre groups have embraced robotic assistance and more recently demonstrated the efficacy of this technology in totally closed-chest, beating heart myocardial revascularization. This endeavor involved an orderly progression and the learning of new surgical skill sets. We review the evolution of robot-enhanced coronary surgery and forecast the future of endoscopic and computer-enhanced, robotic-enabling technology for coronary revascularization. This report describes a computer-assisted totally closed-chest coronary bypass operation, and preliminary results are discussed. The internal thoracic artery (ITA) was harvested through three 5-mm access ports and prepared and controlled endoscopically. A prototype sternal elevator was used to increase intrathoracic working space. A 10-mm endoscopic stabilizer was placed through the second intercostal space, and the left anterior descending coronary artery was controlled with silastic snares. Telerobotic anastomoses were completed end-to-side using custom-made, double-armed 8-0 polytetrafluroethylene sutures. To date, 84 patients have undergone successful myocardial revascularization with robotic assistance with a 0% surgical mortality rate. ITA harvest, anastomotic, and operating times for the entire group have been longer than for conventional surgery at 61.3 +/- 17.9 minutes, 28.5 +/- 28.2 minutes, and 368 +/- 129 minutes, respectively. Bleeding, ventilatory times, arrhythmias, hospital lengths of stay, and return to normal activity have been reduced. Recently, we have developed a new robotic revascularization strategy called Atraumatic Coronary Artery Bypass that is a promising mid-term step on the pathway to totally endoscopic, beating-heart coronary artery bypass. We conclude that computer-enhanced robotic techniques are safe, and further clinical studies are required to define the full potential of this evolving technology. PMID:11977023
A case of complete revascularization with nine sirolimus eluting stents.
Bardhan, A K; Khan, Aftab
Patients with multivessel disease and LV dysfunction are conventionally treated with coronary artery bypass surgery. With the advent of drug eluting stents, complex lesions are now being tackled percutaneously. The ARTS II registry demonstrated the efficacy and safety of sirolimus-eluting stents (SES) in patients with multivessel disease. We report a case of "complete revascularization" with 9 sirolimus-eluting stents in a patient with multivessel disease and LV dysfunction with an angiographic evaluation at 6 months and 1 year. PMID:19218726
Refractory angina pectoris in end-stage coronary artery disease: Evolving therapeutic concepts
Frank C. Schoebel; O. Howard Frazier; Gilian A. J. Jessurun; Mike J. L. De Jongste; Kamuran A. Kadipasaoglu; Thomas W. Jax; Matthias P. Heintzen; Denton A. Cooley; Bodo E. Strauer; Matthias Leschke
Refractory angina pectoris in coronary artery disease is defined as the persistence of severe anginal symptoms despite maximal conventional antianginal combination therapy. Further, the option to use an invasive revascularization procedure such as percutaneous coronary balloon angioplasty or aortocoronary bypass grafting must be excluded on the basis of a recent coronary angiogram. This coronary syndrome, which represents end-stage coronary artery
Off-pump myocardial revascularization in a high-risk patient with essential thrombocythemia.
Darwazah, Ahmad K; Madi, Hamad; Zagha, Rami; Hawash, Yahia
Essential thrombocythemia is a rare type of myeloproliferative disorder. Cerebral, myocardial, and peripheral thrombosis are all frequent complications of the disease. A 71-year-old man presented with severe coronary artery disease, associated with cerebral vascular ischemic changes and erythromelalgia. His platelet count was 1,486 ×10(3)/?L. The patient underwent successful myocardial revascularization by means of an off-pump technique after his platelet count had been reduced by hydroxycarbamide administration. We conclude that the use of off-pump cardiopulmonary bypass in high-risk patients with essential thrombocythemia is safe. Reducing platelet count via the administration of hydroxycarbamide and the careful balancing of antiplatelets and anticoagulants is crucial in determining the outcome of surgery. PMID:25425991
Off-Pump Myocardial Revascularization in a High-Risk Patient with Essential Thrombocythemia
Darwazah, Ahmad K.; Madi, Hamad; Zagha, Rami; Hawash, Yahia
Essential thrombocythemia is a rare type of myeloproliferative disorder. Cerebral, myocardial, and peripheral thrombosis are all frequent complications of the disease. A 71-year-old man presented with severe coronary artery disease, associated with cerebral vascular ischemic changes and erythromelalgia. His platelet count was 1,486 ×103/?L. The patient underwent successful myocardial revascularization by means of an off-pump technique after his platelet count had been reduced by hydroxycarbamide administration. We conclude that the use of off-pump cardiopulmonary bypass in high-risk patients with essential thrombocythemia is safe. Reducing platelet count via the administration of hydroxycarbamide and the careful balancing of antiplatelets and anticoagulants is crucial in determining the outcome of surgery. PMID:25425991
Combined myocardial revascularization and abdominal aortic aneurysm repair.
Hinkamp, T J; Pifarre, R; Bakhos, M; Blakeman, B
Myocardial infarction remains the leading cause of early and late deaths after abdominal aortic reconstruction in patients with abdominal aortic aneurysm. Our approach for the past 4 years has been combined myocardial revascularization with abdominal aortic aneurysm repair in patients with good left ventricle performance. From July 1984 through June 1989, 128 patients underwent abdominal aortic aneurysm repair. Seventeen patients underwent combined abdominal aortic reconstruction with coronary artery bypass grafting. One patient died (5.9%). The remaining patients are all well at current follow-up. Our experience shows that patients with coronary artery disease and abdominal aortic aneurysm may have both lesions safely repaired as a single operative procedure. PMID:1998428
Full myocardial revascularization with bilateral internal mammary artery Y grafts
Naidoo, Rishendran; Byth, Karen; Chen, Cheng; Denniss, A. Robert
Background Bilateral internal mammary artery (BIMA) grafting in coronary artery surgery provides better long term outcomes than single internal mammary artery and saphenous vein grafting but the optimum configuration of BIMAs has not been established. This study analyzed perioperative and late outcomes of patients who underwent BIMA grafting with a composite Y configuration. Methods Patients (n=922) who underwent BIMA Y grafting were identified from a cardiac surgical database and then cross matched against hospital and cardiology databases and the state death register to identify episodes of repeat coronary angiography, cardiac surgical re-intervention and death. Analysis of repeat angiography was performed after retrieval of the angiogram reports. Results In 95% of patients, full myocardial revascularization was achieved with BIMAs alone, using a composite Y configuration with an average of 4.1 IMA to coronary artery anastomoses per patient. The perioperative mortality was 1.5% and the 5-, 10- and 15-year survival estimates were 95%, 87% and 77% respectively. Analysis of 166 symptom-driven post-discharge coronary angiograms showed grafts to the left anterior descending artery and increasing severity of coronary artery stenosis at preoperative angiography as predictors of anastomotic patency. Conclusions Full myocardial revascularization can be achieved with reasonable safety in most patients with triple vessel disease and good left ventricular function, and provides good late survival. PMID:23977621
The history of arterial revascularization: from Kolesov to Tector and beyond
Galvin, Sean D.
Coronary artery bypass grafting (CABG) is the one of the most effective revascularization strategies for patients with obstructive coronary artery disease. Total arterial revascularization using one or both internal thoracic and radial arteries has been shown to improve early outcomes and reduce long-term cardiovascular morbidity. Although CABG has evolved from an experimental procedure in the early 1900's to become one of the most commonly performed surgical procedures, there is still significant variation in grafting strategies amongst surgeons. We review the history and development of CABG with a particular emphasis on the early pioneers and the evolution of arterial grafting. PMID:23977617
The Potential Impact of Functional Imaging on Decision Making and Outcome in Patients Undergoing Surgical Revascularization.
Plass, Andre; Goetti, Robert P; Emmert, Maximilian Y; Caliskan, Etem; Stolzmann, Paul; Wieser, Monika; Donati, Olivio; Alkadhi, Hatem; Falk, Volkmar
Objective?Coronary angiography (CA) remains the standard for preoperative planning for surgical revascularization. However, besides anatomical imaging, current guidelines recommend additional functional imaging before a therapy decision is made. We assess the impact of functional imaging on the strategy of coronary artery bypass grafting (CABG) with particular regards on postoperative patency and myocardial perfusion. Methods?After CA, 55 patients (47 males/8 females; age: 65.1?±?9.5 years) underwent perfusion cardiovascular magnetic resonance (CMR) and dual-source computed tomography (DSCT) before isolated CABG (n?=?31), CABG and concomitant valve surgery (valve?+?CABG; n?=?10) and isolated valve surgery (n?=?14; control). DSCT was used for analysis of significant stenosis, CMR for myocardial-perfusion to discriminate between: no ischemia (normal), ischemia, or scar. The results, unknown to the surgeons, were compared with CA and related to the location and number of distal anastomoses. Nineteen CABG patients underwent follow-up CMR and DSCT (FU: 13?±?3 months) to compare the preop findings with the postop outcomes. Results?Thirty-nine patients either received CABG alone (n?=?31) or a combined procedure (n?=?10) with a total of 116 distal anastomoses. DSCT was compared with CA regarding accuracy of coronary stenosis and showed 91% sensitivity, 88% specificity, and negative/positive predictive values of 89/90%. In total, 880 myocardial segments (n?=?55, 16 segments/patient) were assessed by CMR. In 17% (149/880) of segments ischemia and in 8% (74/880) scar tissue was found. Interestingly, 14% (16/116) of bypass-anastomoses were placed on non-ischemic myocardium and 3% (4/116) on scar tissue. In a subgroup of 19 patients 304 segments were evaluated. Thirty-nine percent (88/304) of all segments showed ischemia preoperatively, while 94% (83/88) of these ischemic segments did not show any ischemia postoperatively. In regard to performed anastomoses, 79% of all grafts (49/62) were optimally placed, whereas 21% (13/62) were either placed into non-ischemic myocardium or scar tissue, including 10% occluded grafts (6/62). Conclusion?In the whole cohort analysis, 17% of grafts were placed in regions with either no ischemia or scar tissue. The subgroup analysis revealed that 94% of all ischemic segments were successfully revascularized after CABG. Thus, functional imaging could be a promising tool in preoperative planning of revascularization strategy. Avoidance of extensive and unnecessary grafting could further optimize outcomes after CABG. PMID:25463355
[Internal carotid artery revascularization].
Mas, Jean-Louis
Carotid endarterectomy remains the standard revascularization technique for the prevention of ischemic stroke resulting from severe carotid stenosis. Surgery is highly beneficial in patients with a symptomatic stenosis of 70% or greater that is not a total or near-total occlusion. The benefit becomes more diluted in patients with a symptomatic 50-69% stenosis, and surgery has no effect, or even increases the risk of stroke, in those with a less than 50% stenosis. Surgery has also been shown to reduce the risk of stroke in asymptomatic patients with a 60-99% stenosis, but the absolute benefit is only 1% per year. There is no clear evidence that surgery benefits asymptomatic women at 5-year follow-up, and the benefit is unknown in asymptomatic patients aged over 75 years. Decision-making must take individual factors into consideration, particularly in patients with an asymptomatic (60-99%) or a moderate (50-69%) symptomatic carotid stenosis, so that the risk-benefit ratio of surgery can be optimized. Current data do not support the preferential use of carotid stenting over carotid endarterectomy in patients with a symptomatic or asymptomatic carotid stenosis who are good candidates for surgery. In those who are not good surgical candidates, carotid stenting might be equivalent to surgery, but whether or not any form of carotid revascularization is superior to medical treatment alone remains unknown. PMID:17688855
Predicting successful percutaneous coronary intervention in patients with chronic total occlusion: the incremental value of a novel morphological parameter assessed by computed tomography.
Chen, Yang; Lu, Bin; Hou, Zhi-Hui; Gao, Yang; Yu, Fang-Fang; Yin, Wei-Hua; Wang, Zhi-Qiang
To study the relationship between percutaneous coronary intervention (PCI) success and various morphological index evaluated by coronary computed tomography angiography (CCTA) in patients with coronary chronic total occlusion (CTO). 272 Consecutive patients with 281 CTO lesions diagnosed by CCTA and invasive coronary angiography were prospectively enrolled. The luminal attenuation of proximal segment of CTO lesions was measured. Other parameters, like lesion length, coronary calcium score, torturous course, stump morphology were also recorded. The attenuation of the proximal segment of CTO lesions was significantly higher in PCI failure group than it was in PCI success group (88 ± 19.7 vs. 70.2 ± 13, p < 0.001). Lesion length in PCI failure group was longer than those in PCI success group (20.4 ± 11.2 vs. 15.1 ± 5.85 mm, p < 0.001) and lesions in PCI failure group were more heavily calcified than lesions in PCI success group (Agatston score 61 vs. 5.7, p < 0.001). The attenuation of the proximal segment of CTO lesions, along with occlusion length and total coronary calcium score were significant independent predictors of PCI failure. The attenuation of the proximal segment of CTO lesions, along with occlusion length and total coronary calcium score as assessed by CCTA have predictive value for PCI outcomes. PMID:25982175
Effect of surgical revascularization of a right coronary artery tributary of an infarcted nonischemic territory on the outcome of patients with three-vessel disease: a prospective randomized trial
Mario Gaudino; Francesco Alessandrini; Franco Glieca; Nicola Luciani; Carlo Cellini; Claudio Pragliola; Mauro Morelli; Fabiana Girola; Gianfederico Possati
BackgroundWe evaluated the in-hospital and long-term effects of surgical grafting of a dominant graftable right coronary artery tributary of an infarcted nonischemic territory in patients with triple-vessel disease who were undergoing coronary artery bypass grafting.
Successful management of Ellis type III left anterior descending artery perforation following percutaneous coronary intervention by a covered stent: Successfully resolved the dramatic complication
Srinivas, Sunil Kumar; Patra, Soumya; Ramalingam, Rangaraj; Agrawal, Navin; Syed, Tanveer; Shankarappa, Ravindranath K.; Manjunath, Cholenahalli Nanjappa
Coronary artery perforation is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Grade III coronary perforation and rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. Advances in coronary intervention have increased the opportunity to treat coronary artery perforation. We are reporting a case of 55 years old hypertensive female who presented with effort angina. Coronary angiogram revealed significant stenosis in the left anterior descending coronary artery. Post PCI, she had Ellis type III coronary perforation and pericardial tamponade and cardiogenic shock. The patient was resuscitated, pericardiocentesis done, autologous blood transfusion given and covered stent deployed. PMID:24653590
The history and development of direct coronary surgery without cardiopulmonary bypass.
Thanikachalam, Mohan; Lombardi, Pierluca; Tehrani, Hassan Y; Katariya, Kushagra; Salerno, Tomas A
The history of direct myocardial revascularization without cardiopulmonary bypass dates to 1961 in the dawn of coronary artery surgery. With the introduction and development of techniques of extracorporeal circulation around the same time, beating heart surgery was largely abandoned. Over the subsequent decades, cardiopulmonary bypass and electromechanical cardioplegic arrest became popular as means of revascularization in a bloodless and motionless field. While coronary artery surgery on the arrested heart remained undisputed for decades, myocardial revascularization on the beating heart was pursued by a few pioneering surgeons around the world, based on the belief that coronary revascularization could be performed equally well without the detrimental effects of cardiopulmonary bypass and electromechanical arrest. Various concepts and techniques developed during the 1980s by these pioneers enabled minimally invasive coronary surgery to be performed in the early 1990s. This break from the mainstream allowed selective myocardial revascularization using a minimal incision and no cardiopulmonary bypass to develop and constructed a base for future extensive revascularizations off-pump. With the subsequent explosion of new techniques for coronary exposure and myocardial stabilization, complete revascularization without cardiopulmonary bypass became possible with consistent results. Emerging from the preview of only a few surgeons just a decade ago, off-pump surgery is currently one of the accepted modalities for complete myocardial revascularization worldwide. This paradigm shift in the approach to myocardial revascularization has led to exiting new future possibilities, such as beating heart totally endoscopic coronary artery surgery. PMID:15548184
Sex Differences in Revascularization
Peter W. Groeneveld; William A. Ghali
TO THE EDITOR: The excellent study of sex and coronary revascu- larization by Ghali and colleagues (1) highlights an important ques- tion facing those who use observational data to investigate ethnic and gender disparities: Are administrative databases sufficiently detailed to control for potential confounders in the relationship of ethnicity and sex to health outcomes? Ghali and colleagues found that the
Myocardial Perfusion Abnormalities Early (12–24 h) after Coronary Stenting or Balloon Angioplasty: Implications Regarding Pathophysiology and Late Clinical Outcome
Ronen Jaffe; Simona Ben Haim; Basheer Karkabi; Avi Front; Sara Gips; Giora Weisz; Nader Khader; Amnon Merdler; Moshe Y. Flugelman; David A. Halon; Basil S. Lewis
Objective: We prospectively examined the prevalence of reversible perfusion defects on very early (12–24 h) thallium-201 single photon emission computed tomography (SPECT) scintigraphy after angiographically successful percutaneous coronary intervention (PCI) by stenting and\\/or stand-alone balloon angioplasty and the predictive value of these defects for late target lesion revascularization (TLR). Patients and Methods: 83 consecutive patients undergoing PCI for 88 lesions
Characteristics of coronary heart disease in renal transplant recipients.
Pirat, B; Müderrisoglu, H; Korkmaz, M E; Ozin, B
The aim of this study was to identify the characteristics of coronary heart disease (CHD) in renal transplant recipients as well as to assess the impact of coronary angiography on allograft function. The 21 cases including 2 women and 19 men who underwent coronary angiography were retrospectively studied for age at transplantation and at diagnosis of coronary disease; risk factors; angio findings; serum creatinine and blood urea nitrogen (BUN) values before and after angio; and revascularization procedures. The mean ages at transplantation and at diagnosis were 40 +/- 7 years and 44 +/- 7 years, respectively. Eighteen patients (86%) had hypertension, 16 (76%) exhibited hyperlipidemia, and 5 (24%) diabetes mellitus. Coronary angiography revealed three-vessel disease in 10 patients, two-vessel disease in 3 patients, one-vessel disease in 4 patients, ectatic vessels in 2 patients, and normal coronary arteries in 2 patients. The mean serum creatinine and BUN levels after angio were not significantly different from the baseline values (pre creatinine and BUN 1.7 +/- 0.5 mg/dL and 33.8 +/- 8.6 mg/dL versus post 1.8 +/- 0.6 mg/dL and 32.8 +/- 10.0 mg/dL, respectively). Ten patients with three-vessel disease underwent coronary artery bypass surgery; 4 patients, coronary angioplasty. The other patients received medical therapy. The study showed an increased likelihood of three-vessel disease among recipients compared with the general population and confirmed that coronary artery bypass surgery may be performed successfully in these patients. In conclusion coronary angiography is a safe diagnostic procedure with respect to allograft function. PMID:15013330
Revascularization in Severe Left Ventricular Dysfunction: Does Myocardial Viability Even Matter?
Singh, Pahul; Sethi, Nishant; Kaur, Navneet; Kozman, Hani
Left ventricular dysfunction is a powerful prognostic predictor in patients with coronary artery disease and increasing number of patients with CAD and ischemic left ventricular (LV) dysfunction is a major clinical problem. Congestive heart failure is a frequent complication which is associated with significant health care costs and two–third of cases have ischemic cardiomyopathy. In such patients, coronary revascularization can lead to symptomatic and prognostic improvement and reversal of LV remodeling which led to the concept of viable myocardium to select patients in whom recovery of LV function and improvement of prognosis will outweigh the risk of surgical revascularization. The aim of this review article is to understand the different modalities for assessing myocardial viability and clinical impact of revascularization in relation to the evidence of viability in patients with LV dysfunction. PMID:26157339
Surgical Revascularization for Ischemic Cardiomyopathy in the Post-STICH Era.
Khera, Sahil; Panza, Julio A
Coronary artery disease (CAD) accounts for significant morbidity and mortality in the United States and most developed countries. Patients with heart failure secondary to CAD have demonstrable poorer outcomes compared with those patients with heart failure because of other causes. Even when the causative relationship between CAD and systolic dysfunction can be unequivocally established, the controversy of revascularization in patients with ischemic cardiomyopathy continues to challenge clinicians. The potential benefit of revascularization has to be weighed against the higher operative and postoperative mortality of coronary artery bypass graft surgery in patients with very low ejection fraction and the possible futility of a high-risk intervention in certain patients. This review focuses on the role of surgical revascularization in patients with ischemic cardiomyopathy in light of data emerging from the original Surgical Treatment for Ischemic Heart Failure trial and its substudies, with an emphasis on the clinical implications for patient selection. PMID:25715329
Coronary artery bypass grafting after orthotopic heart transplantationq
M. Muscia; M. Pasic; R. Meyer; E. Wellnhoferb Loebe; Y. Weng
Objective: Graft coronary disease (GCD) remains the major determinant of long-term survival after heart transplantation. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited, and palliative surgical coronary revascularization has been attempted. The aim of this report was to retrospectively analyze our results of coronary artery bypass grafting after cardiac transplanta- tion. This paper
Coronary artery bypass grafting after orthotopic heart transplantation
M. Musci; M. Pasic; R. Meyer; M. Loebe; E. Wellnhofer; Y. Weng; H. Kuppe; R. Hetzer
Objective: Graft coronary disease (GCD) remains the major determinant of long-term survival after heart transplantation. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited, and palliative surgical coronary revascularization has been attempted. The aim of this report was to retrospectively analyze our results of coronary artery bypass grafting after cardiac transplantation. This paper correlates
Role of radionuclide cardiac imaging in coronary artery bypass surgery
Iskandrian, A.S.; Heo, J.; Mostel, E.
The main applications of cardiac nuclear imaging in coronary artery bypass surgery include: patient selection, prediction of improvement in resting LV function after revascularization, diagnosis of perioperative myocardial infarction, assessment of the results of revascularization, evaluation of new or recurrent symptoms, and in risk stratification. Proper understanding of which test to be used, when, and why may be important to optimize patient management.
[Successful eculizumab treatment for multiple coronary thrombosis complicated in paroxysmal nocturnal hemoglobinuria].
Taniguchi, Ayuko; Ikezoe, Takayuki; Takeuchi, Asako; Togitani, Kazuto; Yoshimoto, Mitsuhiro; Tanioka, Katsutoshi; Kitaoka, Hiroaki; Yokoyama, Akihito
We herein report a rare case of paroxysmal nocturnal hemoglobinuria (PNH) who repeatedly developed coronary arterial thromboembolism. Anticoagulant therapies including heparin, aspirin as an antiplatelet agent and even drug-eluting stent placement in the coronary artery failed to prevent the recurrence of ischemic heart disease. Of note, initiating the administration of a humanized anti-C5 antibody, eculizumab, achieved prompt thrombolysis and maintenance treatment with eculizumab prevented the recurrence of thromboembolic disease in this patient. Taking these observations together, we suggest that the use of eculizumab be considered for treatment or prevention of arterial thrombosis complicated by PNH, although arterial thrombosis is an extremely rare event in the Japanese population. PMID:25186487
Recurrent angina after coronary angioplasty: mechanisms, diagnostic and therapeutic options
Izzo, Paolo; Macchi, Andrea; De Gennaro, Luisa; Gaglione, Antonio; Di Biase, Matteo
Recurrent angina in patients who underwent percutaneous coronary intervention is defined as recurrence of chest pain or chest discomfort. Careful assessment is recommended to differentiate between non-cardiac and cardiac causes. In the case of the latter, recurrent angina occurrence can be related to structural ('stretch pain', in-stent restenosis, in-stent thrombosis, incomplete revascularization, progression of coronary atherosclerosis) or functional (coronary micro-vascular dysfunction, epicardial coronary spasm) causes. Even though a complete diagnostic algorithm has not been validated, ECG exercise testing, stress imaging and invasive assessment of coronary blood flow and coronary vaso-motion (i.e. coronary flow reserve, provocation testing for coronary spasm) may be required. When repeated coronary revascularization is not indicated, therapeutic approaches should aim at targeting the underlying mechanism for the patient's symptoms using a variety of drugs currently available such as beta-blockers, calcium-channel blockers, ivabradine or ranolazine. PMID:24062904
Transmyocardial laser revascularization. Does it have a role in the treatment of ischemic heart disease?
Frazier, O H; Kadipasaoglu, K A; Cooley, D A
Transmyocardial laser revascularization, with or without coronary artery bypass grafting, is an alternative modality for complete revascularization in selected patients with coronary artery disease. Arguably, this modality works by shunting left ventricular blood directly into the ischemic myocardium via laser-mediated transmural channels. In clinical trials, drilling of laser channels has been strongly correlated with long-term improvement of angina, but a causal relationship has not yet been documented. For now, the usefulness of transmyocardial laser revascularization and the nature of its mechanism remain controversial. Some researchers question the existence of myocardial sinusoids altogether. Others question the physiologic possibility of moving blood from the left ventricular cavity into the myocardium against a pressure gradient. Further questions concern the possible routes through which the additional blood gains access to the myocardium; the difficulty of objectively documenting improved myocardial perfusion after transmyocardial laser revascularization; and the nature of the mechanism responsible for the observed clinical benefit. This article examines the different aspects of this controversy and discusses the current status of transmyocardial laser revascularization, as well as possible future directions. PMID:9566059
A comparison of directional atherectomy with coronary angioplasty in patients with coronary artery disease
Eric J. Topol; Ferdinand Leya; Cass A. Pinkerton; Patrick L. Whitlow; Berthold Hofling; Charles A. Simonton; Ronald R. Masden; Patrick W. Serruys; Martin B. Leon; David O. Williams; Spencer B. King; B. Daniel; D. B. Mark; J. M. Isner; D. R. Holmes; S. G. Ellis; K. L. Lee; G. P. Keeler; L. G. Berdan; T. Hinohara; R. M. Califf
BACKGROUND. Directional coronary atherectomy is a new technique of coronary revascularization by which atherosclerotic plaque is excised and retrieved from target lesions. With respect to the rate of restenosis and clinical outcomes, it is not known how this procedure compares with balloon angioplasty, which relies on dilation of the plaque and vessel wall. We compared the rate of restenosis after
Concomitant subclavian and coronary artery disease
Thomas J Takach; George J Reul; Igor Gregoric; Zvonimer Krajcer; J. Michael Duncan; James J Livesay; Denton A Cooley
Background. Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia.Methods. We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between
Left subclavian artery stenting: an option for the treatment of the coronary-subclavian steal syndrome
de Almeida, Bruno Lorençăo; Kambara, Antonio Massamitsu; Rossi, Fabio Henrique; Moreira, Samuel Martins; de Oliveira, Eduardo Silva Jordao; Linhares Filho, Frederico Augusto de Carvalho; Metzger, Patrick Bastos; Passalacqua, Aldo Zampieri
Introduction The subclavian steal syndrome is characterized by the vertebral artery flow inversion, due to a stenotic lesion in the origin of the subclavian artery. The Coronary-subclavian Steal Syndrome is a variation of the Subclavian Steal Syndrome and is characterized by inversion of flow in the Internal Thracic artery that has been used as conduct in a myocardial revascularization. Its diagnosis must be suspected in patients with difference in pulse and arterial pressure in the upper limbs, that present with angina pectoris and that have done a myocardial revascularization. Its treatment must be a surgical bypass or a transluminal angioplasty. Objective The objective is to show the left subclavian artery stenting as a safe and effective method to treat the coronary-subclavian steal syndrome. Methods Historical prospective, non-randomized trial, through revision of the hospital records of the patients treated with the stenting of the left subclavian artery, from January 2006 to September 2012. Results In the mentioned period, 4.291 miocardial revascularizations were performed with the use of the left mammary artery, and 16 patients were identified to have the Coronary-subclavian steal syndrome. All of them were submitted to endovascular treatment. The success rate was 100%; two patients experienced minor complications; none of them presented with major complications. Eleven of the 16 patients had ultrassonographic documentation of patent stent for at least one year; two patients lost follow up and other two died. Conclusion The stenting of the left subclavian artery is a good option for the treatment of the Coronary-subclavian Steal Syndrome, with high level of technical and clinical success. PMID:25140474
Improvement of left ventricular dysfunction during exercise by walking in patients with successful percutaneous coronary intervention for acute myocardial infarction.
Koizumi, Tomomi; Miyazaki, Akira; Komiyama, Nobuyuki; Sun, Kezhu; Nakasato, Takashi; Masuda, Yoshiaki; Komuro, Issei
A growing body of evidence suggests that walking reduces the incidence of coronary events, so the present study investigated whether walking influences left ventricular function in 30 patients with acute myocardial infarction (AMI) who had undergone successful percutaneous coronary intervention (PCI). The patients were randomly assigned to either a 3-month exercise training program of walking (group W, n=15) or a control group (group C, n=15). At both the beginning and end of the study, patients underwent exercise stress echocardiography to determine left ventricular ejection fraction (LVEF) at rest and during exercise. At baseline, there was no difference in LVEF at rest or during exercise between the two groups. After 3 months, LVEF during exercise was significantly improved compared with at rest in group W (61+/-3% during exercise vs 57+/-5% at rest, p<0.01), whereas no difference was observed between the LVEF at rest and that during exercise in group C (54+/-5% at rest vs 52+/-7% during exercise, NS). Walking may be beneficial for improving left ventricular function during exercise in patients with AMI. PMID:12604873
The age, creatinine, and ejection fraction score to risk stratify patients who underwent percutaneous coronary intervention of coronary chronic total occlusion.
Di Serafino, Luigi; Borgia, Francesco; Maeremans, Joren; Pyxaras, Stylianos A; De Bruyne, Bernard; Wijns, William; Heyndrickx, Guy; Dens, Jo; Di Mario, Carlo; Barbato, Emanuele
Age, creatinine, and ejection fraction (ACEF) score predict clinical outcomes in patients who underwent elective percutaneous coronary intervention (PCI) of nonocclusive coronary stenoses. We aimed at assessing the prognostic value of the ACEF score in patients who underwent successful PCI of chronic total occlusion (CTO). ACEF score was calculated in 587 patients treated with PCI of CTO: successful in 433 (74%; success group) and failed in 154 patients (26%; failure group). Patients were divided in ACEF tertiles: first <0.950, second from 0.950 to 1.207, and third ACEF tertile >1.207. Major adverse cardiac events (MACE = overall death + nonfatal myocardial infarction + clinically driven target vessel revascularization) were assessed in 558 patients (95%) up to 24 months (8 to 24 months). In success group, higher MACE rate was significantly associated with increasing ACEF tertile (first = 7%, second = 13%, third ACEF = 18%, p = 0.02). MACE-free survival was significantly decreased with increasing ACEF tertile (log-rank 5.58, p = 0.018). In the failure group, lower MACE rate was significantly associated with increasing ACEF tertile (p = 0.041). This was mainly driven by significant decreasing rate of target vessel revascularization along the tertiles (first = 34%, second = 19%, third ACEF = 10%, p = 0.007). Compared with success group, in failure group, MACE rate was significantly higher in the first tertile (p <0.001) and similar in the third tertile (p = 0.59). In conclusion, ACEF score represents a simple tool in the prognostication of patients successfully treated with PCI of CTO and identifies those patients who would not derive any significant clinical harm despite failed percutaneous revascularization of the CTO. PMID:25152423
Successful Covering of a Hepatic Artery Aneurysm with a Coronary Stent Graft
Sakai, Hidetsugu; Urasawa, Kazushi; Oyama, Naotsugu; Kitabatake, Akira [Hokkaido University Graduate School of Medicine, Department of Cardiovascular Medicine (Japan)
In a 54-year-old woman with liver cirrhosis who underwent orthotopic liver transplantation, the postoperative course was complicated by aneurysm formation in the hepatic artery. Abdominal ultrasonography showed a daily increase in the size of the aneurysm in spite of careful management including strict rest and continuous intravenous infusion of antihypertensive agents. Since the patient's poor systemic status was a major obstruction to operative resection, transcatheter therapy was thought more preferable. We evaluated the lesion with intravascular ultrasonography as an adjunct to angiography and a dissection with a flap was well visualized. The aneurysm was covered with a commercially available stent-graft, designed for treatment of the coronary artery. This is a rare case in which a Jostent was implanted into the hepatic artery after liver transplantation.
Myocardial revascularization in Jehovah Witnesses.
Seifert, P E; Auer, J E; Hohensee, P
The refusal of certain patients to accept blood transfusions need not be a deterrent to surgery. We report on nine Jehovah's Witnesses who over a one-year period underwent myocardial revascularization without significant blood loss or decrease in hematocrit values. PMID:2786287
Success and Challenges of a Community Healthy Lifestyles Intervention in Merseyside (UK) to Target Families at Risk from Coronary Heart Disease
ERIC Educational Resources Information Center
Peerbhoy, D.; Majumdar, A. J.; Wightman, N. A.; Brand, V. L.
Objective: To document the lifestyle health impacts (activity, diet and physiological), along with the operational success and challenges, of a programme for families presenting one or more coronary heart disease (CHD) risk factor. Design: Data are based on a wider evaluation of a government-funded community initiative conducted in a deprived area…
Changes in Heart Rate Variability Parameters after Elective Percutaneous Coronary Intervention
Abrootan, Saeed; Yazdankhah, Saeed; Payami, Babak; Alasti, Mohammad
Background: Patients with chronic stable angina often have a state of sympathetic hyperactivity. It is considered associated with myocardial ischemia and disappears after ischemia elimination. The aim of this study was to investigate the changes in heart rate variability parameters, a noninvasive technique for the evaluation of the autonomic nervous system activity, after successful revascularization in these patients to evaluate this theory. Methods: The patients were enrolled among those who underwent successful percutaneous coronary intervention. Short-term heart rate variability analyses of all the patients were obtained, and time-domain indices (standard deviation of normal-to-normal intervals [SDNN], standard deviation of differences of successive R-R intervals [SDSD], root-mean square differences of successive R-R intervals [rMSSD], percentage of R-R intervals differing > 10 ms from the preceding one [PNN10], percentage of R-R intervals differing > 20 ms from the preceding one [PNN20], percentage of R-R intervals differing > 30 ms from the preceding one [PNN30], percentage of R-R intervals differing > 40 ms from the preceding one [PNN40], percentage of R-R intervals differing > 50 ms from the preceding one [PNN50], percentage of R-R intervals differing > 60 ms from the preceding one [PNN60], and percentage of R-R intervals differing > 70 ms from the preceding one [PNN70]) were analyzed. All the measurements were made before and after percutaneous coronary intervention. Results: This study included 64 patients, comprising 27 men and 37 women at a mean age of 56.8 ± 9.1 years. There was a significant difference only between pre- and post-revascularization SDNN (27.5 ± 19.72 vs. 41 ± 41.4; p value = 0.013). The other parameters showed no significant differences after successful coronary intervention. Conclusion : Our data indicate that the increase in SDNN in patients with stable angina pectoris undergoing percutaneous coronary intervention seems to be prominent.
Liver abscess following superior mesenteric artery revascularization for acute mesenteric ischemia
Pravin M. Shah; Sateesh C. Babu; Heena P. Rajdeo; Roy H. Clauss
A case of pyogenic liver abscess following successful mesenteric artery revascularization is described in a patient with acute\\u000a mesenteric ischemia. Prior to revascularization, arteriography confirmed celiac and superior mesenteric artery occlusion.\\u000a Occurrence of liver abscess Is explained on the basis of ischemia impairing the barrier function of the intestinal mucosa,\\u000a contributing to portal bacteremia that seeds Ischemic or necrotic liver.
Functional and structural correlates of persistent ST elevation after acute myocardial infarction successfully treated by percutaneous coronary intervention
Galiuto, Leonarda; Barchetta, Sabrina; Paladini, Serena; Lanza, Gaetano; Rebuzzi, Antonio G; Marzilli, Mario; Crea, Filippo
Background In the thrombolytic era, persistence of ST?segment elevation was considered a marker of left ventricular (LV) aneurysm. ST?segment elevation may still be found persistently raised after successful primary percutaneous coronary intervention (PCI). Echocardiographic correlates of this finding, however, are still poorly known. Methods and results 82 consecutive patients with first ST?segment elevation myocardial infarction and successful PCI were divided into patients with persistent ST?segment elevation at discharge (sum of ST >4?mm) (n?=?33) and those without persistent ST?segment elevation (n?=?49). Conventional and myocardial contrast echocardiography were performed at discharge and at 6?months. At discharge, LV aneurysm was more common in patients with persistent ST elevation (27% vs 8%, p<0.005). Similarly, the wall motion score index was higher (2.5 vs 2.0, p<0.005) and microvascular damage larger (2.3 vs 1.8, p<0.005) in patients with persistent ST?segment elevation. At 6?months' follow?up, LV volumes were similar in the two groups. Conclusions After primary PCI, persistent ST?segment elevation is associated with LV aneurysm formation in 30% of cases, it is not associated with significantly larger LV dilatation but with larger microvascular damage and dysfunctioning risk area. PMID:17309911
Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions.
Christakopoulos, Georgios E; Christopoulos, Georgios; Carlino, Mauro; Jeroudi, Omar M; Roesle, Michele; Rangan, Bavana V; Abdullah, Shuaib; Grodin, Jerrold; Kumbhani, Dharam J; Vo, Minh; Luna, Michael; Alaswad, Khaldoon; Karmpaliotis, Dimitri; Rinfret, Stephane; Garcia, Santiago; Banerjee, Subhash; Brilakis, Emmanouil S
Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris. PMID:25784515
Concomitant Occlusive Disease of the Coronary Arteries and Great Vessels
Thomas J Takach; George J Reul; Denton A Cooley; James J Livesay; J. Michael Duncan; David A Ott; Grady L Hallman
Background. Although an increasing number of elderly and high-risk patients, including those with generalized atherosclerosis, are undergoing coronary revascularization, few reports exist regarding the management of patients who have both occlusive disease of the great vessels and coronary artery disease.Methods. Between 1972 and 1996, 31 consecutive patients (mean age, 56.5 years; 74% men) with multivessel coronary artery disease and symptomatic
Sequestered hypoplastic pulmonary lobe supplied by the circumflex coronary artery in a patient with coronary artery disease: a case report.
Marinos, Thomas; Bitzikas, Grigorios; Madesis, Athanasios; Galanos, Othon
Bronchopulmonary sequestrations are usually supplied by single or multiple branches from the descending aorta. We report on a rare form of sequestration of a hypoplastic mid-pulmonary lobe with arterial supply from the circumflex coronary artery coincidentally discovered during coronary angiography in a female patient with coronary artery disease and a history of recurrent hemoptysis. The patient underwent myocardial revascularization and resection of the sequestered lobe in a single-stage approach. PMID:16467062
Incidence and Treatment of Elastic Recoil Occurring in the 15 Minutes Following Successful Percutaneous Transluminal Coronary Angioplasty * * This study was supported by a Training in Cardiovascular Research Grant, NIH 5-T32 HL07360-17, a Texas Affiliate Grant-In-Aid from the American Heart Association, NIH Grant R01HL53225-01 from the National Heart, Lung, and Blood Institute, NIH Ischemic SCOR Grant HL17669, and the Harry S. Moss Heart Fund
William C. Daniel; Mark J. Pirwitz; John E. Willard; Richard A. Lange; L. David Hillis; Charles Landau
This study was performed (1) to assess the incidence and magnitude of elastic recoil occurring within 15 minutes of successful coronary angioplasty, and (2) to determine the effect of subsequent additional balloon inflations on coronary luminal diameter in patients displaying substantial recoil. The coronary angiograms of 50 consecutive patients who underwent a successful percutaneous transluminal coronary angioplasty were analyzed using
Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: A prospective randomized study
Raimondo Ascione; Simon Williams; Clinton T. Lloyd; Thiagarajamirthy Sundaramoorthi; Antonis A. Pitsis; Gianni D. Angelini
Objective: Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement. Methods: Two hundred patients with coronary artery disease
Proteomic profiling of oxidative stress in human victims of traffic-related injuries after lower limb revascularization and indication for secondary amputation
Chih-Hung Lin; Pei-Wen Wang; Tai-Long Pan; Grzegorz Bazylak; Eric Kar-Wai Liu; Fu-Chan Wei
Microsurgical replantation and revascularization are frequently performed to salvage devascularized severe lower-extremity fractures in the human victims of road traffic-related injuries. However, some patients require secondary amputation within 1 week of successful revascularization due to tissue necrosis and sepsis. Enhanced efforts to understand the underlying molecular mechanism of such events are needed and should characterized in depth. Thus, functional proteomics
Midterm follow-up with exclusive use of arterial grafts in complete myocardial revascularization of patients with triple vessel coronary artery disease Seguimento clínico a médio prazo com uso exclusivo de enxertos arteriais na revascularizaçăo completa do miocárdio em pacientes com doença coronária triarterial
Luiz Augusto; F. LISBOA; Luís Alberto; O. DALLAN; Luiz Boro PUIG; Carlos ABREU FILHO; Ricardo Cerquinho LECA; Luís Augusto; P. DALLAN; Sérgio Almeida de OLIVEIRA
Objective: To evaluate the midterm benefits of exclusive use of arterial grafts in patients with triple vessel coronary arteriosclerotic disease who underwent complete coronary artery bypass grafting. Method: Between July 1995 and July 1997, 137 consecutive patients with triple vessel coronary atherosclerotic disease underwent complete coronary artery bypass grafting exclusively using arterial grafts. Of these patients, 112 (81.7%) were male,
Carotid revascularization: risks and benefits
O'Brien, Marlene; Chandra, Ankur
Despite a decline during the recent decades in stroke-related death, the incidence of stroke has remained unchanged or slightly increased, and extracranial carotid artery stenosis is implicated in 20%–30% of all strokes. Medical therapy and risk factor modification are first-line therapies for all patients with carotid occlusive disease. Evidence for the treatment of patients with symptomatic carotid stenosis greater than 70% with either carotid artery stenting (CAS) or carotid endarterectomy (CEA) is compelling, and several trials have demonstrated a benefit to carotid revascularization in the symptomatic patient population. Asymptomatic carotid stenosis is more controversial, with the largest trials only demonstrating a 1% per year risk stroke reduction with CEA. Although there are sufficient data to advocate for aggressive medical therapy as the primary mode of treatment for asymptomatic carotid stenosis, there are also data to suggest that certain patient populations will benefit from a stroke risk reduction with carotid revascularization. In the United States, consensus and practice guidelines dictate that CEA is reasonable in patients with high-grade asymptomatic stenosis, a reasonable life expectancy, and perioperative risk of less than 3%. Regarding CAS versus CEA, the best-available evidence demonstrates no difference between the two procedures in early perioperative stroke, myocardial infarction, or death, and no difference in 4-year ipsilateral stroke risk. However, because of the higher perioperative risks of stroke in patients undergoing CAS, particularly in symptomatic, female, or elderly patients, it is difficult to recommend CAS over CEA except in populations with prohibitive cardiac risk, previous carotid surgery, or prior neck radiation. Current treatment paradigms are based on identifying the magnitude of perioperative risk in patient subsets and on using predictive factors to stratify patients with high-risk asymptomatic stenosis. PMID:25045271
Successful management of a huge thrombus in coronary aneurysmatic dilatation after failed mechanical thrombectomy during acute myocardial infarction.
Ielasi, Alfonso; Anzuini, Angelo
The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have 'failed' thrombectomy, characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 55-year-old man who was admitted to our institution with chest pain non-ST-elevation myocardial infarction due to a huge nonocclusive thrombus in an aneurysmatic segment of the left anterior descending coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with unfractioned heparin infusion and warfarin. Repeat coronary angiography at 7 days revealed complete thrombus resolution with thrombolysis in myocardial infarction grade 3 anterograde flow.This case demonstrates the potential for appropriate anticoagulation therapy as a treatment option for the management of patients following failed thrombectomy in PPCI. PMID:22929567
Below-the-knee revascularization. Advanced techniques.
This review summarizes new developments in revascularization and advanced techniques to treat lesions below the knee (BTK). The primary goal of endovascular therapy is the re-establishment of pulsatile, straight-line flow to the foot. This treatment results in relieving ischemic pain, healing of (neuro)ischemic ulcers, preventing limb loss, improving quality of life and potentially prolong survival. Balloon angioplasty is the currently established therapy, bare-metal stents are reserved for failed percutaneous transluminal angioplasty (PTA). Novel devices such as laser, excisional and rotational atherectomy systems, drug eluting stents or drug coated balloons still lack data demonstrating improved efficacy compared to conventional balloon angioplasty. The typical patient group of complex below-the-knee lesions represents an increasing population due to the increasing prevalence of diabetes and end-stage renal failure. Excellent acute technical success rates above 90%, a low frequency of complications, and high limb salvage rate of about 95% even in patients with long segment and diffuse disease seem to justify a more widespread use of endovascular therapy in tibial arteries. However, the current results of balloon angioplasty studies show a 1-year restenosis rate between 30% for short stenoses treatment and up to 80% following recanalization of an occlusion. PMID:19741578
Single-pulse 30-J holmium laser for myocardial revascularization-a study on ablation dynamics in comparison to CO2 laser-TMR
Ralf Brinkmann; Dirk Theisen; Tobias Brendel; Reginald Birngruber
Endocardial laser revascularization (ELR) is a new technique to treat coronary heart disease in a percutaneous, minimally invasive approach. A holmium laser (?=2.12 ?m) was developed to emit pulse energies of up to 30 J in order to ablate the desired channels in a single laser pulse. The energy was transmitted by multimode flexible optical waveguides as required for ELR.
Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomized controlled trial
Luís Roberto Gerola; Enio Buffolo; Waldir Jasbik; Bruno Botelho; Joăo Bosco; Luís A Brasil; Joăo Nelson R Branco
BackgroundTo evaluate hospital mortality and morbidity after myocardial revascularization in a prospective and multicenter study, comparing on-pump versus off-pump in a special subset of patients with lesions in the left descending artery, alone or associated with the right coronary artery.
Successful percutaneous coronary intervention in a patient with combined deficiency of FV and FVIII due to novel compound heterozygous mutations in LMAN1.
Patel, A J; Liu, H-H; Lager, R A; Malkovska, V; Zhang, B
Percutaneous coronary intervention (PCI) in patients with congenital coagulation factor deficiencies presents a unique challenge. They are not only at increased risk of perioperative bleeding but can also suffer thrombosis of the stent as preventive anticoagulation and antiplatelet therapy is difficult. Several cases of successful PCI have been described in patients with haemophilia A and B, but there are no reports in patients with combined coagulation factor deficiencies. We used PCI to treat the coronary artery disease in a patient with the combined deficiency of factor V and factor VIII (F5F8D) and analysed the molecular basis of the disorder for this patient. A 68-year-old patient was admitted for urgent PCI with bare metal stent placement after the diagnosis of the F5F8D. Peripheral blood DNA was extracted for the sequence analysis of LMAN1 and MCFD2 genes. Mutations in LMAN1 was confirmed by molecular cloning of the PCR product and resequencing of the resulting clones. The patient underwent successful PCI with good long-term outcome. Our patient tolerated anticoagulation therapy well, with unfractionated heparin, and double antiplatelet therapy while he was initially supported with fresh frozen plasma and recombinant FVIII. Molecular analysis revealed that the patient carries unusual compound heterozygous frameshift mutations on the same microsatellite repeat region in exon 8 of LMAN1, one of which is a novel mutation (c.912delA). Our results suggest that patients with F5F8D can safely undergo PCI for coronary artery disease, with the treatment individualized to the specific patient. PMID:23557496
Twenty-year evolution of Percutaneous coronary intervention and its impact on clinical outcomes a report from the NHLBI-sponsored, multicenter 1985–86 Percutaneous transluminal coronary angioplasty and 1997–2006 Dynamic Registries
Venkitachalam, Lakshmi; Kip, Kevin E; Selzer, Faith; Wilensky, Robert L; Slater, James; Mulukutla, Suresh R; Marroquin, Oscar C; Block, Peter C; Williams, David O; Kelsey, Sheryl F
Background Percutaneous coronary intervention has undergone rapid progress both in technology and adjunct therapy. However, documentation of long-term temporal trends in relation to contemporary practice is lacking. Methods and Results We analyzed PCI use and outcomes in 8976 consecutive patients in the multicenter NHLBI-sponsored 1985–86 Percutaneous coronary transluminal coronary angioplasty (PTCA) and 1997–2006 Dynamic Registries waves [wave 1: 1997–98, bare metal stents; wave 2: 1999, uniform use of stents; wave 3: 2001–02, brachytherapy; waves 4 and 5: 2004–2006, drug-eluting stents]. Patients undergoing PCI in the recent waves were older and more often reported comorbidities than those in the balloon era. PCI was more often performed for acute coronary syndromes and, in spite of the greater disease burden, was more often selective. Procedural success was achieved and maintained more often in the stent era. Significant reductions were observed in in-hospital rates (%) of myocardial infarction (PTCA Registry: 4.9, wave 1: 2.7, wave 2: 2.8, wave 3: 1.9, wave 4: 2.6, wave 5: 2, Ptrend:<0.001) and emergency CABG (PTCA Registry: 3.7, wave 1: 0.4, wave 2: 0.4, wave 3: 0.3, wave 4:0.4, wave 5: 0, Ptrend:<0.001). Compared to the PTCA Registry, risk for repeat revascularization (31–365 days following index PCI) was significantly lower in the Dynamic waves (adjusted hazard ratio, wave 1: 0.72, wave 2: 0.51, wave 3: 0.51, wave 4: 0.30, wave 5: 0.36; P< 0.05 for all). Conclusion Percutaneous interventions, in the last two decades, has evolved to include more urgent, comorbid cases, yet achieving high success rates with significantly reduced need for repeat revascularization. PMID:20031687
Survival benefit of coronary-artery bypass grafting accounted for deaths in those who remained untreated
Boris G Sobolev; Guy Fradet; Robert Hayden; Lisa Kuramoto; Adrian R Levy; Mark J FitzGerald
BACKGROUND: Currently there are no direct estimates of mortality reduction afforded by coronary-artery bypass grafting (CABG) that take into account the deaths among patients for whom coronary revascularization was indicated but who did not undergo the treatment. The objective of this analysis was to compare survival after the treatment decision between patients who underwent CABG and those who remained untreated.
Off-pump coronary bypass grafting: how to use the octopus tissue stabilizer
Erik W. L Jansen; JaapR Lahpor; Cornelius Borst; PaulF Gründeman; JohanJ Bredée
Off-pump coronary artery bypass grafting requires immobilization of the coronary artery. A suction device (Octopus Tissue Stabilizer), attached to the epicardium and connected rigidly to the operating table rail, was used through limited and full surgical access for single-vessel and multivessel arterial revascularization, respectively. An outline for its application, as used by us to construct 122 anastomoses in 70 patients,
... and animations for grades K-6. The Coronary Arteries | Share Coronary Circulation The heart muscle, like every ... into two main coronary blood vessels (also called arteries). These coronary arteries branch off into smaller arteries, ...
New Technologies in Coronary Artery Surgery
Taggart, David; Nir, Rony-Reuven; Bolotin, Gil
Coronary artery disease remains the leading cause of death in developed countries. Major recent studies such as SYNTAX and FREEDOM have confirmed that coronary artery bypass grafting (CABG) remains the gold standard treatment in terms of survival and freedom from myocardial infarction and the need for repeat revascularization. The current review explores the use of new technologies and future directions in coronary artery surgery, through 1) stressing the importance of multiple arterial conduits and especially the use of bilateral mammary artery; 2) discussing the advantages and disadvantages of off-pump coronary artery bypass; 3) presenting additional techniques, e.g. minimally invasive direct coronary artery bypass grafting, hybrid, and robotic-assisted CABG; and, finally, 4) debating a novel external stenting technique for saphenous vein grafts. PMID:23908868
New technologies in coronary artery surgery.
Taggart, David; Nir, Rony-Reuven; Bolotin, Gil
Coronary artery disease remains the leading cause of death in developed countries. Major recent studies such as SYNTAX and FREEDOM have confirmed that coronary artery bypass grafting (CABG) remains the gold standard treatment in terms of survival and freedom from myocardial infarction and the need for repeat revascularization. The current review explores the use of new technologies and future directions in coronary artery surgery, through 1) stressing the importance of multiple arterial conduits and especially the use of bilateral mammary artery; 2) discussing the advantages and disadvantages of off-pump coronary artery bypass; 3) presenting additional techniques, e.g. minimally invasive direct coronary artery bypass grafting, hybrid, and robotic-assisted CABG; and, finally, 4) debating a novel external stenting technique for saphenous vein grafts. PMID:23908868
Persistent Socioeconomic Differences in Revascularization After Acute Myocardial Infarction Despite a Universal Health Care System—A Danish Study
Jeppe N. Rasmussen; Sřren Rasmussen; Gunnar H. Gislason; Steen Z. Abildstrom; Tina K. Schramm; Christian Torp-Pedersen; Lars Křber; Finn Diderichsen; Merete Osler; Mette Madsen
Background Use of invasive revascularization [percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)] after\\u000a acute myocardial infarction (AMI) in Denmark increased between 1996 and 2004. We investigated how this affected socioeconomic\\u000a differences in their use.\\u000a \\u000a \\u000a \\u000a Materials and methods All patients aged 30–74 years in hospital for a first AMI in Denmark between 1996 and 2004 were included. Cox proportional\\u000a hazard models
Use of the Boomerang catalyst advantage closure device to facilitate complex multistaged percutaneous revascularization procedures for the treatment of critical limb ischemia.
Garcia, Joel A; Casserly, Ivan P
An increasing spectrum of complex peripheral arterial disease may be successfully treated using percutaneous revascularization techniques. A pair of challenging peripheral revascularization procedures in patients with critical limb ischemia is presented, where an array of interventional tools and techniques were required, and the off-label use of the Boomerang catalyst system closure device was important in managing a variety of complex arterial access issues and ultimately allowing procedural success. PMID:19530181
Transmyocardial revascularization ameliorates ischemia by attenuating paradoxical catecholamine-induced vasoconstriction
D. Le Elizabeth; Eric R. Powers; Jian-Ping Bin; Howard Leong-Poi; N. Craig Goodman; Sanjiv Kaul
Background The mechanism by which transmyocardial revascularization (TMR) offers clinical benefit is controversial. We hypothesized that\\u000a TMR ameliorates ischemia by reversing paradoxical catecholamine-induced vasoconstriction.\\u000a \\u000a \\u000a \\u000a Methods and Results Chronic ischemic cardiomyopathy was created in 11 dogs by placing ameroid constrictors on the proximal coronary arteries and\\u000a their major branches. Six weeks later, 35 channels were created percutaneously in the left circumflex artery region,
Cardiopulmonary bypass in revascularization and fluid management of exercise-induced acute myocardial infarction.
Whitson, Bryan A; Nath, Dilip S; Knudtson, Joshua R; Shumway, Sara J
A 52-year-old man was resuscitated from a cardiac arrest during a marathon run. During initial evaluation, he received a significant amount of crystalloid fluid to maintain end-organ perfusion. Based on electrocardiogram findings, myocardial infarction was suspected and an angiogram was performed. An acute thrombosis of the left anterior descending vessel was noted, angioplastied, and stented. Given that he was in cardiogenic shock, acidotic, and hemodynamically labile, an emergent coronary artery bypass grafting with cardiopulmonary bypass was performed to simultaneously revascularize the myocardium and remove intravascular fluid. PMID:16948763
Conservative strategy for treatment of stable coronary artery disease
Rezende, Paulo Cury; Scudeler, Thiago Luis; da Costa, Leandro Menezes Alves; Hueb, Whady
Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function. In relation to the major outcomes of death and myocardial infarction, it is not clear in the literature if an invasive strategy of myocardial revascularization is superior to a conservative strategy of optimized medical therapy. Moreover, with the exception of patients with left main coronary disease, this similarity in prognosis also occurs in different subgroups of patients. PMID:25685763
Statins and percutaneous coronary intervention: a complementary synergy.
Echeverri, Darío; Cabrales, Jaime
The inclusion of statins and stents in coronary disease management during the 1980s has marked a dramatic change in the natural history of the disease. Separately, each of these therapies have progressed rapidly and have achieved a prime position in the current armamentarium. The simultaneous use of statins in patients undergoing percutaneous coronary revascularization procedures with stent implantation has shown a significant beneficial synergistic effect by reducing ischemia and necrosis, and improving coronary blood flow in patients with stable coronary disease, as well as in acute coronary syndromes. The use of high dose statins in conjunction with coronary angioplasty with stent implantation has shown great efficacy and safety in patients with severe coronary disease. PMID:24079365
Acute Ischemic Stroke Treatment, Part 2: Treatment "Roles of Capillary Index Score, Revascularization and Time"
Al-Ali, Firas; Elias, John J.; Filipkowski, Danielle E.
Due to recent results from clinical intra-arterial treatment for acute ischemic stroke (IAT-AIS) trials such as the interventional management of stroke III, IAT-AIS and the merit of revascularization have been contested. Even though intra-arterial treatment (IAT) has been shown to improve revascularization rates, a corresponding increase in good outcomes has only recently been noted. Even though a significant percentage of patients achieve good revascularization in a timely manner, results do not translate into good clinical outcomes (GCOs). Based on a review of the literature, the authors suspect limited GCOs following timely and successful revascularization are due to poor patient selection that led to futile and possibly even harmful revascularization. The capillary index score (CIS) is a simple angiography-based scale that can potentially be used to improve patient selection to prevent revascularization being performed on patients who are unlikely to benefit from treatment. The CIS characterizes presence of capillary blush related to collateral flow as a marker of residual viable tissue, with absence of blush indicating the tissue is no longer viable due to ischemia. By only selecting patients with a favorable CIS for IAT, the rate of GCOs should consistently approach 80–90%. Current methods of patient selection are primarily dependent on time from ischemia. Time from cerebral ischemia to irreversible tissue damage seems to vary from patient to patient; so focusing on viable tissue based on the CIS rather than relying on an artificial time window seems to be a more appropriate approach to patient selection.
Evaluation of penile revascularization for erectile dysfunction: a 10-year follow-up
Y Vardi; I Gruenwald; U Gedalia; S Nassar; A Engel; Y Har-Shai
The objective of this study was to report long-term success rates for penile revascularization (PR) and investigate factors responsible for failures. During the past 10 y, data were obtained on 52 patients who underwent PR. Surgical technique was selected according to preoperative arteriographic findings. The mean age was 28.5 y and the mean follow-up was 70.8 months. Success was defined
Comprehensive assessment of coronary fractional flow reserve
Qi, Xiaolong; Fan, Guoxin; Zhu, Deqiu; Ma, Wanrong
Fractional flow reserve (FFR) is considered nowadays as the gold standard for invasive assessment of physiologic stenosis significance and an indispensable tool for decision-making in coronary revascularization. Robust studies have shown that FFR is more effective in accurately identifying which lesions should be stented, and revascularization guided by FFR improves the outcome of coronary artery disease in patients. Therefore, FFR has been upgraded to a class A recommendation in current guidelines when the ischemic potential for specific target lesions is controversial. This article reviews the laboratory practice, functional evaluation of FFR as a gold standard and its emerging clinical application. In addition, novel noninvasive technologies of FFR measurement are discussed in depth.
[Coronary stents: 30 years of medical progress].
Silvain, Johanne; Cayla, Guillaume; Collet, Jean-Philippe; Fargeot, Catherine; Montalescot, Gilles
The history of interventional cardiology has been marked by several technologic revolutions since the late 1970s. The first key step was the use of inflatable balloon angioplasty as an alternative to CABG surgery for coronary revascularization, followed by intracoronary delivery of bare metal stent (BMS) and drug eluting stents (DES) to drastically reduce intracoronary restenosis observed with BMS. Improved stents platforms and polymers (absorbable or biocompatible) led to a dramatic reduction in the rate of late stent thrombosis. Self-expanding stents are now available to improve stent a position especially in acute myocardial infarction. The emergence of new fully bioabsorbable stents that can be combined with antiproliferative drugs is the ongoing revolution. A new generation of stents is continuously improving and likely to become the ideal stent for coronary revascularization in the near future. PMID:24685222
Off-pump coronary artery bypass surgery in a renal transplant patient
Koji Hattori; Ryo Hoshino; Masato Tochii; Masato Sato; Mitsuru Yamashita; Motomi Ando
Off-pump coronary artery bypass grafting is rarely applied to patients who have previously received a renal transplant in\\u000a Japan. A 59-year-old male renal transplant recipient was admitted for unstable angina pectoris. Emergency coronary angiography\\u000a revealed triple-vessel disease. Intraaortic balloon pumping was applied, followed by emergency off-pump coronary bypass grafting\\u000a for complete revascularization. Intraaortic balloon pumping was ceased immediately after the
Iatrogenic vascular injury during peripheral revascularization.
Bunt, T J; Manship, L; Moore, W
Iatrogenic vascular injury may occur during peripheral revascularization procedures secondary to the application of vascular occlusive devices. This review summarizes the known mechanical causes of such injury, relates this to clamp design, and suggests methods to minimize such injury by appropriate selection and handling of vascular occlusive clamps. PMID:3889383
Immediate and Six-month Clinical Outcome of Percutaneous Coronary Intervention in a Tertiary Hospital in the Sultanate of Oman
Prashanth, Panduranga; Mukhaini, Mohamed; Riyami, Abdulla A.; Sulaiman, Kadhim; Shahrabani, Rashid; Riyami, Abdulla M.
Objectives To evaluate the clinical characteristics, angiographic profile, in-hospital and six-month clinical outcome of patients who underwent percutaneous coronary intervention in a tertiary hospital in the Sultanate of Oman. Methods Two hundred and five consecutive patients with both acute coronary syndrome and stable coronary artery disease, who underwent percutaneous coronary intervention between January 2007?and June 2007, were retrospectively analyzed.?Follow-up information was obtained from outpatient visits of these patients at six-months. Main outcome measures The primary end point in this study was the occurrence of major adverse cardiovascular events (MACE), defined as cardiac death, any myocardial infarction (MI), cerebrovascular accident (CVA) and target vessel revascularization (TVR) with either repeat percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). Secondary end points included angiographic success rate, procedural success rate, angina status, and the rate of clinical and angiographic restenosis. Results The angiographic and procedural success rate was 98% and 95% respectively. Fifty-one percent of patients surveyed had single vessel disease, 34% had double vessel disease and triple vessel disease was seen in 15% of patients. Type A lesion was found in 16%, Type B in 55% and Type C in 29% of patients. The majority of patients had single vessel stenting (83%). The mean ± SD number of stents per patient was 1.6 ± 0.9.There were four in-hospital deaths (2%) and six patients (2.9%) had non-ST elevation myocardial infarction before hospital discharge. Out of 205 patients, 53 patients were lost to follow-up. Among the 148 patients followed up, 105 patients (71%) were asymptomatic at follow-up, 36 (24%) patients had stable angina and 7 (5%) had a late myocardial infarction including three patients with stent thrombosis (2%). Among the 43 patients with angina or late infarction, 28 patients underwent coronary angiogram. Angiographic in-stent restenosis was seen in 14 patients. Of them, 8 patients underwent CABG and 6 patients repeat PCI. Fourteen patients had patent stents.The remaining fifteen patients were on optimal medications including two patients with stent thrombosis as they refused coronary angiogram. Overall, 132 of 148?patients (105 asymptomatic/14 patent stents/13 with angina) (89%) were free from major adverse cardiac events. Considering anginal status and repeat angiograms, composite clinical (15 patients) and angiographic (14 patients) six-month restenosis rate in percutaneous coronary intervention patients (29/148) was 19.5%. Conclusion Results of percutaneous coronary intervention in our setup is excellent with good immediate results, low complication rate, good six-month clinical outcome and is comparable to international standards. PMID:22334836
Vascular grafting strategies in coronary intervention
NASA Astrophysics Data System (ADS)
Knight, Darryl; Gillies, Elizabeth; Mequanint, Kibret
With the growing need for coronary revascularizations globally, several strategies to restore blood flow to the heart have been explored. Bypassing the atherosclerotic coronary arteries with autologous grafts, synthetic prostheses and tissue-engineered vascular grafts continue to be evaluated in search of a readily available vascular graft with clinically acceptable outcomes. The development of such a vascular graft including tissue engineering approaches both in situ and in vitro is herein reviewed, facilitating a detailed comparison on the role of seeded cells in vascular graft patency.
Middle aortic syndrome. Effectiveness and durability of complex arterial revascularization techniques.
Messina, L M; Reilly, L M; Goldstone, J; Ehrenfeld, W K; Ferrell, L D; Stoney, R J
Middle aortic syndrome typically occurs as severe hypertension in young patients who have weak or absent femoral pulses and an abdominal bruit. It results from a diffuse narrowing of the distal thoracic and abdominal aorta, commonly involving the visceral and renal arteries. The clinical presentation, angiographic assessment, and surgical outcome of 10 patients (mean age: 19.5 years) who underwent one-stage revascularization for middle aortic syndrome were reviewed to determine the effectiveness and durability of one-stage revascularization techniques to relieve these complications. All patients were hypertensive (mean blood pressure: 176 mmHg); six (60%) had severe, poorly controlled hypertension, two of whom had previous failed operations for renovascular hypertension and one who presented with malignant hypertension and acute renal failure. Five patients had disabling myocardial insufficiency, only one of whom had documented coronary artery disease. Four patients had intermittent claudication. Aortography showed variable length high-grade midaortic stenosis, nine had visceral artery involvement, and eight had renal artery involvement. All patients underwent one-stage revascularization by a variety of autogenous and prosthetic techniques. The postoperative recovery was uncomplicated in eight of nine patients and was often associated with dramatic reduction in blood pressure. There was a single death from disruption of the thoracic anastomosis in a patient who had diffuse cystic medial necrosis of the aorta. Arterial biopsy in nine patients indicated evidence for both acquired and congenital origins of the midaortic stenosis. Late follow-up evaluation (mean: 4.1 years) showed normal growth and development, preservation of renal function, and relief of myocardial insufficiency in all patients. Seven patients (77%) are cured of their hypertension, and two (23%) have only mild hypertension. These results indicate that one-stage revascularization of patients with middle aortic syndrome can result in effective and durable relief of these severe life-threatening complications. PMID:3753060
Evaluation of outcome and cost-effectiveness using an FDG PET-guided approach to management of patients with coronary disease and severe left ventricular dysfunction (PARR2): rationale, design, and methods
Rob Beanlands; Graham Nichol; Terrence D. Ruddy; Robert A. deKemp; Paul Hendry; Dennis Humen; Normand Racine; Heather Ross; Francois Benard; Geoffrey Coates; Robert M. Iwanochko; Ernest Fallen; George Wells
Patients with severe ventricular dysfunction and coronary disease have high morbidity and mortality. They may benefit from revascularization but have significant perioperative morbidity and mortality. Positron emission tomography (PET) imaging with F-18-fluorodeoxyglucose (FDG) can detect viable myocardium that may recover from revascularization in such patients. It is unclear whether use of FDG PET in this population improves outcome or is
Rotablation in the treatment of high-risk patients with heavily calcified left-main coronary lesions
Chiang, Meng-Hsiu; Yi, Hung-Tao; Tsao, Cheng-Rong; Chang, Wei-Chun; Su, Chieh-Shou; Liu, Tsun-Jui; Liang, Kae-Woei; Ting, Chih-Tai; Lee, Wen-Lieng
Objective Heavily calcified left-main coronary diseases (LMCA) remain a formidable challenge for percutaneous interventions (PCI). This study was to investigate the safety and efficacy of using rotational atherectomy (RA) in treating such lesions in actual practice. Methods From February 2004 to March 2012, all consecutive patients who received RA for heavily-calcified LMCA lesions in our cath lab were enrolled. The relevant clinical and angiographic characteristics at the time of index PCI, as well as the clinical follow-up outcomes, were retrieved and analyzed. Results A total of 34 consecutive patients were recruited with a mean age 77.2 ± 10.2 years. There were 82.4% presented with acute coronary syndrome and 11.8% with cardiogenic shock. Chronic renal disease and diabetes were seen in 64.7% and 52.9%, respectively. Triple-vessel coronary disease was found in 76.5% of them. The mean SYNTAX score was 50 ± 15 and EuroSCORE II scale 5.6 ± 4.8. The angiographic success rate was 100% with a procedural success rate of 91.2%. The mean number of burrs per patient was 1.7 ± 0.5. Crossing-over stenting was used in 64.7%. Most stents were drug-eluting (67.6%). Intra-aortic ballon pump was used in 20.6% of the procedures. Three patients died during hospitalization, all due to presenting cardiogenic shock. No major complication occurred. Among 31 hospital survivors, the major adverse cardiac events (MACE) rate was 16.1%, all due to target lesion revascularization or target vessel revascularization. Conclusions In high-surgical-risk elderly patients, plaque modification with RA in PCI of heavily-calcified LMCA could be safely accomplished with a minimal complication rate and low out-of-hospital MACE. PMID:24133507
[Clinical research of safflower injection on hibernating myocardial revascularization].
Zheng, Chang-Zhu; Xian, Yu-Qiong; Chen, Jing; Xu, Ying-Hui; Shi, Qian; Wang, Yu-Hua; Ju, Hai-Ning
Coronary artery disease (CAD) is one of the leading causes of death. Safflower attracts great attention owing to its anti-ischemia/reperfusion injury effect. Ninety-three patients with CAD were included and randomized into safflower treatment group, PCI group and control group. Low-dose dobutamine stress echocardiography (DSE) was performed to measure end-systolic volume (ESV), end-diastolic volume (EDV), left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) to determine the recovery of hibernating myocardium and cardiac function in all patients before treatment and after 3-month follow-up. The study was to investigate the effects of safflower on hibernating myocardial revascularization and cardiac function. It was found that LVEF was significantly improved, while the ESV and WMSI were significantly reduced after 2-week treatment in safflower and PCI treatment groups. No significant differences were found between safflower and PCI treatment groups in ESV, EDV, WMSI and LVEF after treatment Safflower injection effectively improved hibernating myocardial function. PMID:25011274
Complete infarct-related artery revascularization in acute myocardial infarction patients. CORAMI Registry
Mrevlje, Blaz; Janu?, Bogdan; Dziewierz, Artur; Rakowski, Tomasz; Legutko, Jacek; Bartu?, Stanis?aw; Dudek, Dariusz
Introduction There are still limited data on the occurrence of multiple stenotic lesions within the infarct-related artery (IRA) in acute myocardial infarction (MI), and there is no consensus on the optimal treatment of this patient subgroup, which varies between centers and operators. Aim To analyse the clinical efficacy of percutaneous coronary intervention (PCI) strategy of culprit lesion only in patients with myocardial infarction. Material and methods Patients with acute MI with the presence of at least two significant lesions in the IRA – (1) the target culprit lesion which required immediate stenting (> 50–100% stenosis) and (2) a second distal critical lesion (70–90%) – were included in the registry. Both lesions in the IRA were considered to be independent lesions requiring two separate stent platforms to be covered (no overlap). The decision on the treatment strategy of either complete (CR) or culprit-lesion-only (CLO) revascularization was at the discretion of the operator. Results There were altogether 95 patients enrolled in the registry, 63 (66%) in the group with CR of the IRA and 32 (34%) with CLO revascularization, which did not differ in terms of baseline demographics. In-hospital and long-term outcomes were similar between the groups. Stent thrombosis at 1 year occurred in 1.6% in CR and in 6.2% in CLO groups respectively (statistically not significant). There were no patients from the CLO group who had a planned percutaneous coronary intervention (PCI) of the 2nd lesion in the IRA during 1-year observation. Conclusions At 1 year the clinical outcome was similar between those with complete and CLO PCI. Complete coverage of significant lesions did not increase the risk of stent thrombosis or need for repeated revascularization in long-term observation. PMID:26161098
Myocardial ischemia is a key factor in the management of stable coronary artery disease
Iwasaki, Kohichiro
Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis. PMID:24772253
Anomalous origin of the left coronary artery from the pulmonary artery associated with an accessory atrioventricular pathway and managed successfully with surgical and interventional electrophysiological treatment: a case report
Introduction The combination of anomalous left coronary artery origin from the pulmonary artery and an accessory pathway has not been reported previously in the medical literature. In medicine, the coexistence of two clinical causes can lead to the same clinical findings, and this can make the researcher's attempt to distinguish between the two of them and, hence, the correct diagnosis and treatment difficult. Case presentation A six-month-old boy from Pakistan was brought to our hospital with tachypnea and supraventricular tachycardia and, on the basis of echocardiography and multi-slice computed tomography, was diagnosed with an anomalous left coronary artery origin from the pulmonary artery. The presence of an anomalous left coronary artery origin from the pulmonary artery was not initially recognized, and left ventricular dysfunction was considered as a result of supraventricular tachycardia. He underwent direct re-implantation of the left coronary artery to the aorta using the trapdoor flap technique. Recurrent episodes of supraventricular tachycardia resistant to maximal pharmacological treatment occurred post-operatively. A left posterolateral accessory pathway was successfully ablated by using a trans-septal approach. Conclusions It should not be forgotten by anyone that many times in medicine what seems obvious is not correct. It can be difficult to distinguish two clinical entities, and frequently one is considered a result of the other. This is the first report of the coexistence of an anomalous left coronary artery origin from the pulmonary artery and recurrent supraventricular tachycardia due to an accessory pathway in a child that was treated successfully with combined surgical and interventional electrophysiological treatment. This case may represent a first educational step in the field of congenital heart disease, that is, that anomalies such as an anomalous left coronary artery origin from the pulmonary artery may be concealed in a child with other serious cardiac problems, in this case mitral regurgitation, dilation of the left ventricle, and recurrent episodes of tachycardia. PMID:21846372
Angiogenesis Is Enhanced in Ischemic Canine Myocardium by Transmyocardial Laser Revascularization 1 1 This study was supported in part by a research grant from CardioGenesis Corporation, Sunnyvale, California
Noriyoshi Yamamoto; Takushi Kohmoto; Anguo Gu; Carolyn DeRosa; Craig R. Smith; Daniel Burkhoff
Objectives. This study sought to test whether transmyocardial laser revascularization (TMLR) stimulates angiogenesis in an animal model of chronic ischemia.Background. TMLR relieves angina and may also improve blood flow in patients who are not candidates for traditional therapies. The mechanisms of these benefits are not fully defined.Methods. Ischemia was created in 14 dogs by proximal left anterior descending coronary ameroid
Mechanical Revascularization for Acute Ischemic Stroke: A Single-Center, Retrospective Analysis
Jeromel, Miran, E-mail: email@example.com; Milosevic, Z. V., E-mail: firstname.lastname@example.com; Kocijancic, I. J., E-mail: firstname.lastname@example.com; Lovric, D., E-mail: email@example.com [University Medical Centre Ljubljana, Clinical Institute of Radiology, Department for Diagnostic and Interventional Neuroradiology (Slovenia); Svigelj, V., E-mail: firstname.lastname@example.com; Zvan, B., E-mail: firstname.lastname@example.com [University Medical Centre Ljubljana, Division Vascular and Intensive Neurology, Department of Neurology (Slovenia)
BackgroundEndovascular mechanical revascularization (thrombectomy) is an increasingly used method for intracranial large vessel recanalization in acute stroke. The purpose of the study was to analyze the recanalization rate, clinical outcome, and complication rate in our stroke patients treated with mechanical revascularization. A total of 57 patients with large vessel stroke (within 3 h for anterior and 12 h for posterior circulation) were treated with mechanical revascularization at a single center during 24 months. The primary goal of endovascular treatment using different mechanical devices was recanalization of the occluded vessel. Recanalization rate (reported as thrombolysis in cerebral infarction [TICI] score), clinical outcome (reported as National Institutes of Health Stroke Scale [NIHSS] score and modified Rankin scale [mRS] score), as well as periprocedural complications were analyzed. The mean age of the patients was 63.1 {+-} 12.9 years, with baseline median NIHSS score of 14 (interquartile range, 9.5-19). Successful recanalization (TICI 2b or 3) was achieved in 41 (72 %) patients. Twenty patients (35 %) presented with favorable outcome (mRS {<=}2) 30 days after stroke. Overall, significant neurological improvement ({>=}4 NIHSS point reduction) occurred in 36 (63 %) patients. A clinically significant procedure-related adverse events (vessel disruption, peri/postprocedural intracranial bleeding) defined with decline in NIHSS of {>=}4 or death occurred in three (5 %) patients. The study showed a high recanalization rate with improved clinical outcome and a low rate of periprocedural complications in our stroke patients treated with mechanical revascularization. Therefore, we could conclude that endovascular revascularization (primary or in combination with a bridging thrombolysis) was an effective and safe procedure for intracranial large vessel recanalization in acute stroke.
Initial and follow-up results of the Tenax coronary stent.
Carrié, D; Khalifé, K; Hamon, M; Citron, B; Monassier, J P; Sabatier, R; Lipiecky, J; Mourali, S; Sarfaty, L; Elbaz, M; Fourcade, J; Puel, J
The Tenax coronary stent is laser sculpted from high precision 316 L stainless steel using advanced production procedures. An a-SiC: H (hydrogen-rich amorphous silicon carbide) coating reduces its thrombogenicity and improves its biocompatibility. From April to July 1998, 266 stents were implanted in 241 patients (aged 62.7 +/- 10.5 years) in five centers. The clinical indication for intervention was unstable angina (33.2%) and recent myocardial infarction (29.5%) in many cases. Most lesions (53.8%) had complex characteristics (Class B2 or C). The target vessel was the LAD in 42.5% and the right coronary artery in 36.8% of all cases. Four primary stent deployment failures occurred and implantation was successful in 259 (97.4%) of 266 stents. No death and no Q-wave myocardial infarction or emergency CABG occurred during hospital stay. Clinical success, defined as successful deployment without procedural or clinical event, was achieved in 230 (95.4%) of 241 patients. One-year clinical follow-up shows a low need for target lesion revascularization (17/237 [7.1%] patients) and a 15.8% rate of major adverse cardiac events (36/237 patients). The clinical and angiographic outcomes of our study suggest that the hybrid, amorphous hydrogenated silicon carbide coated design is promising and merits further evaluation in larger clinical trials. PMID:12053317
Pulp Revascularization of Immature Permanent Teeth: A Review of the Literature and a Proposal of a New Clinical Protocol
Namour, Mélanie
Tissue engineering is a growing field. In the near future, it will probably be possible to generate a complete vital tooth from a single stem cell. Pulp revascularization is dependent on the ability of residual pulp and apical and periodontal stem cells to differentiate. These cells have the ability to generate a highly vascularized and a conjunctive rich living tissue. This one is able to colonize the available pulp space. Revascularization is a new treatment method for immature necrotic permanent teeth. Up to now, apexification procedures were applied for these teeth, using calcium dihydroxide or MTA to produce an artificial apical barrier. However, the pulp revascularization allows the stimulation of the apical development and the root maturation of immature teeth. Two pulp revascularization techniques are used in the literature, one using calcium dihydroxide and the second using a triple antibiotic paste. Based on these two different pulp revascularization protocols, which obtain the desired therapeutic success, the literature will be reviewed and analyzed according to the relevance of their choice of materials. Based on the literature, we propose a new relevant protocol and a new mixture of antibiotics. PMID:25383384
Elevated Brain Natriuretic Peptide Predicts Blood Pressure Response After Stent Revascularization in Patients With Renal Artery Stenosis
Jose A. Silva; Albert W. Chan; Christopher J. White
Background—A significant number (20% to 40%) of hypertensive patients with renal artery stenosis will not have blood pressure improvement after successful percutaneous revascularization. Identifying a group of patients with refractory hypertension and renal artery stenosis who are likely to respond to renal stent placement would be beneficial. Methods and Results—Brain natriuretic peptide (BNP) was measured in 27 patients with refractory
Chronic Coronary Artery Disease: Diagnosis and Management
Cassar, Andrew; Holmes, David R.; Rihal, Charanjit S.; Gersh, Bernard J.
Coronary artery disease (CAD) is the single most common cause of death in the developed world, responsible for about 1 in every 5 deaths. The morbidity, mortality, and socioeconomic importance of this disease make timely accurate diagnosis and cost-effective management of CAD of the utmost importance. This comprehensive review of the literature highlights key elements in the diagnosis, risk stratification, and management strategies of patients with chronic CAD. Relevant articles were identified by searching the PubMed database for the following terms: chronic coronary artery disease or stable angina. Novel imaging modalities, pharmacological treatment, and invasive (percutaneous and surgical) interventions have revolutionized the current treatment of patients with chronic CAD. Medical treatment remains the cornerstone of management, but revascularization continues to play an important role. In the current economic climate and with health care reform very much on the horizon, the issue of appropriate use of revascularization is important, and the indications for revascularization, in addition to the relative benefits and risks of a percutaneous vs a surgical approach, are discussed. PMID:19955250
Moyamoya syndrome associated with Alagille syndrome: outcome after surgical revascularization.
Baird, Lissa C; Smith, Edward R; Ichord, Rebecca; Piccoli, David A; Bernard, Timothy J; Spinner, Nancy B; Scott, R Michael; Kamath, Binita M
Vasculopathy is well-described in Alagille syndrome (ALGS); however, few data exist regarding neurosurgical interventions. We report 5 children with ALGS with moyamoya who underwent revascularization surgery. Postsurgical complications included 1 stroke and 1 death from thalamic hemorrhage. Global function improved in survivors. Revascularization is reasonably safe in patients with ALGS and may improve neurologic outcomes. PMID:25465847
Neurobehavioral and Life-Quality Changes after Cerebral Revascularization.
ERIC Educational Resources Information Center
Baird, Anne Dull; And Others
Studied neuropsychological and life-quality changes six months after carotid endarterectomy, superficial temporal artery to middle cerebral artery bypass, multiple revascularization, and vertebrobasilar revascularization procedures. Compared changes with those in patients with recent severe spinal complaints and in patients for whom…
Robotically assisted totally endoscopic coronary artery bypass surgery
Canale, Leonardo Secchin; Mick, Stephanie; Mihaljevic, Tomislav; Nair, Ravi
Robotically assisted totally endoscopic coronary artery bypass surgery has emerged as a feasible and efficient alternative to conventional full sternotomy coronary artery bypass graft surgery in selected patients. This minimally invasive approach using the daVinci robotic system allows fine intrathoracic maneuvers and excellent view of the coronary arteries. Both on-pump and off-pump operations can be performed to treat single and multivessel disease. Hybrid approaches have the potential of offering complete revascularization with the "best of both worlds" from surgery (internal mammary artery anastomosis in less invasive fashion) and percutaneous coronary intervention (least invasive approach). In this article we review the indications, techniques, short and long term results, as well as current developments in totally endoscopic robotic coronary artery bypass operations. PMID:24251021
Novel oral anticoagulants in acute coronary syndrome.
Costopoulos, Charis; Niespialowska-Steuden, Maria; Kukreja, Neville; Gorog, Diana A
Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide with a prevalence that has now reached pandemic levels as a consequence of the rapid modernization of the developing world. Its presentation as an acute coronary syndrome (ACS) is a frequent reason for hospital admission and of profound implications for personal, societal and global health. Despite improvements in the management of ACS with anti-platelet and anticoagulant therapy and revascularization techniques, many patients continue to suffer recurrent ischemic events. The need to reduce future cardiovascular events has led to the development of novel therapies to prevent coronary thrombosis, targeting thrombin-mediated pathways. These include direct Xa inhibitors (apixaban, rivaroxaban and darexaban), direct thrombin inhibitors (dabigatran) and PAR 1 antagonists (vorapaxar and atopaxar). This article critically reviews the comparative mechanisms of action, the risks and benefits, together with the clinical evidence base for the use of these novel oral agents in the management of ACS patients. PMID:22989603
How Do Hospitals Respond to Market Entry? Evidence from a Deregulated Market for Cardiac Revascularization.
Li, Suhui; Dor, Avi
Regulatory entry barriers to hospital service markets, namely Certificate of Need (CON) regulations, are enforced in many US states. Policy makers in other states are considering reinstating CON policies in tandem with service expansions mandated under the Affordable Care Act. Although previous studies examined the volume effects of CON, demand responses to actual entry into local hospital markets are not well understood. In this paper, we empirically examine the demand-augmenting, demand-redistribution, and risk-allocation effects of hospital entry by studying the cardiac revascularization markets in Pennsylvania, a state in which dynamic market entry occurred after repeal of CON in 1996. Results from interrupted time-series analyses indicate demand-augmenting effects for coronary artery bypass graft (CABG) and business-stealing effects for percutaneous coronary intervention (PCI) procedures: high entrant market share mitigated the declining incidence of CABG, but it had no significant effect on the rising trend in PCI use, among patients with coronary artery disease. We further find evidence that entry by new cardiac surgery centers tended to sort high-severity patients into the more invasive CABG procedure and low-severity patients into the less invasive PCI procedures. These findings underscore the importance of considering market-level strategic responses by hospitals when regulatory barriers are rescinded. Copyright © 2014 John Wiley & Sons, Ltd. PMID:24990327
Transmyocardial revascularization by a 1000-watt CO2 laser: sole therapy (Abstract Only)
NASA Astrophysics Data System (ADS)
Crew, John R.; Dean, Marilyn; Jones, Reinold; Fisher, John C.
The concept of transmyocardial revascularization (TMR) providing blood flow to the left heart muscle based on the reptilian heart model has now been extended from an adjunctive procedure with coronary artery bypass to sole therapy. At Seton Hospital and Medical Center TMR is now being performed for the first time in clinical trials with patients who have no other mechanism of perfusion and a history of either failed PTCA or coronary artery bypass, with angina already under maximum medical therapy with a demonstrable ischemic muscle target. Longevity and reperfusion by tomographic thallium of these laser-drilled holes has been previously demonstrated but effectiveness of these channels for primary perfusion (sole therapy) apart from normal coronary bypass collateral supply is under investigation. Phase I of the FDA study has been completed with 15 cases and now Phase II includes three other beta test sites along with alternative therapy in marginal cases as the investigational format for the next 50 cases. More than 2 year followup in the first 15 cases is presented.
Is an Integrated Approach Warranted for Concomitant Carotid and Coronary Artery Disease?
Thomas J Takach; George J Reul; Denton A Cooley; J. Michael Duncan; David A Ott; James J Livesay; Grady L Hallman; O. H Frazier
Background. The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial.Methods. Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis >70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke).
Arterial hypertension and associated factors in patients submitted to myocardial revascularization.
Colósimo, Flávia Cortez; Sousa, Alexandre Gonçalves de; Silva, Gilmara Silveira da; Piotto, Raquel Ferrari; Pierin, Angela Maria Geraldo
OBJECTIVE To identify the prevalence of arterial hypertension and associated factors in patients submitted to myocardial revascularization. METHOD Cross-sectional study using the database of a hospital in Săo Paulo (SP, Brazil) containing 3010 patients with coronary artery disease submitted to myocardial revascularization. A multiple logistic regression was performed to identify variables independently associated with hypertension (statistical significance: p<0.05). RESULTS Prevalence of hypertension was 82.8%. After the variables were adjusted, the associated factors were as follows: age, odds ratio (OR): OR=1.01; 95% confidence interval (CI): CI:1.00-1.02; female gender: (OR=1.77;CI:1.39-2.25); brown-skin race: (OR=1.53;CI:1.07-2.19); obesity: (OR=1.53;CI:1.13-2.06); diabetes: (OR=1.90;CI:1.52-2.39); dyslipidemia: (OR=1.51;CI:1.23-1.85); and creatinine>1.3: (OR=1.37;CI:1.09-1.72). CONCLUSION A high prevalence of arterial hypertension and association with both non-modifiable and modifiable factors was observed. PMID:25992817
Early Outcomes of Double-Vessel Coronary Endarterectomy in Comparison with Single-Vessel Coronary Endarterectomy
Marzban, Mehrab; Karimi, Abassali; Ahmadi, Hossein; Davoodi, Saeed; Abbasi, Kyomars; Movahedi, Namvar; Salehiomran, Abbas; Abbasi, Seyed Hesameddin; Kawoosi, Yasaman; Yazdanifard, Parin
Our goal was to investigate the safety of single- and double-vessel coronary endarterectomy as an adjunct to coronary artery bypass grafting in patients with diffuse coronary disease. In reviewing the records of 9,443 patients who underwent isolated coronary artery revascularization over a 4-year period, we found 310 patients (3.28%) who underwent concomitant coronary artery endarterectomy, 39 of whom (12.6%) required double endarterectomy (Group 2) and the rest of whom required single endarterectomy (Group 1). Variables of these groups were compared by means of univariate analysis. In Group 1, 76.3% were men, with a mean age of 58.73 ± 9.36 yr. Regarding postoperative myocardial infarction as evaluated by electrocardiography and the MB isoenzyme of creatine kinase, 13% of the patients in Group 1 and 15.4% in Group 2 were so affected. The early mortality rate was 3.3% in Group 1 and 10.3% in Group 2 (P <0.05). In univariate analysis, the following variables were significant: 3-vessel disease, postoperative atrial fibrillation, dialysis, length of hospital stay, and death. In multivariate analysis of endarterectomized arteries, the vascular combinations most strongly associated with death were left anterior descending coronary artery + right coronary artery and right coronary artery + diagonal. There was no association between endarterectomy of particular vessels and perioperative myocardial infarction. Although coronary endarterectomy has become a safe procedure, adding a 2nd endarterectomy worsens the prognosis dramatically, and surgeons should be especially cautious about such an addition if the 1st endarterectomy is in left anterior descending coronary artery or right coronary artery territory. PMID:18612488
Effect of PCI on Quality of Life in Patients with Stable Coronary Disease
William S. Weintraub; John A. Spertus; Paul Kolm
In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evalua- tion (COURAGE) trial, we randomly assigned 2287 patients with stable coronary dis- ease to PCI plus optimal medical therapy or to optimal medical therapy alone. We assessed angina-specific health status (with the use of the Seattle Angina Question- naire) and overall physical and mental function (with the use of the
Minimally Invasive Surgery for Coronary Artery Disease with Associated Lung Cancer
Hung-I Lu; Yi-Cheng Wu; Ming-Ju Hsieh; Hui-Ping Liu; Pyng Jing Lin
Simultaneous surgical management of patients with co-existing ischemic heart disease and lung carcinoma remains controversial. Traditionally, these operations have been staged, with coronary artery revascularization first, followed by pulmonary resection at a later date. Under this procedure, tumor resection is delayed, and these staged procedures may increase morbidity and cost. Our experience with minimally invasive surgery in the cardiac and
A review of 1,582 consecutive Octopus off-pump coronary bypass patients
James C Hart; Ted H Spooner; John Pym; Thomas F Flavin; James R Edgerton; Michael J Mack; Erik W. L Jansen
Background. Off-pump coronary bypass may provide a safer form of surgical revascularization by avoiding the unwanted complications of cardiopulmonary bypass, particularly in the increasingly complex patients being referred for operation. This study reviews the entire experience of the Medtronic Octopus System (Medtronic, Minneapolis, MN) for beating heart bypass from 7 surgeons. Demographics, operative procedures, early outcomes, and trends in usage
"Renovascular Hypertension: Is there still a role for stent revascularization? " Current Opinion in Nephrology and Hypertension
Textor, Stephen C.
Purpose Management of renovascular hypertension remains controversial and problematic, in part due to failure of prospective trials to demonstrate added benefit to revascularization. Recent Findings Effective drug therapy often can achieve satisfactory blood pressure control, although concerns persist for the potential for progressive, delayed loss of kidney function beyond a stenotic lesion. Recent studies highlight benefits of renal artery stenting in subsets of patients including those with recurrent pulmonary edema and those intolerant to blockade of the renin-angiotensin system. Occasional patients with recent deterioration in renal function recover sufficient GFR after stenting to avoid requirements for renal replacement therapy. Emerging paradigms from both clinical and experimental studies suggest that hypoxic injury within the kidney activates inflammatory injury pathways and microvascular rarification that may not recover after technically successful revascularization alone. Initial data suggest that additional measures to repair the kidney, including the use of cell-based therapy, may offer the potential to recover kidney function in advanced renovascular disease. Summary Specific patient groups benefit from renal revascularization. Nephrologists will increasingly be asked to manage complex renovascular patients different from those in randomized trials that require intensely individualized management. PMID:23917028
Coronary calcium does not accurately predict near-term future coronary events in high-risk adults
Robert C. Detrano; Nathan D. Wong; Terence M. Doherty; Robert M. Shavelle; Weiyi Tang; Leonard E. Ginzton; Matthew J. Budoff; Kenneth A. Narahara
Background—Prognostic risk models have had limited success in predicting coronary events in subjects with multiple risk factors. We and others have proposed an alternative approach using radiographically detectable coronary calcium. We evaluated and compared the predictive value of these 2 approaches for determining coronary event risk in asymptomatic adults with multiple coronary risk factors. In addition, we assessed the predictive
Off-pump coronary artery bypass grafting in octogenarians
Tomoki Shimokawa; Naoki Minato; Noriko Yamada; Yuji Takeda; Yasushi Hisamatsu; Manabu Itoh
Objectives: Off-pump coronary artery bypass grafting (CABG) has become accepted for myocardial revascularization because it reduces perioperative\\u000a morbidity. We assessed the safety and efficacy of bypass surgery on the beating heart in elderly patients. Methods: Off-pump CABG was done in 25 patients aged 80 years or older between February 1996 and February 2001. We retrospectively\\u000a compared clinical results for these
Invasive testing for coronary artery disease: FFR, IVUS, OCT, NIRS.
Groves, Elliott M; Seto, Arnold H; Kern, Morton J
Coronary angiography is the gold standard for the diagnosis of coronary artery disease and guides revascularization strategies. The emergence of new diagnostic modalities has provided clinicians with adjunctive physiologic and image-based data to help formulate treatment strategies. Fractional flow reserve can predict whether percutaneous intervention will benefit a patient. Intravascular ultrasonography and optical coherence tomography are intracoronary imaging modalities that facilitate the anatomic visualization of the vessel lumen and characterize plaques. Near-infrared spectroscopy can characterize plaque composition and potentially provide valuable prognostic information. This article reviews the indications, basic technology, and supporting clinical studies for these modalities. PMID:25091966
Fractional flow reserve derived from coronary CT angiography in stable coronary disease: a new standard in non-invasive testing?
Nřrgaard, B L; Jensen, J M; Leipsic, J
Fractional flow reserve (FFR) measured during invasive coronary angiography is the gold standard for lesion-specific decisions on coronary revascularization in patients with stable coronary artery disease (CAD). Current guidelines recommend non-invasive functional or anatomic testing as a gatekeeper to the catheterization laboratory. However, the "holy grail" in non-invasive testing of CAD is to establish a single test that quantifies both coronary lesion severity and the associated ischemia. Most evidence to date of such a test is based on the addition of computational analysis of FFR to the anatomic information obtained from standard-acquired coronary CTA data sets at rest (FFRCT). This review summarizes the clinical evidence for the use of FFRCT in stable CAD in context to the diagnostic performance of other non-invasive testing modalities. Key Points • The process of selecting appropriate patients for invasive coronary angiography is inadequate • Invasive fractional flow reserve is the standard for assessing coronary lesion-specific ischemia • Fractional flow reserve may be derived from standard coronary CT angiography (FFR CT ) • FFR CT provides high diagnostic performance in stable coronary artery disease. PMID:25680721
Congenital coronary artery fistulae: a rare cause of heart failure in adults
Coronary artery fistulae are uncommon, reported in 0.25% of patients undergoing coronary angiography. Two patients with congenital coronary artery fistula and coronary artery disease who presented with symptoms of exacerbated congestive heart failure out of proportion to their atherosclerotic burden were successfully treated by epicardial fistula ligation and coronary artery bypass grafting with marked improvement in functional status. PMID:24886594
[Simultaneous carotid and vertebral revascularization in the aged].
Illuminati, G; Caliň, F G; Bertagni, A; Piermattei, A; Vietri, F; Martinelli, V
Five patients of a mean age of 76, have been submitted to combined vertebral and carotid artery revascularization for a severe vertebro-basilar insufficiency. Vertebral artery revascularization consisted of a transposition to the common carotid artery in one case and of a carotid-distal vertebral artery saphenous bypass graft. The associated carotid artery revascularization consisted of a carotid endarterectomy with patch in 4 cases and without patch in one case. There were no postoperative mortality and no postoperative stroke. Postoperative morbidity included a transitory revascularization syndrome, a myocardial ischemia and a Horner's syndrome. Complete relief of vertebrobasilar symptoms was obtained in 4 patients whereas in one patient only a mild positional vertigo persisted. All vascular reconstructions have been assessed with postoperative arteriography and duplex-scan every six months. At 11 months mean follow-up, all revascularizations are patent. Combined carotid and vertebral artery surgery is effective in well selected cases, and it does not enhance the risk of the two operations performed separately. It also eliminate the possibility of failure of isolated carotid revascularization for vertebrobasilar symptoms. PMID:9432582
[Revascularization of the carotid and vertebral arteries in the elderly].
Illuminati, G; Bezzi, M; D'Urso, A; Giacobbi, D; Ceccanei, G; Vietri, F
From January 1994 to July 2004, 323 patients underwent 348 revascularization of carotid bifurcation for atherosclerotic stenoses. Eighty eight patients (group A) were 75 year-old or older, whereas 235 (group B) were younger than 75 years. Postoperative mortality/neurologic morbidity rate was 1% in group A, and 1.4% in group B. At 5 years, patency and freedom from symptoms/stroke were, respectively, 91% and 92% in group A, and 89% and 91% in group B. None of these differences was statistically significant. In the same time period, 26 internal carotid arteries were revascularized in 24 patients, 75 or more aged, for a symptomatic kinking. Postoperative mortality/morbidity rate was absent, whereas, at 5 years, patency and freedom from symptoms/stroke were, respectively, 88% and 92%. Twelve vertebral arteries were revascularized in 12 patients, 75 or more aged, for invalidating symptoms of vertebrobasilar insufficiency. Postoperative mortality/neurologic morbidity rate was absent. In one case postoperative recurrence of symptoms occurred, despite a patent revascularization. Patency and freedom from symptoms/stroke were 84% and 75%, at 5 years. Revascularization of carotid and vertebral arteries in the elderly can be accomplished with good results, superposable to those of standard revascularization of carotid bifurcation in a younger patients' population. PMID:15803810
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients with Coronary Artery Disease and Diabetic Nephropathy: A Single Center Experience
Bae, Ki Sun; Park, Hyeong Cheon; Kang, Byung Seung; Park, Jong Won; Chon, Nu Ri; Oh, Kyung Jin; Yoon, Young Won; Hong, You Sun
Background Patients with diabetic nephropathy (DN) and coronary artery disease (CAD) represent a subset of patients with high cardiovascular morbidity and mortality. The optimal revascularization strategy using either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The purpose of this study was to compare the clinical outcomes of PCI to CABG in DN patients with CAD. Methods The clinical and angiographic records of DN patients with CAD who underwent either CABG (n=52) or PCI (n=48) were retrospectively analyzed. Results The baseline characteristics were similar in the two groups except for the severity of the CAD. At 30 days, the death rate (PCI: 2.1% vs. CABG: 9.6%, p=0.21) and major adverse cardiac events (MACE) rate (PCI: 2.1% vs. CABG: 9.6%, p=0.21) were similar in comparisons between the PCI and CABG groups. At three years, the death rate (PCI: 18.8% vs. CABG: 19.2%, p=0.94) was similar between the PCI and CABG groups but the MACE rate (PCI: 47.9% vs. CABG: 21.2%, p=0.006) was higher in the PCI group compared to the CABG group. In addition, the repeat revascularization rate was higher in the PCI group compared to the CABG group (PCI: 12.5% vs. CABG: 1.9%, p=0.046). Conclusions The CABG procedure was associated with a lower incidence of MACE and repeat revascularization for up to three years of follow-up in DN patients with CAD. However, the overall survival rate was similar in the CABG and PCI groups. Therefore, CABG may be superior to PCI with regard to MACE and repeat revascularization. PMID:17939329
Relationship between Body Mass Index and Outcome of Elective Percutaneous Coronary Intervention
Alidoosti, Mohammad; Salarifar, Mojtaba; Hajizeinali, Ali Mohammad; Kassaian, Seyed Ebrahim; Nematipour, Ebrahim; Aghajani, Hasan; Lotfi-Tokaldany, Masoumeh; Kazazi, Elham Hakki
Abstract Background: Studies have shown controversial effects of obesity on major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI). We sought to investigate the impact of the body mass index (BMI) on the mid-term outcome following successful PCI. Methods: Between March 2006 and August 2008, 3948 patients underwent successful elective PCI in Tehran Heart Center, Tehran, Iran, and were retrospectively included in this study. Patients who underwent PCI on the same day as the occurrence of myocardial infarction were excluded. The demographic, procedural, in-hospital, and follow-up information of these patients was extracted from the PCI Data Registry of our institution. The patients were divided into three groups: normal weight (No. 1058, BMI < 25 kg/m2 age = 58 ± 10 years); overweight (No. 1867, 25 ? BMI < 30 kg/m2, age = 57 ± 10 years); and obese (No. 1023, BMI ? 30 kg/m2, age = 56 ± 10 years). MACE included death, myocardial infarction, target vessel revascularization, and target lesion revascularization. Results: Compared with the other patients, the obese individuals were significantly younger and more frequently female, had a higher ejection fraction, and more frequently presented with hypertension, diabetes, and hyperlipidemia. There was no association between the BMI and the angiographic and procedural findings in the univariate analysis. While no difference was found in the rate of in-hospital death between the groups, the number of the obese patients undergoing emergent cardiac surgery was marginally different in the univariate analysis (p value = 0.06). At 9 months' follow-up, MACE had occurred in 92 (2.3%) patients and cardiac mortality was 9 (0.2%). After adjustments for confounders, no significant difference was observed in terms of MACE between the BMI groups. Conclusion: The BMI had no significant effect on the rate of MACE at 9 months' follow-up in our study population. Interventionists' recommendations for patients undergoing PCI should, therefore, not be significantly influenced by the BMI status. PMID:26157459
P. A. Wielopolski; R. J. M. van Geuns; P. J. de Feyter; M. Oudkerk
. Conventional coronary angiography (CA) is the standard of excellence for the evaluation of coronary artery disease. However,\\u000a non-invasive imaging modalities have developed that can play an important clinical role in the diagnosis. Magnetic resonance\\u000a imaging (MRI) can offer a comprehensive evaluation of the heart and the coronary arteries by virtue of its high soft tissue\\u000a contrast capabilities, double-oblique tomographic
Meta-analysis of multivessel versus culprit-only percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndrome and multivessel coronary disease.
Jang, Jae-Sik; Jin, Han-Young; Seo, Jeong-Sook; Yang, Tae-Hyun; Kim, Dae-Kyeong; Kim, Dong-Soo; Cho, Kyoung-Im; Kim, Bo-Hyun; Park, Yong Hyun; Je, Hyung-Gon
Even in the era of contemporary drug-eluting stents, it is not clear whether percutaneous coronary intervention (PCI) for nonculprit lesions can improve long-term outcomes in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary disease. Relevant studies published through August 2014 were searched and identified in the electronic databases. Summary estimates were obtained using a random-effects model. From 368 initial citations, 8 observational studies with 8,425 patients (3,227 multivessel and 5,198 culprit-only PCI) were included. Mean follow-up duration was 18 months. There were no significant differences in all-cause mortality (odds ratios [ORs] 0.85, 95% confidence interval [CI] 0.70 to 1.04) and myocardial infarction (OR 0.86, 95% CI 0.55 to 1.35). However, multivessel PCI was associated with a significantly lower rate of repeat revascularization (OR 0.75, 95% CI 0.56 to 1.00). Comparison of multivessel versus culprit-only PCI disclosed OR for major adverse cardiac events of 0.74 (95% CI 0.57 to 0.97). In conclusion, multivessel PCI reduced repeat revascularization without significant benefits in terms of mortality or myocardial infarction at the long-term follow-up in patients with NSTE-ACS and multivessel coronary disease. Future randomized studies that examine the safety and efficacy of multivessel PCI in NSTE-ACS are warranted. PMID:25724783
Clinical significance of no-reflow phenomenon observed on angiography after successful treatment of acute myocardial infarction with percutaneous transluminal coronary angioplasty
Itsuro Morishima; Takahito Sone; Shinji Mokuno; Shin Taga; Akemi Shimauchi; Yoshitaka Oki; Junichiro Kondo; Hideyuki Tsuboi; Hiromi Sassa
The clinical significance of the angiographic no-reflow phenomenon was evaluated in 93 patients with acute myocardial infarction treated by percutaneous transluminal coronary angioplasty (PTCA). On the basis of the post-PTCA angiograms, patients were divided into three groups: normal angiogram (group 1, n=65), slight no-reflow (group 2, n = 13), and severe no-reflow (group 3, n = 15). Regional wall motion
Current status and future directions in computer-enhanced video- and robotic-assisted coronary bypass surgery
W. Douglas Boyd; Kojiro Kodera; Kenneth D. Stahl; Reiza Rayman
Since 1997, both the Cleveland Clinic and London Health Sciences Centre groups have embraced robotic assistance and more recently demonstrated the efficacy of this technology in totally closed-chest, beating heart myocardial revascularization. This endeavor involved an orderly progression and the learning of new surgical skill sets. We review the evolution of robot-enhanced coronary surgery and forecast the future of endoscopic
Coronary Ostial Stenosis after Aortic Valve Replacement
Ziakas, Antonios G.; Economou, Fotios I.; Charokopos, Nicholas A.; Pitsis, Antonios A.; Parharidou, Despina G.; Papadopoulos, Thomas I.; Parharidis, Georgios E.
Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention. Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option. PMID:20844624
Analysis of the bypass angioplasty revascularization investigation trial using a multistate model of clinical outcomes.
Zhang, Xiao; Li, Quanlin; Rogatko, Andre; Tighiouart, Mourad; Hardison, Regina M; Brooks, Maria Mori; Kelsey, Sheryl F; Kaul, Sanjay; Bairey Merz, C Noel
Current cardiovascular randomized trials typically use composite outcomes. We hypothesized that the Bypass Angioplasty Revascularization Investigation (BARI) outcomes and conclusions would differ using a multistate model relative to the intervention for the composite outcome of death (D) and nonfatal Q-wave myocardial infarction (MI). We used a multistate model which uses transition paths to simultaneously assess multiple end points. Using the 10-year follow-up BARI data, we post hoc analyzed outcomes according to 3 transition paths: (1) from intervention to MI; (2) from intervention to death; and (3) from MI to death. Of 1,829 patients randomized to the intervention of percutaneous transluminal coronary angioplasty or coronary artery bypass grafting (CABG), 700 (38%) experienced the composite event D/MI which included 230 (13%) nonfatal MI and 470 (26%) death without antecedent nonfatal MI, whereas 79 of 230 (34%) experienced death after nonfatal MI. Outcomes of the 3 individual transition paths were analyzed by a multistate model. In contrast to standard survival analyses, after adjustment for baseline clinical covariates, outcomes after percutaneous transluminal coronary angioplasty or CABG were not significantly different for intervention to MI (p = 0.33) or intervention to death (p = 0.23), but MI to death favored CABG (p = 0.02). Deconstruction of the BARI data using a multistate model identifies a significant difference in individual transition-stage outcomes and therefore trial conclusions in contrast to the standard methods of survival analysis. These observations suggest multistate models should be considered in the design and analysis of randomized cardiovascular trials which use composite outcomes. PMID:25724784
Renal Athersosclerotic reVascularization Evaluation (RAVE Study): Study protocol of a randomized trial [NCT00127738
Sheldon W Tobe; M Atri; N Perkins; R Pugash; Chaim M Bell
BACKGROUND: It is uncertain whether patients with renal vascular disease will have renal or mortality benefit from re-establishing renal blood flow with renal revascularization procedures. The RAVE study will compare renal revascularization to medical management for people with atherosclerotic renal vascular disease (ARVD) and the indication for revascularization. Patients will be assessed for the standard nephrology research outcomes of progression
Comparison of bare-metal stents and drug-eluting stents in coronary ostial lesions (from the National Heart, Lung, and Blood Institute Dynamic Registry).
Vasaiwala, Samip; Vlachos, Helen; Selzer, Faith; Marroquin, Oscar; Mulukutla, Suresh; Abbott, J Dawn; Williams, David O
We compared the effectiveness of drug-eluting stents (DESs) to bare-metal stents (BMSs) in ostial lesions from an unrestricted patient cohort with 3-year follow-up. DESs have proved more effective at decreasing repeat revascularization rates compared to BMSs in patients with uncomplicated coronary artery disease. Whether DESs provide similar benefits in ostial lesions is not clearly defined. We analyzed data from 775 patients in the National, Heart, Lung, and Blood Institute Dynamic Registry undergoing stenting of ostial lesions with DESs or BMSs. Patients were followed for 3 years for the occurrence of myocardial infarction (MI), repeat revascularization (coronary bypass surgery/repeat percutaneous coronary intervention), and death. In total 439 patients had 464 ostial lesions treated with BMSs and 336 patients had 351 ostial lesions treated with DESs. Adjusted DES versus BMS 3-year hazard ratios were 1.03 (95% confidence interval 0.60 to 1.78, p = 0.90) for death, 1.40 (0.83 to 2.37, p = 0.21) for MI, and 0.81 (0.59 to 1.11, p = 0.19) for repeat revascularization. In patients undergoing percutaneous coronary intervention for aorto-ostial disease (n = 200), death and repeat revascularization did not differ between stent types, but DES-treated patients had more MI during follow-up. For coronary ostial disease (n = 574), 3-year observed rates of death or MI did not differ; however, repeat revascularization was more common in the BMS group. In conclusion, use of DESs for ostial lesions was associated with no difference in the hazard of death, MI, or overall rates of repeat revascularization compared to BMS use. PMID:22762712
Medical and Revascularization Therapies for Asymptomatic Carotid Stenosis.
Dharmadhikari, Sushrut; Chaturvedi, Seemant
Asymptomatic internal carotid artery stenosis increases with age and is more common in men. Carotid endarterectomy and stenting have reduced stroke rates in patients with asymptomatic carotid stenosis in clinical trials. A variety of risk stratification methods are available for selection of patients with carotid stenosis for revascularization. In the past decade, there is increasing evidence that the rate of stroke declined with the use of aggressive multi-modal medical therapy. These developments have led to new clinical trials to compare revascularization versus aggressive medical therapy in patients with asymptomatic carotid stenosis. PMID:26068476
"Lower Limbs Revascularization from Supraceliac and Thoracic Aorta".
Wistuba, Mariel Riedemann; Alonso-Pérez, Manuel; Al-Sibbai, Amer Zanabili; González-Gay, Mario; Alvarez Marcos, Francisco; Camblor, Lino A; Llaneza-Coto, José Manuel
Revascularization of femoral arteries from descending thoracic or supraceliac aorta is an uncommon procedure, in part because of the popularization of the technically easier extra-anatomic bypasses. However, using those aortic levels as the source of the bypass inflow is a useful alternative in selected patients with aortoiliac disease, with excellent results. We report long-term results in 4 patients with revascularization from thoracic aorta and another 2 cases from aorta at supraceliac level. This technique should be considered as a good alternative in patients with adverse abdominal conditions or with a severely diseased infrarenal aorta due to heavy calcification. PMID:25771745
... the NHLBI on Twitter. What Is a Coronary Calcium Scan? A coronary calcium scan is a test ... you have calcifications in your coronary arteries. Coronary Calcium Scan Figure A shows the position of the ...
Heart disease, Coronary heart disease, Coronary artery disease; Arteriosclerotic heart disease; CHD; CAD ... Coronary heart disease (CHD) is the leading cause of death in the United States for men and women. Coronary ...
Coronary Artery Bypass Grafting
... from the NHLBI on Twitter. What Is Coronary Artery Bypass Grafting? Coronary artery bypass grafting (CABG) is ... bypass multiple coronary arteries during one surgery. Coronary Artery Bypass Grafting Figure A shows the location of ...
Early and mid-term results of minimally invasive coronary artery bypass grafting
Pande, Shantanu; Agarwal, Surendra K.; Gupta, Devendra; Mohanty, Satayapriya; Kapoor, Aditya; Tewari, Satyendra; Bansal, Anubhav; Ambesh, Sushil P.
Introduction Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique. Method We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months–4 years) is available. Results Median age was 58.5 years (41–77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up. Conclusion MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting. PMID:24814114
P. A. Wielopolski; R. J. M. van Geuns; P. J. de Feyter; M. Oudkerk
. Coronary angiography (CA) is presently considered the gold standard for the assessment of the coronary arteries. However,\\u000a the presence of ionizing radiation, its invasiveness and the small associated risk of morbidity prompted long ago the development\\u000a of more patient-friendly imaging modalities. A promising technique, magnetic resonance imaging (MRI), has been regarded as\\u000a the major modality in the coming decade.
Robotically-Assisted Coronary Artery Bypass Grafting
Folliguet, Thierry A.; Dibie, Alain; Philippe, François; Larrazet, Fabrice; Slama, Michel S.; Laborde, François
Objectives. Robotic surgery enables to perform coronary surgery totally endoscopically. This report describes our experience using the da Vinci system for coronary artery bypass surgery. Methods. Patients requiring single-or-double vessel revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. Results. From April 2004 to May 2008, fifty-six patients were enrolled in the study. Twenty-four patients underwent robotic harvesting of the mammary conduit followed by minimal invasive direct coronary artery bypass (MIDCAB), and twenty-three patients had a totally endoscopic coronary artery bypass (TECAB) grafting. Nine patients (16%) were converted to open techniques. The mean total operating time for TECAB was 372 ± 104 minutes and for MIDCAB was 220 ± 69 minutes. Followup was complete for all patients up to one year. There was one hospital death following MIDCAB and two deaths at follow up. Forty-eight patients had an angiogram or CT scan revealing occlusion or anastomotic stenoses (>50%) in 6 patients. Overall permeability was 92%. Conclusions. Robotic surgery can be performed with promising results. PMID:20339505
Coronary artery disease and diabetes - Management during Ramadan.
Khan, Idris Ahmed
Ramadan is the Islamic holy month of fasting and practiced by all adult Muslims all over the world at the same time simultaneously. Although people who are ill or diabetics with coronary heart disease are exempted from fasting, they still desire to fast and this is a challenge to themselves and the treating physician. We performed a systematic review of the available Medline English literature on the subject from January 1982 to December 2014 so as to help guide physicians in managing these patients. The results revealed that although the metabolic parameters change during Ramadan fasting, but this does not lead to any significant increase in the incidence of acute coronary events. Most adults with stable coronary artery disease can fast without significant complications, but those with unstable disease or recent or pending revascularization procedures should generally refrain from fasting. Regular monitoring by the physician is mandatory along with adjustment of the dosages. PMID:26013792
Myocardial revascularization for situs inversus totalis and dextrocardia
Pramod Bonde; G. F. Campalani
Situs inversus totalis with dextrocardia is rare and presentation with coronary artery disease in the ninth decade of life is even rarer. Here we describe a case where a patient underwent coronary stenting and subsequently coronary bypass surgery for the same.
Complete reversal of ischemic wall motion abnormalities by combined use of gene therapy with transmyocardial laser revascularization
Umer Sayeed-Shah; Michael J. Mann; Jeffrey Martin; Sergery Grachev; Sharon Reimold; Rita Laurence; Victor Dzau; Lawrence H. Cohn
Introduction:Transmyocardial laser revascularization is believed to induce an angiogenic response within ischemic myocardium. We evaluated transgene expression in the setting of transmyocardial laser revascularization and hypothesized that intramyocardial injection of plasmid DNA encoding the gene for vascular endothelial growth factor could enhance the revascularization achieved by transmyocardial laser revascularization, resulting in improved cardiac function. Methods: Ten Yorkshire pigs had carbon
[Replantation and revascularization of the thumb in musculoskeletal trauma center--presentation of 2 cases].
Szczesny, Grzegorz; Baza?a, Maciej
Summary We present two cases of successful microsurgical replantation and revascularization of the thumb of dominating extremity in young men performed in orthopedic department, to whom operative treatment in specialized replantation center could not be performed. Microvasculature of the finger was restored anastomosing microsurgically its artery and vein under operative microscope, and bone fracture was stabilized intramedullary with Kirschner wires. In both cases vitality of the finger was restored, which enabled proper healing of soft tissues and bone, leading to restoration of satisfactory function of the thumb. Due to high value for the function of the hand, thumb injuries threading with its loss should be managed primarily. Due to small vessel diameter those procedures require special instrumentation and trained personnel, and thus shouldbe done in replantation centers. Nevertheless, when treatment in an appropriate center is unavailable, those procedures could also be successfully performed by trained orthopedists. PMID:21853913
The tourniquet revisited as an adjunct to lower limb revascularization
Alfonso Ciervo; Herbert Dardik; Feng Qin; Fred Silvestri; Fred Wolodiger; Barry Hastings; Sung Lee; Audwin Pangilinan; Kurt Wengerter
Purpose: The purpose of this study was to evaluate the role and efficacy of the tourniquet in lower limb revascularization.Methods: During a 3-year period, 195 patients underwent 205 infrainguinal reconstruction operations in the lower extremity. These patients underwent bypass with a tourniquet and inflow occlusion (group 1) or bypass without a tourniquet (group 2). The type of infrainguinal reconstruction, tourniquet
Bioresorbable scaffolds for percutaneous coronary interventions
Gogas, Bill D.
Innovations in drug-eluting stents (DES) have substantially reduced rates of in-segment restenosis and early stent thrombosis, improving clinical outcomes following percutaneous coronary interventions (PCI). However a fixed metallic implant in a vessel wall with restored patency and residual disease remains a precipitating factor for sustained local inflammation, in-stent neo-atherosclerosis and impaired vasomotor function increasing the risk for late complications attributed to late or very late stent thrombosis and late target lesion revascularization (TLR) (late catch-up). The quest for optimal coronary stenting continues by further innovations in stent design and by using biocompatible materials other than cobalt chromium, platinum chromium or stainless steel for engineering coronary implants. Bioresorbable scaffolds made of biodegradable polymers or biocorrodible metals with properties of transient vessel scaffolding, local drug-elution and future restoration of vessel anatomy, physiology and local hemodynamics have been recently developed. These devices have been utilized in selected clinical applications so far providing preliminary evidence of safety showing comparable performance with current generation drug-eluting stents (DES). Herein we provide a comprehensive overview of the current status of these technologies, we elaborate on the potential benefits of transient coronary scaffolds over permanent stents in the context of vascular reparation therapy, and we further focus on the evolving challenges these devices have to overcome to compete with current generation DES. Condensed Abstract:: The quest for optimizing percutaneous coronary interventions continues by iterative innovations in device materials beyond cobalt chromium, platinum chromium or stainless steel for engineering coronary implants. Bioresorbable scaffolds made of biodegradable polymers or biocorrodible metals with properties of transient vessel scaffolding; local drug-elution and future restoration of vessel anatomy, physiology and local hemodynamics were recently developed. These devices have been utilized in selected clinical applications providing preliminary evidence of safety showing comparable intermediate term clinical outcomes with current generation drug-eluting stents. PMID:25780795
Coronary Perforation and Covered Stents: An Update and Review
Al-Mukhaini, Mohammed; Panduranga, Prashanth; Sulaiman, Kadhim; Riyami, Abdulla Amour; Deeb, Mohammed; Riyami, Mohamed Barkat
Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventional cardiology. Coronary perforations are classified as type I (extraluminal crater), II (myocardial or pericardial blushing), and III (contrast streaming or cavity spilling). Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardial drainage. However, type III perforations can be managed with covered stents without need for surgical intervention. PMID:22121463
Use of Drug-Eluting Stents in Patients With Coronary Artery Disease and Renal Insufficiency
El-Menyar, Ayman A.; Al Suwaidi, Jassim; Holmes, David R.
Renal insufficiency (RI) has been shown to be associated with increased major adverse cardiovascular events after percutaneous coronary intervention. We reviewed the impact of RI on the pathogenesis of coronary artery disease and outcomes after percutaneous coronary intervention in the form of drug-eluting stent (DES) implantation in these high-risk patients. We searched the English-language literature indexed in MEDLINE, Scopus, and EBSCO Host research databases from 1990 through January 2009, using as search terms coronary revascularization, drug-eluting stent, and renal insufficiency. Studies that assessed DES implantation in patients with various degrees of RI were selected for review. Most of the available data were extracted from observational studies, and data from randomized trials formed the basis of a post hoc analysis. The outcomes after coronary revascularization were less favorable in patients with RI than in those with normal renal function. In patients with RI, DES implantation yielded better outcomes than did use of bare-metal stents. Randomized trials are needed to define optimal treatment of these high-risk patients with coronary artery disease. PMID:20118392
Pulp revascularization after repositioning of impacted incisor with a dilacerated root and a detached apex.
Plakwicz, Pawe?; Kapu?ci?ska, Agnieszka; Kuku?a, Krzysztof; Czochrowska, Ewa Monika
Severely impacted and dilacerated incisors are rarely considered for surgical exposure because they may not respond favorably to orthodontic extrusion. These incisors are often extracted, resulting in the need for tooth replacement; however, prosthetic solutions are limited in growing patients. Transalveolar autotransplantation of an impacted incisor may be the only method to preserve the natural tooth and maintain the shape of the alveolus. The severely impacted upper central incisor (#9) with a developing root was diagnosed in a 9-year-old girl. The unfavorable tooth position and dilaceration of its root made orthodontic extrusion of the impacted incisor impossible. Initial orthodontic space opening at the recipient site was performed before the surgery. Transalveolar transplantation of the impacted incisor to its normal position was performed to avoid tooth extraction. The incisor was later aligned using fixed orthodontic appliances. At the 5-year follow-up, the transplanted incisor presented features that were typical of a revascularized tooth (ie, obliteration of root canal but a positive response to vitality tests). Healthy periodontal tissues and continued root development were also noted. However, the root apex, which separated from the transplant at the time of the surgery, continued formation in its initial position. Transalveolar transplantation of an unfavorably impacted upper central incisor with a dilacerated root is a successful treatment, which stands the test of time. The early stage of root development allowed revascularization of the tooth despite dilaceration of the root and detachment of its apex. PMID:25770037
Pulp Revascularization- It's your Future Whether you Know it or Not?
Dudeja, Pooja Gupta; Grover, Shibani; Srivastava, Dhirendra; Sharma, Vivek
Pulpal regeneration after tooth injury is not easy to accomplish. In teeth with immature apices and exposed vital pulp tissue, partial or complete pulpotomy is indicated to preserve pulpal function and allow continued root development. In many cases, injury causes loss of pulp vitality and arrested root development leading to a tooth with poor crown root ratio, a root with very thin walls, an open blunderbuss apex and development of apical pathosis. The ideal treatment in such cases would be to obtain further root development and thickening of dentinal walls by stimulating the regeneration of a functional pulp dentin complex. This outcome has been observed after reimplantation in avulsed immature permanent teeth but has been thought impossible in a necrotic infected tooth. This case series evaluates the efficacy of revascularization procedure in immature, non vital permanent teeth. Pulp regeneration was attempted in four patients at Department of Conservative Dentistry, ESIC Dental College, New Delhi using blood clotting approach. The cases were treated and followed up regularly at regular intervals ranging from 6 months to 3 years to assess the treatment response clinically and radiographically. The patients remained clinically asymptomatic with three out of four patients even responding positively to pulp responsiveness tests. Radiographic examination also revealed increased root formation and thickening of dentinal walls. It was concluded that the triad of a disinfected canal, a matrix (blood clot) in to which new tissue could grow and an effective coronal seal produced the desirable environment for successful revascularization.
Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease
Satyendra Giri; Leslee J. Shaw; Dakshina R. Murthy
Background—Coronary artery disease can develop prematurely and is the leading cause of death among diabetics, making noninvasive risk stratification desirable. Methods and Results—Patients with symptoms of coronary artery disease who were undergoing stress myocardial perfusion imaging (MPI) from 5 centers were prospectively followed (2.51.5 years) for the subsequent occurrence of cardiac death, myocardial infarction (MI), and revascularization. Stress MPI results
Modifications of Coronary Risk Factors
Albu, Jeanine; Gottlieb, Sheldon H.; August, Phyllis; Nesto, Richard W.; Orchard, Trevor J.
In addition to the revascularization and glycemic management interventions assigned at random, the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) design includes the uniform control of major coronary artery disease risk factors, including dyslipidemia, hypertension, smoking, central obesity, and sedentary lifestyle. Target levels for risk factors were adjusted throughout the trial to comply with changes in recommended clinical practice guidelines. At present, the goals are low-density lipoprotein cholesterol <2.59 mmol/L (<100 mg/dL) with an optional goal of <1.81 mmol/L (<70 mg/dL); plasma triglyceride level <1.70 mmol/L (<150 mg/dL); blood pressure level <130 mm Hg systolic and <80 mm Hg diastolic; and smoking cessation treatment for all active smokers. Algorithms were developed for the pharmacologic management of dyslipidemia and hypertension. Dietary prescriptions for the management of glycemia, plasma lipid profiles, and blood pressure levels were adapted from existing clinical practice guidelines. Patients with a body mass index >25 were prescribed moderate caloric restriction; after the trial was under way, a lifestyle weight-management program was instituted. All patients were formally prescribed both endurance and resistance/flexibility exercises, individually adapted to their level of disability and fitness. Pedometers were distributed as a biofeedback strategy. Strategies to achieve the goals for risk factors were designed by BARI 2D working groups (lipid, cardiovascular and hypertension, and nonpharmacologic intervention) and the ongoing implementation of the strategies is monitored by lipid, hypertension, and lifestyle intervention management centers. PMID:16813737
Coronary air embolism treated with aspiration catheter
Patterson, M S; Kiemeneij, F
Coronary air embolism remains a recognised complication of coronary catheterisation despite a strong emphasis on prevention. Current treatment consists of supportive measures with 100% oxygen and analgesia. Recent case reports describe the use of mechanical treatments aimed at dispersing or removing the air embolus with variable success. A case of coronary air embolism causing an acute coronary syndrome is described that was definitively treated with an aspiration system. The effectiveness of the aspiration system in the distal section of an obtuse marginal artery indicates that such dedicated aspiration systems may prove useful in the standard treatment of air embolism. PMID:15831621
Management and Long-Term Prognosis of Spontaneous Coronary Artery Dissection.
Lettieri, Corrado; Zavalloni, Dennis; Rossini, Roberta; Morici, Nuccia; Ettori, Federica; Leonzi, Ornella; Latib, Azeem; Ferlini, Marco; Trabattoni, Daniela; Colombo, Paola; Galli, Mario; Tarantini, Giuseppe; Napodano, Massimo; Piccaluga, Emanuela; Passamonti, Enrico; Sganzerla, Paolo; Ielasi, Alfonso; Coccato, Micol; Martinoni, Alessandro; Musumeci, Giuseppe; Zanini, Roberto; Castiglioni, Battistina
The optimal management and short- and long-term prognoses of spontaneous coronary artery dissection (SCAD) remain not well defined. The aim of this observational multicenter study was to assess long-term clinical outcomes in patients with SCAD. In-hospital and long-term outcomes were assessed in 134 patients with documented SCAD, as well as the clinical impact and predictors of a conservative rather than a revascularization strategy of treatment. The mean age was 52 ± 11, years and 81% of patients were female. SCAD presented as an acute coronary syndromes in 93% of patients. A conservative strategy was performed in 58% of patients and revascularization in 42%. On multivariate analysis, distal versus proximal or mid location of dissection (odds ratio 9.27) and basal Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or 3 versus 0 or 1 (odds ratio 0.20) were independent predictors of conservative versus revascularization strategy. A conservative strategy was associated with better in-hospital outcomes compared with revascularization (rates of major adverse cardiac events 3.8% and 16.1%, respectively, p = 0.028); however, no significant differences were observed in the long-term outcomes. In conclusion, in this large observational study of patients with SCAD, angiographic features significantly influenced the treatment strategy, providing an excellent short- and long-term prognosis. PMID:25937347
Coronary artery disease performance measures and statin use in patients with recent percutaneous coronary intervention or recent coronary artery bypass grafting (from the NCDR PINNACLE registry).
Bandeali, Salman J; Gosch, Kensey; Alam, Mahboob; Kayani, Waleed T; Jneid, Hani; Fiocchi, Fran; Wilson, James M; Chan, Paul S; Deswal, Anita; Maddox, Thomas M; Virani, Salim S
The association between coronary revascularization strategy (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) and compliance with coronary artery disease (CAD) performance measures is not well studied. Our analysis studied patients enrolled in the Practice Innovation and Clinical Excellence registry, who underwent coronary revascularization using PCI or CABG in the 12 months before their most recent outpatient visit in 2011. We compared the attainment of CAD performance measures and statin use in eligible patients with PCI and CABG using hierarchical logistic regression models. Our study cohort consisted of 112,969 patients (80,753 with PCI and 32,216 with CABG). After adjustment for site and patient characteristics, performance measure compliance for tobacco use query (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.76 to 0.86), antiplatelet therapy (OR 0.9; 95% CI 0.86 to 0.94) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (OR 0.89; 95% CI 0.84 to 0.94) was lower in CABG compared with patients with PCI. Patients who underwent recent CABG had higher rates of ?-blocker (OR 1.25; 95% CI 1.16 to 1.33) and statin treatment (OR 1.37; 95% CI 1.31 to 1.43) compared with patients with PCI. Of the 79 practice sites, 15 (19%) had ?75% of their patients with CAD (CABG or PCI) meeting 75% to 100% of all eligible CAD performance measures. In conclusion, gaps persist in compliance with specific CAD performance measures in patients with recent PCI or CABG, and 1 in 5 practices had ?75% compliance of eligible CAD performance measures in the most of their patients. PMID:25721483
Is the addition of ECG gating to technetium-99m sestamibi SPET of value in the assessment of myocardial viability? An evaluation based on two-dimensional echocardiography following revascularization.
González, P; Massardo, T; Muńoz, A; Jofré, J; Rivera, A; Yovanovich, J; Maiers, E; Ayala, F; Humeres, P; Ramírez, A; Arriagada, M; Zavala, A
The main goal of this study was to evaluate whether the addition of ECG gating to technetium-99m sestamibi single-photon emission tomographic (SPET) perfusion imaging assists the prediction of recovery of regional wall motion abnormalities after revascularization. Thirty-six patients with coronary artery disease were included in the study. All had wall motion abnormalities, and 31 (86%) had a clinical history of myocardial infarction. Coronary artery bypass surgery was performed in 18 patients and angioplasty in the remainder. All underwent ECG-gated and non-gated SPET at rest and after intravenous dipyridamole. Two-dimensional echocardiography was performed at a mean of 27 days before revascularization and at a mean of 69 days following revascularization to assess segmental wall motion changes. Perfusion prior to revascularization was analysed qualitatively and quantitatively on gated and non-gated SPET, and the results compared with those of echocardiography. Bullseye parameters were obtained from a normal database, generated from data in 40 normal volunteers, using dipyridamole ECG-gated and non-gated sestamibi SPET. There was good concordance between gated and non-gated qualitative analysis (79% with kappa=0.65) for normal, viable or necrotic segments. Gated SPET predicted functional recovery in 27 of 35 (77%) segments showing echocardiographic improvement while non-gated SPET did so in 30 of 39 (77%) such segments. Gated SPET predicted no functional recovery in 20 of 45 (44%) segments that did not show improved wall motion after revascularization, while with non-gated SPET the figure was 18 of 51 (35%). The positive predictive values of gated and non-gated SPET with regard to the recovery of wall motion following revascularization were 52% and 48%, while the negative predictive values were 71% and 67%, respectively. 99mTc-sestamibi had a low predictive value for recovery of function if visual assessment was used in the analysis of SPET data. Quantitative bullseye sestamibi parameters (defect extension and severity, reversibility and percentage change in extension), from gated or non-gated studies, appear best to distinguish which segments will display improved motility on the echocardiogram after revascularization. The addition of ECG gating does not significantly increase the predictive value of SPET imaging with regard to recovery of function. PMID:8781135
Economic Impact of Angioplasty Salvage Techniques, With an Emphasis on Coronary Stents: A Method Incorporating Costs, Revenues, Clinical Effectiveness and Payer Mix
Paul T. Vaitkus; William T. Witmer; Richard G. Brandenburg; Susannah K. Wells; Jonathan B. Zehnacker
Objectives. We sought to broaden assessment of the economic impact of percutaneous transluminal coronary angioplasty (PTCA) revascularization salvage strategies by taking into account costs, revenues, the off-setting effects of prevented clinical complications and the effects of payer mix.Background. Previous economic analyses of PTCA have focused on the direct costs of treatment but have not accounted either for associated revenues or
[Relation between cardiology and cardiosurgery in a center without cardiosurgery: an organizational proposal in the coronary syndromes].
Casella, Gianni; Pavesi, Pier Camillo; Sangiorgio, Pietro; Rubboli, Andrea; Nobile, Giampiero; Gordini, Giovanni; Pierangeli, Angelo; Bracchetti, Daniele
A modern cardiology department has very frequent relations with a heart surgery center for the management of stable and unstable patients with coronary artery disease. Therefore, these relations need to be formally defined. This impelling necessity stems from the clinical evidence that a high number of unstable patients need a timely revascularization as well as from the economical pressure to correctly allocate the limited surgical resources available. Thus three main contexts should be clearly defined: 1) surgical support during coronary angioplasty (PTCA), when this activity is performed on-site; 2) timely revascularization of unstable patients admitted to the coronary care unit or the ward; 3) surgical prioritization of stable subjects undergoing diagnostic catheterization. The increased experience in PTCA as well as several technical improvements, namely stents, has dramatically reduced the need for emergency surgical revascularization and has induced an evolution in the stand-by strategy with new concepts such as "surgical back-up" or "next available operating room". Therefore, the role of heart surgery has switched from the emergency treatment of the frequent complications of PTCA to the timely revascularization of subjects not suitable for percutaneous interventions. Thus, PTCA "without on-site" surgical facilities is gaining widespread acceptance. With the aim of defining the requirements to perform PTCA at hospitals without coronary surgery facilities, several aspects are reviewed. Furthermore, the concepts of timely surgical revascularization in unstable patients as well as the management of surgical prioritization for stable subjects submitted to diagnostic catheterization are discussed in detail. Therefore, there is still a tight relation between cardiology and heart surgery in several clinical contexts. However, the main issues of these relations as well as outcomes do not differ significantly whether heart surgery is on-site or off-site. PMID:12040847
Bishop, Harry A.; O'Loughlin, Bernard J.
The rapid injection of opaque media through a large bore, closed-end, side-hole catheter positioned adjacent to the sinuses of Valsalva reliably opacifies the coronary arteries. The potential toxicity of a rapidly introduced large volume of contrast agent and the necessity of peripheral arteriotomy are drawbacks of this procedure. Such innovations as loop-ended catheters, balloon occlusion of the aorta, percutaneous arterial catheterization and acetylcholine cardiac arrest have been introduced as attempts are made to increase the reliability and safety of coronary arteriography. ImagesFigure 1.Figure 2. PMID:18732385
Obesity and coronary artery disease: evaluation and treatment.
Garcia-Labbé, David; Ruka, Emmeline; Bertrand, Olivier F; Voisine, Pierre; Costerousse, Olivier; Poirier, Paul
With the increasing prevalence of obesity, clinicians are now facing a growing population of patients with specific features of clinical presentation, diagnostic challenges, and interventional, medical, and surgical management. After briefly discussing the effect of obesity on atherosclerotic burden in this review, we will focus on strategies clinicians might use to ensure better outcomes when performing revascularization in obese and severely obese patients. These patients tend to present comorbidities at a younger age, and their anthropometric features might limit the use of traditional cardiovascular risk stratification approaches for ischemic disease. Alternative techniques have emerged, especially in nuclear medicine. Positron emission tomography-computed tomography might be the diagnostic imaging technique of choice. When revascularization is considered, features associated with obesity must be considered to guide therapeutic strategies. In percutaneous coronary intervention, a radial approach should be favoured, and adequate antiplatelet therapy with new and more potent agents should be initiated. Weight-based anticoagulation should be contemplated if needed, with the use of drug-eluting stents. An "off-pump" approach for coronary artery bypass grafting might be preferable to the use of cardiopulmonary bypass. For patients who undergo bilateral internal thoracic artery grafting, harvesting using skeletonization might prevent deep sternal wound infections. In contrast to percutaneous coronary intervention, lower surgical bleeding has been observed when lean body mass is used for perioperative heparin dose determination. PMID:25661553
Incomplete Revascularization is Associated with Higher Risk of Long-Term Mortality after Stenting in the Era of First Generation Drug-Eluting Stents
Wu, Chuntao; Dyer, Anne-Marie; Walford, Gary; Holmes, David R.; King, Spencer B.; Stamato, Nicholas J.; Sharma, Samin; Jacobs, Alice K.; Venditti, Ferdinand J.; Hannan, Edward L.
The association between incomplete revascularization (IR) and long-term mortality following stenting in the era of drug-eluting stents (DES) is not well understood. In this study, we test the hypothesis that IR is associated with a higher risk of long-term (5-year) mortality following stenting for multivessel coronary disease. Using data from New York State's Percutaneous Coronary Intervention Reporting System, 21,767 patients with multivessel disease who underwent stenting between October 2003 and December 2005 were identified. Complete revascularization (CR) was achieved in 6,844 (31.4%) patients, and 14,923 (68.6%) patients were incompletely revascularized. The CR and IR patients were propensity-matched on a 1:1 ratio on the number of diseased vessels, the presence of total occlusion, type of stents, and the probability of achieving CR estimated using a logistic model with established risk factors as independent variables. Patients were followed for vital status until December 31, 2008 using the National Death Index. Differences in survival between the matched CR and IR patients were compared. Among the 6,511 pairs of propensity-matched patients, the 5-year survival rate for IR was lower compared to CR (79.3% vs. 81.4%, P=0.004), and the risk of death during follow-up was 16% higher for IR in comparison to CR (hazard ratio=1.16, 95% confidence interval: 1.06–1.27, P=0.001). In addition, subgroup analyses demonstrated that the association between IR and long-term mortality was not dependent on major patient risk factors. In conclusion, IR is associated with an increased risk of long-term mortality following stenting for multivessel disease in the DES era. PMID:23756548
Coronary arteriography and angioplasty
King, S.B.; Douglas, J.S.
This book explores biomedical radiography of the heart. Topics considered include six bench marks in the history of cardiac catheterization; normal coronary anatomy; anomalies of the coronary arteries; pathoanotomy of the coronary arteries and complications; indications, limitations, and risks of coronary arteriography and left ventriculography; catheterization techniques in coronary arteriography and left ventriculography: the Sones technique; catheterization techniques in coronary arteriography and left ventriculography: the Judkins technique; modification of Judkins catheters; catheterization techniques in coronary arteriography and left ventriculography multipurpose technique; new views in coronary arteriography; quantitative evaluation of left ventricular function; complications of coronary arteriography: management during and following the procedure; interpretation of coronary arteriograms and left ventriculograms; prevalence and distribution of disease in patients catheterized for suspected coronary disease at Emory University Hospital; the Cardiac Catheterization Laboratory; selection for surgery or percutaneous transluminal coronary angioplasty; intracoronary thrombolysis; and percutaneous transluminal coronary angioplasty.
... ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack . Over time, ruptured plaque also hardens and narrows ...
Myocardial revascularization in dextrocardia with situs inversus totalis
Cheemalapati Sai Krishna; Palli Venkata Naresh Kumar; Kanteti Ram Mohan; Dibya Kumar Baruah
Dextrocardia with situs inversus totalis occurs with an incidence of 1 in 10,000 and the pattern of susceptibility to coronary\\u000a disease is similar to the general population. An adult male patient with situs inversus-dextrocardia who underwent percutaneous\\u000a intervention for a discrete lesion in the right coronary artery presented two years later with rapid progression of lesions\\u000a in the left coronary
Late intervention in an asymptomatic pediatric patient with anomalous left coronary artery
Lam, John C; Giuffre, Michael; Myers, Kimberley A
Anomalous left coronary artery from the pulmonary artery (ALCAPA) is most commonly diagnosed within the first year of life with congestive heart failure symptomatology reflecting left ventricle (LV) dysfunction. The late diagnosis of ALCAPA is presented in a 5-year-old without significant LV dysfunction, mild LV dilatation and only mild mitral regurgitation that did not change significantly after surgery. The timing of surgical intervention in the late diagnosis of ALCAPA remains unclear despite risks of significant ongoing myocardial injury secondary to coronary artery hypoperfusion and progressive mitral valve dysfunction. Intervention in this case allows for revascularization which may reverse ventricular and valvular dysfunction. PMID:25228967
Effect of renal revascularization on the development of renal dysfunction in atherosclerotic ischemic nephropathy.
Hagemann, Rodrigo; Silva, Vanessa dos Santos; Franco, Roberto Jorge da Silva; Barretti, Pasqual; Martin, Luis Cuadrado
Chronic kidney disease (CKD) is characterized by a progressive loss of renal function and its main causes are hypertension and diabetes mellitus. Among the causes of hypertension is atherosclerotic renal disease (ARD). The development of CKD in patients with ARD appears to be due not only to the involvement of the main renal arteries, but also of the renal microcirculation, which may explain the fact that the success of the procedure does not guarantee an improvement in the progression of CKD. To date there is no evidence of benefit of angioplasty compared to medical treatment alone in patients with ARD. The present paper analyzes the most significant studies on renal outcomes in patients with ARD undergoing revascularization or medical treatment alone. PMID:25517284
Chronic innominate artery occlusion with hyperacute intracranial thromboembolism: Revascularization with simultaneous local thromboaspiration and mechanical thrombectomy
Gordhan, Ajeet; Vanle, Jesse
Chronic innominate artery occlusion with acute right internal carotid terminus thromboembolism and successful revascularization using simultaneous local thromboaspiration and mechanical thrombectomy has not been previously described. A 51-year-old male presented with transient left hemiparesis. A CT angiogram of the head and neck demonstrated chronic occlusion of the right innominate artery with no intracranial thromboembolism. More profound symptoms recurred twelve hours after admission. A diagnostic catheter-based angiogram confirmed occlusion of the innominate artery and identified hyper-acute right carotid terminus thromboembolism. Angioplasty of the innominate artery was followed by simultaneous mechanical and aspiration thrombectomy of the right internal carotid artery terminus. Combination local thromboaspiration and mechanical thrombectomy was shown in this case to be effective in achieving a favorable clinical outcome. PMID:25926931
Target Lesion Revascularization After Wingspan Assessment of Safety and Durability
David J. Fiorella; Elad I. Levy; Aquilla S. Turk; Felipe C. Albuquerque; G. Lee; Henry H. Woo; Babu G. Welch; David B. Niemann; Phillip D. Purdy; Beverly Aagaard-Kienitz; Peter A. Rasmussen; L. Nelson Hopkins; Thomas J. Masaryk; Cameron G. McDougall
Background and Purpose—In-stent restenosis (ISR) occurs in approximately one-third of patients after the percutaneous transluminal angioplasty and stenting of intracranial atherosclerotic lesions with the Wingspan system. We review our experience with target lesion revascularization (TLR) for ISR after Wingspan treatment. Methods—Clinical and angiographic follow-up results were recorded for all patients from 5 participating institutions in our US Wingspan Registry. ISR
The 'Perfect Storm' and Acute Coronary Syndrome Onset: Do Psychosocial Factors Play a Role?
Burg, Matthew M.; Edmondson, Donald; Shimbo, Daichi; Shaffer, Jonathan; Kronish, Ian M.; Whang, William; Alcántara, Carmela; Schwartz, Joseph E.; Muntner, Paul; Davidson, Karina W.
The revolution in cardiac care over the past two decades, characterized by emergent revascularization, drug eluting stents, anti-platelet medications, and advanced imaging has had little impact on overall ACS recurrence, or ACS prevention. The "Perfect Storm" refers to a confluence of events and processes, including atherosclerotic plaque, coronary flow dynamics, hemostatic and fibrinolytic function, metabolic and inflammatory conditions, neurohormonal dysregulation, and environmental events that give rise to, and result in an ACS event. In this article we illustrate the limits of the traditional main effect research model, giving a brief description of the current state of knowledge regarding the development of atherosclerotic plaque and the rupturing of these plaques that defines an ACS event. We then apply the Perfect Storm conceptualization to describe a program of research concerning a psychosocial vulnerability factor that contributes to increased risk of recurrent ACS and early mortality, and that has defied our efforts to identify underlying pathophysiology and successfully mount efforts to fully mitigate this risk. PMID:23621970
Fibromuscular Dysplasia Leading to Spontaneous Coronary Artery Dissection with Sudden Cardiac Arrest
Bajwa, Ata; Bhatnagar, Udit; Sharma, Amit; El-Halawany, Hani; Thompson, Randall C.
A 30-year-old previously healthy female, who was six-week postpartum, experienced sudden collapse and tonic-clonic seizure. Emergency medicine services arrived at the scene and the patient was found to be in ventricular fibrillation. Advanced cardiovascular life support (ACLS) was initiated with return of spontaneous circulation. Afterwards, her initial EKG showed atrial fibrillation with rapid ventricular rate, ST elevation in leads II, III, and aVF, and ST depression in V2–V4. She was transferred to a tertiary care hospital where emergent angiogram was performed revealing obstruction of blood flow in the proximal and mid right coronary artery (RCA). A hazy and irregularly contoured appearance of the RCA was consistent with diagnosis of fibromuscular dysplasia. Subsequently, intravascular ultrasonogram (IVUS) was performed which confirmed the diagnosis of RCA dissection. Successful revascularization of the RCA was performed using two bare mental stents. After a complicated course in hospital, she was discharged in stable condition and did very well overall. PMID:26146572
Reappearance of anterior QRS forces after coronary bypass surgery. An electrovectorcardiographic study.
Zeft, H J; Friedberg, H D; King, J F; Manley, J C; Huston, J H; Johnson, W D
This report describes the reappearance of anterior QRS electrical forces in six patients after direct coronary arterial bypass surgery. Each patient had severe coronary artery disease including a segmental stenosis of the left anterior descending artery. Revascularization was performed by direct anastomosis of the left mammary artery to the left anterior descending coronary artery and saphenous vein bypass of other stenotic coronary arteries. Preoperative electrocardiograms and vectorcardiograms showed patterns of anterior wall myocardial infarction with absent or diminutive anterior QRS forces. In each case, postoperative studies demonstrated the regeneration of anterior QRS forces within 10 days of operation. Although these patients represent a small percent of those with a preoperative pattern of infarction who undergo coronary revascularization, the findings demonstrate that electrically silent areas of myocardium may be altered and are not always synonymous with myocardial cell death. Chronic myocardial ischemia may in certain instances produce electrocardiographic and vectorcardiographic patterns of myocardial infarction that may be reversible upon reestablishment of perfusion to ischemic areas. PMID:1080350
[Two cases of acute coronary syndrome after intake of Clavis Panax].
Atar, Asl? ?nci; Er, Okan; Güven, Abdullah; Eryonucu, Beyhan
Atherosclerotic cardiovascular disease is an epidemic in today's world. It is one of the most common causes of hospitalization and death. Therefore, remedies to control or heal the disease are continuously sought. In addition to scientifically researched therapies, patients frequently utilize alternative medicine. However, effective and toxic doses, metabolisms, and drug interactions of the herbs and herbal nutrition supplements are largely unknown. Herein, we present two cases with acute coronary syndrome. The first case was admitted with a diagnosis of acute inferior myocardial infaction (MI) and a stent was implanted to the occluded right coronary artery (RCA). There was a 50% stenosis in his left anterior descending artery (LAD). He was admitted with a diagnosis of non-ST elevation MI (NSTEMI) 6 months later. In the coronary angiogram, there was stent restenosis in RCA, the lesion in LAD had become thrombotic and progressed to a stenosis of 90%. He was referred to surgical revascularization. The second case was admitted for acute inferior MI and a stent was implanted to the occluded circumflex artery. Two months later, he was hospitalized for NSTEMI. Progression of coronary plaques to stenosis and stent restenosis was detected and he was referred to surgical revascularization. Both patients used the product sold as Clavis Panax, which contains panax ginseng, tribulus terrestris, and oat, after their first coronary intervention. Intake of a mixture of plant extracts may have serious consequences in humans as drug interactions and side effects are unknown. PMID:22864326
Advances and innovations in revascularization of extracranial vertebral artery.
Brasiliense, Leonardo B C; Albuquerque, Felipe C; Spetzler, Robert F; Hanel, Ricardo A
Revascularization of the extracranial vertebral artery has evolved significantly since the adoption of endovascular techniques. The current neurosurgical armamentarium includes microsurgical and endovascular approaches. The indications for each treatment modality, however, still need to be further delineated. In contrast to carotid artery endarterectomy and carotid artery angioplasty/stenting, there is limited comparative evidence on the efficacy of medical, open, and endovascular treatment of atherosclerotic disease of the extracranial vertebral artery. More recently, drug-eluting stents have gained momentum after high rates of in-stent restenosis have been reported with bare metal stents placed in the vertebral artery. In this article, we discuss the indications, clinical assessment, and surgical nuances of microsurgical and endovascular revascularization for atherosclerotic disease of the extracranial vertebral artery. Despite a general tendency to consider endovascular treatment in the majority of patients, ultimately, open and endovascular revascularization of extracranial vertebral artery should be regarded as complementary therapies and both treatment options need to be discussed in selected patients. PMID:24402479
Immediate- and short-term outcome following recanalization of long chronic total occlusions (> 50 mm) of native coronary arteries with the Frontrunner catheter.
Loli, Akil; Liu, Rex; Pershad, Ashish
Thirty percent of diagnostic angiograms have at least 1 chronic total occlusion (CTO). The 10-year survival of patients with a CTO is improved if they have the CTO successfully recanalized. The success of recanalization with conventional wires is 50% and the impact of new technology on recanalization is unknown. This abstract reports a single center experience with one such new device, the Lumend Frontrunner catheter in revascularization of this difficult lesion subset. A consecutive series of 18 patients with CTO's of native coronary arteries were enrolled in this single center, single operator series. The mean age of the CTO was 5.3 years. The indication for attempt at recanalization was ischemia in the territory of the CTO on SPECT imaging. Success was defined as TIMI flow restoration and < 40% residual stenosis. Primary success (defined as TIMI 3 Flow restoration and < 40% residual stenosis) was achieved in 77% of patients. At 30 days and out to 6 months, clinical TVR was 11% (2/18) in this difficult lesion subset. Conventional predictors of failure to recanalize CTOs do not appear to hold true with the use of the Frontrunner catheter. In this small series, dual cusp injections and use of the Microglide catheter appears to correlate with favorable outcomes. Fluoroscopy times and contrast use are high when attempting recanalization of CTOs with this technology. PMID:16775901
Orbital Atherectomy for Treating De Novo Severely Calcified Coronary Narrowing (1-Year Results from the Pivotal ORBIT II Trial).
Généreux, Philippe; Lee, Arthur C; Kim, Christopher Y; Lee, Michael; Shlofmitz, Richard; Moses, Jeffrey W; Stone, Gregg W; Chambers, Jeff W
Percutaneous coronary intervention of severely calcified lesions has historically been associated with major adverse cardiac event (MACE) rates as high as 30%. In the ORBIT II (Evaluate the Safety and Efficacy of OAS in Treating Severely Calcified Coronary Lesions) trial, treatment of de novo severely calcified lesions with the Diamondback 360° Coronary Orbital Atherectomy System (OAS) resulted in low rates of procedural and 30-day adverse ischemic events. The long-term results from this trial have not been reported. We sought to determine the 1-year outcomes after orbital atherectomy of severely calcified coronary lesions. ORBIT II was a single-arm trial enrolling 443 subjects at 49 US sites with severely calcified lesions usually excluded from randomized trials. OAS utilizes a centrifugal differential sanding mechanism of action for plaque modification prior to stent implantation. After OAS drug-eluting stents were implanted in 88.2% of the patients. The primary safety end point was 30-day MACE, the composite of cardiac death, myocardial infarction, or target vessel revascularization [TVR]. The present analysis reports the 1-year follow-up results from ORBIT II. One-year data were available in 433 of 443 patients (97.7%), with median follow-up time of 16.7 months. The 1-year MACE rate was 16.4%, including cardiac death (3.0%), myocardial infarction (9.7%), and target vessel revascularization (5.9%). The 1-year target lesion revascularization rate was 4.7%, and stent thrombosis occurred in 1 patient (0.2%). Independent predictors of 1-year MACE and target vessel revascularization were diameter stenosis at baseline and the use of bare-metal stents. In patients with severely calcified lesions who underwent percutaneous coronary intervention, the use of OAS was associated with low rates of 1-year adverse ischemic events compared with historical controls. This finding has important clinical implications for the selection of optimum treatment strategies for patients with severely calcified lesions. PMID:25910525
Carotid and coronary disease management prior to open and endovascular aortic surgery. What are the current guidelines?
Thompson, J P
Several bodies produce broadly concurring and updated guidelines for the evaluation and treatment of cardiovascular disease in both surgical and non-surgical patients. Recent developments include revised recommendations on preoperative stress testing, referral for possible coronary revascularization and medical management. It is recognized that non-invasive cardiac tests are relatively poor at predicting perioperative risk, and "prophylactic" coronary revascularization has a limited role. The planned aortic intervention (open or endovascular repair) also influences preoperative management. Patients presenting for elective abdominal aortic aneurysm (AAA) repair should only be referred for cardiological testing if they have active symptoms of coronary artery disease (CAD), known CAD and poor functional exercise capacity, or multiple risk factors for CAD. Coronary revascularization before AAA surgery should be limited to patients with established indications, so cardiac stress testing should only be performed if it would change management i.e. the patient is a candidate for and would benefit from coronary revascularization. When endovascular aortic repair is planned, it is reasonable to proceed to surgery without further cardiac stress testing or evaluation unless otherwise indicated. All non-emergency patients require medical optimization, but perioperative beta blockade benefits only certain patients. Some of the data informing recent guidelines have been questioned and some guidelines are being revised. Current guidelines do not specifically address the management of patients with known or suspected carotid artery disease who may require aortic surgery. For these patients, an individualized approach is required. This review considers recent guidelines. Algorithms for investigation and management based on their recommendations are included. PMID:24796897
Coronary artery disease in type 2 diabetes mellitus: Recent treatment strategies and future perspectives
Naito, Ryo; Kasai, Takatoshi
Patients with type 2 diabetes mellitus (T2DM) are at a higher risk of developing coronary artery disease (CAD) than are non-T2DM patients. Moreover, the clinical outcomes in CAD with T2DM are poor despite improvements in medications and other interventions. Coronary artery bypass grafting is superior to percutaneous coronary intervention in treating multivessel coronary artery disease in diabetic patients. However, selecting a revascularization strategy depends not only on the lesion complexity but also on the patient's medical history and comorbidities. Additionally, comprehensive risk management with medical and non-pharmacological therapies is important, as is confirmation regarding whether the risk-management strategies are being appropriately achieved. Furthermore, non-pharmacological interventions using exercise and diet during the earlier stages of glucose metabolism abnormalities, such as impaired glucose tolerance, might be beneficial in preventing the development or progression of T2DM and in reducing the occurrence of cardiovascular events. PMID:25810811
Myocardial Edema Imaging in Acute Coronary Syndromes
Walls, Michael C.; Verhaert, David; Raman, Subha V.
Acute coronary syndromes (ACS) continue to be the most common morbid condition of industrialized nations. The advent of and technical improvements in revascularization and medical therapy have led to a steady decline in mortality rates. However, many patients who suffer unstable angina or myocardial infarction require further testing and risk stratification to guide therapeutic selection and prognosis assignment. Myocardial edema imaging with cardiac magnetic resonance (CMR) affords the ability to define the amount of myocardium at risk, refine estimates of prognosis and provide guidance for therapies with excellent sensitivity compared to standard clinical markers. This review will discuss the rationale for edema imaging, how it is performed using CMR and its potential clinical applications. PMID:22102557
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The life and hard times of a coronary surgeon
Goldman, Bernard S
Coronary artery bypass is arguably the most extensively studied operation in surgical history. The technical advances and beneficial effects on symptoms and prognosis have been well documented over four decades. Percutaneous coronary interventions (PCIs) have also evolved through numerous modifications, and symptom relief has been substantiated; both modalities have been challenged by many randomized controlled trials. The rapid growth of PCIs has decreased coronary artery bypass volumes, and resulted in concerns about training, teaching, research, jobs and income. The most important concern, however, is the increasing 'off-label' application of PCIs with drug-eluting stents to a variety of untested coronary lesions. The randomized controlled trials studied a small fraction of those registered and excluded patients who are known to benefit from surgery and, thus, these studies were inherently biased. The results were then extrapolated to 'real-world' patients, who had been misinformed and misled about the performance and prognosis of coronary stents, as was later revealed in various registries. Hospitals should develop a collaborative revascularization strategy to provide patients and families with realistic alternatives. PMID:17347687
Serial quantitative coronary angiography and coronary events
Wendy J. Mack; Min Xiang; Robert H. Selzer; Howard N. Hodis
Background Although assessment of progression of atherosclerosis by quantitative coronary angiography (QCA) is used as a surrogate for coronary events, no validation study has compared the several QCA measures used.Methods and Results The Cholesterol Lowering Atherosclerosis Study was a clinical trial testing the efficacy of colestipol-niacin on the progression of coronary atherosclerosis. Baseline\\/2-year coronary angiograms were obtained on 156 men
[Nutritional epidemiology of coronary disease].
Ferričres, J
The nutritional epidemiology of coronary disease is complex because nutrition is composed of a large number of factors which are susceptible to interfere with each other and to affect the coronary risk after a long period of exposure. The methodology of nutritional studies relies on known and validated enquiry techniques, but they are difficult to perform in the general population. The lipid nutritional hypothesis of coronary disease was centred on cholesterol and the saturated fatty acids. This lipid theory has allowed great advances in the pathophysiological and therapeutic areas. The concepts of a French paradox and global diet have allowed research in nutritional epidemiology to be refocused on other nutrients (lipids and non-lipids) and on alimentary fashions and lifestyle in general. The success of proposed diets at the population level depends strictly on correctly validated scientific data, and on the cultural and social context of where the prevention messages warrant dissemination. PMID:14655545
Early surgery after coronary revascularization: a fine line between bleeding and thrombosis.
De Biase, C; Capuano, E; De Luca, S; D'Anna, C; Luciano, R; Piscione, F; Trimarco, B; Galasso, G
Management of PCI patients undergoing early surgery is still a matter of debate. Noteworthy, PCI patients require a dual antiplatelet therapy (DAPT), with aspirine and a thienopiridine (clopidogrel, prasugrel, ticagrelor), because of the high risk of stent thrombosis (ST), myocardial infarction (MI) and death, especially within the first month. Indeed, the number of surgical interventions after PCI is actually increasing, and physicians are looking for the best antiplatelet therapy management, in order to reduce both, bleeding and thrombosis risk. In this paper, current guidelines therapy management and new optional strategies to reduce the cardiovascular risk, related to early surgery, are discussed. PMID:25674544
Early Surgery after Coronary Revascularization: A Fine Line Between Bleeding and Thrombosis
De Biase, C; Capuano, E; De Luca, S; D'Anna, C; Luciano, R; Piscione, F; Trimarco, B; Galasso, G
Management of PCI patients undergoing early surgery is still a matter of debate. Noteworthy, PCI patients require a dual antiplatelet therapy (DAPT), with aspirine and a thienopiridine (clopidogrel, prasugrel, ticagrelor), because of the high risk of stent thrombosis (ST), myocardial infarction (MI) and death, especially within the first month. Indeed, the number of surgical interventions after PCI is actually increasing, and physicians are looking for the best antiplatelet therapy management, in order to reduce both, bleeding and thrombosis risk. In this paper, current guidelines therapy management and new optional strategies to reduce the cardiovascular risk, related to early surgery, are discussed. PMID:25674544
Anatomic and electrophysiologic relation between the coronary sinus and mitral annulus: Implications for ablation of left-sided accessory pathways
Jerold S. Shinbane; Michael D. Lesh; William G. Stevenson; Thomas S. Klitzner; Paul D. Natterson; Isaac Wiener; Philip C. Ursell; Leslie A. Saxon
To determine whether precise left-sided accessory pathway localization is possible from the coronary sinus, electrocardiogram (ECG) characteristics from the coronary sinus pair demonstrating earliest activation via the accessory pathway were compared to simultaneous mitral annular ablation catheter ECGs at successful ablation sites in 48 patients. To define the coronary sinus–mitral annular relation, the coronary sinus to mitral annulus distance (D)
Revascularization of ischemic tissues with SIKVAV and neuropeptide Y (NPY).
Grant, D S; Zukowska, Z
Angiogenesis, the process of new vessel growth, is necessary for many normal physiological and pathological processes such as tumor growth, wound healing and ischemia. We have recently examined in vitro and in vivo the ability of two potent angiogenic compounds, SIKVAV (a peptide derived from the alpha chain of laminin-1) and Neuropeptide Y (NPY) to revascularize ischemic tissue. These compounds were tested in an ex vivo capillary sprouting angiogenesis assay that uses rat aortic rings. Both NPY and SIKVAV in the presence of VEGF, stimulated the formation of long sprouts at concentrations of 1 ng NPY (0.2 pmol/L) and 100 micrograms SIKVAV. In comparison very little sprouting occurred in the control rings and 50 ng of VEGF alone was required to induce equivalent number of sprouts as NPY. SIKVAV and NPY were further tested in vivo in a rat hindlimb ischemic model. Both compounds (500 micrograms SIKVAV and 10 ng of NPY) were embedded in the rat hind limb following unilateral ligation of the femoral artery 1 cm proximal to the adductor hiatus. After two weeks control peptides show little or no revascularization of the hindlimb distal to the ligation; however, both SIKVAV and NPY demonstrated a two-fold increase in new vessels in the region proximal to the ligation. Histological sections of latex perfused hindlimb demonstrated that ligated limbs had very few latex-filled dermal capillaries. Limbs treated with SIKVAV and NPY, however, demonstrated normal distribution in the dermal capillary beds. These data indicate that both SIKVAV and NPY are potent angiogenic factors that show promising potential clinical application to the revascularization of ischemic tissue. PMID:10949662
Outcomes of Percutaneous Coronary Intervention on Saphenous Vein Graft and Native Coronary Vessels
Alidoosti, Mohammad; Hosseini, Seyed Kianoosh; Sharafi, Ahmad; Nematipour, Ebrahim; Salarifar, Mojtaba; Poorhoseini, Hamidreza; Kassaian, Seyed Ebrahim; Zeinali, Ali Mohammad Haji; Amirzadegan, Alireza; Sadeghian, Mohammad; Lotfi-Tokalday, Masoumeh
Background The optimal target for revascularization in patients with history of coronary artery bypass graft surgery (CABG) is unclear. This study was designed to compare the outcome of percutaneous coronary intervention (PCI) on saphenous vein grafts (SVG) and that on native vessels in patients with previous CABG in terms of major adverse cardiac events (MACE). Methods The study drew upon data on consecutive patients hospitalized for PCI and MACE rate during a nine-month follow-up period. The patients were divided according to the target vessel for PCI into two groups: SVG and native vessel. Results Between 2003 and 2007, 226 patients underwent PCI 6.57 ± 4.55 years after CABG. Their mean age was 59.52±9.38 years, and 176 (77.9%) were male. PCI was performed on the SVG in 63 (27.9%) patients and on the native coronary artery in the rest. During a nine-month follow-up period, 9 (4%) patients suffered MACE; the prevalence of MACE was not significantly different between the SVG group (4.8%) and the native vessel group (4.9%), (p value = 0.999). Conclusion PCI on grafted and native vessels did not affect MACE in patients undergoing PCI after CABG. PMID:23074621
Patients With Suspected Coronary Artery Disease Referred for Examinations in the Era of Coronary Computed Tomography Angiography.
Zorlak, Ajda; Zorlak, Amet; Thomassen, Anders; Gerke, Oke; Munkholm, Henrik; Mickley, Hans; Diederichsen, Axel C Pyndt
Invasive coronary angiography (ICA) is the gold standard in the diagnosis of coronary artery disease (CAD), however, associated with rare but severe complications. Patients with a high pretest risk should be referred directly for ICA, whereas a noninvasive strategy is recommended in the remaining patients. In the setting of a university hospital, we investigated the pattern of diagnostic tests used in daily clinical practice. During a 1-year period, consecutive patients with new symptoms suggestive of CAD and referred for exercise stress test, coronary computed tomography angiography (CCTA), single-photon emission computed tomography (SPECT), or ICA qualified for inclusion. The patients were followed for 1 year, and additional downstream diagnostic tests and need of coronary revascularization were registered. A total of 1,069 patients were included. A noninvasive test was the first examination in 797 patients (75%; exercise stress test in 37, CCTA in 450, and SPECT in 310), whereas 272 (25%) were referred directly to ICA. The ICA group had a significant higher pretest probability for CAD, and the percentage of patients with evidence of significant CAD was 31% (84 of 272 patients), whereas 18% (144 of 797 patients) in the noninvasive group (p <0.0001). In the comparison between CCTA and SPECT, there were no significant differences in downstream testing (16% [72 of 444 patients] vs 17% [53 of 310], p = 0.55), and revascularization rate (20% [14 of 69 patients with positive findings] vs 9% [6 of 67], p = 0.09). In conclusion, a noninvasive diagnostic test was chosen as the first test in 3 of 4 patients. Of the patients referred directly for noninvasive examination, 1/5 had significant CAD, whereas 1/3 of those for invasive examination. PMID:26051377
Acute Coronary Syndromes: Diagnosis and Management, Part I
Kumar, Amit; Cannon, Christopher P.
The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non—ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization in the United States. A quick but thorough assessment of the patient's history and findings on physical examination, electrocardiography, radiologic studies, and cardiac biomarker tests permit accurate diagnosis and aid in early risk stratification, which is essential for guiding treatment. High-risk patients with UA/NSTEMI are often treated with an early invasive strategy involving cardiac catheterization and prompt revascularization of viable myocardium at risk. Clinical outcomes can be optimized by revascularization coupled with aggressive medical therapy that includes anti-ischemic, antiplatelet, anticoagulant, and lipid-lowering drugs. Evidence-based guidelines provide recommendations for the management of ACS; however, therapeutic approaches to the management of ACS continue to evolve at a rapid pace driven by a multitude of large-scale randomized controlled trials. Thus, clinicians are frequently faced with the problem of determining which drug or therapeutic strategy will achieve the best results. This article summarizes the evidence and provides the clinician with the latest information about the pathophysiology, clinical presentation, and risk stratification of ACS and the management of UA/NSTEMI. PMID:19797781
Prognostic Value of Ischemia Monitoring with On-Line Vectorcardiography in Patients with Unstable Coronary Artery Disease
Peter Lundin; Jens Jensen; Bertil Lindahl; Lars Wallentin; Sven V. Eriksson
Aim: The aim of this study was to determine whether on-line vectorcardiography (VCG) gives independent prognostic information, regarding death, myocardial infarction (MI), and revascularization in patients with unstable coronary artery disease, i.e. unstable angina or non-Q-wave MI. Methods and Results: One hundred and fifty patients (mean age 69 ± 10), participating in a randomized study of low-molecular-weight heparin in unstable
Coronary artery bypass grafting in chronic renal dialysis patients: intensive perioperative dialysis and extensive usage of arterial grafts
T. Koyanagi; H. Nishida; M. Endo; H. Koyanagi
Twenty-three chronic renal dialysis patients underwent coronary artery bypass grafting (CABG). Eigh- teen patients were maintained on hemodialysis and 5 patients received continuous ambulatory peritoneal dialysis. Eighteen patients (78%) had triple vessel disease or left main disease. The mean number of revascularized vessels was 2.2 kO.8, and the graft materials used were left internal thoracic artery (21), right internal thoracic
Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass
Olivier Chavanon; Michel Durand; Rachid Hacini; Hélčne Bouvaist; Marianne Noirclerc; Tarek Ayad; Dominique Blin
Background. Total arterial and off-pump revascularization are increasingly used in coronary artery bypass grafting. This study describes our experience with the exclusive use of both left internal thoracic artery and gastroepiploic artery by means of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of patients with two-vessel disease.Methods. From January 1995 to July 2000, 171 consecutive patients
Prognostic Value of Multidetector Computed Tomography Coronary Angiography in Diabetes
Andreini, Daniele; Pontone, Gianluca; Mushtaq, Saima; Bertella, Erika; Conte, Edoardo; Baggiano, Andrea; Veglia, Fabrizio; Agostoni, Piergiuseppe; Annoni, Andrea; Formenti, Alberto; Montorsi, Piero; Ballerini, Giovanni; Bartorelli, Antonio L.; Fiorentini, Cesare; Pepi, Mauro
OBJECTIVE To assess the prognostic role of multidetector computed tomography coronary angiography (MDCT-CA) in patients with diabetes with suspected coronary artery disease (CAD). Use of MDCT-CA is increasing in patients with suspected CAD. However, data supporting its prognostic value in patients with diabetes are limited. RESEARCH DESIGN AND METHODS Between January 2006 and September 2007, 429 consecutive diabetic patients were prospectively studied with MDCT-CA for detecting the presence and assessing the extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronary arteries and nonobstructive (<50%) and obstructive (?50%) coronary lesions. The composite rates of hard cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina) and all cardiac events (including revascularization) were the end points of the study. RESULTS Twenty-four patients were excluded because MDCT-CA data were not able to be interpreted. Of the remaining 405 patients, clinical follow-up (mean 62 ± 9 months) was obtained in 390 (98%). Multivariate analysis showed that predictors of hard and all events were obstructive CAD, three-vessel CAD, and left main coronary artery (LMCA) disease. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 78% for hard events and 56% for all events in patients with nonobstructive CAD, and 60% for hard events and 16% for all events in patients with obstructive CAD. Three-vessel CAD and LMCA disease were associated with a higher rate of hard cardiac events. CONCLUSIONS MDCT-CA provides long-term prognostic information for patients with diabetes with suspected CAD, showing excellent prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present. PMID:23801796
New Treatment Applying Low Level Laser Therapy for Acute Dehiscence Saphenectomy in Post Myocardial Revascularization.
NASA Astrophysics Data System (ADS)
Pinto, Nathali Cordeiro; Shoji, Nara; Junior, Mauro Favoretto; Muramatso, Mikiya; Chavantes, Maria Cristina; Stolf, Noedir A. G.
Introduction: In Brazil, the main cause of death is the coronary heart disease and the surgical treatment applied in such cases is the Myocardial Revascularization (MR). Patients undergoing to MR through saphenous vein bypass development dehiscence in 10% of the cases. Dehiscence of surgical incision through Biomodulation treatment with Low Level Laser Therapy (LLLT) in patients who underwent to MR seems to be an unprecedented new therapy and a less invasive technique, which can benefit patients and Institutions, reducing costs. Methodology: It was analyzed 7 diabetic patients, mean age 51, 8 years old that post MR surgery presented dehiscence of the saphenectomy incision on lower limb with erithema, edema and pain. The wounds area varies from 2,2 until 34,8 cm and deep from 0,1 until 1,1 cm. It was used only Diode Laser C.W. (655 nm wavelength), Power = 25 mW, Time = 30 s, Fluence = 4 J/cm2 applied punctually around surgical wound's sore, by 2 cm distance. Results: It was observed granulated tissue all around the incision, as well as decreased inflammatory process, reduction fibrin and wound's size, besides analgesic effect since the first application. It was required in superficial wounds only 3 applications, while in the extensive wounds 8-10 applications were necessary. The LLLT has shown a remarkable role as a wound healing facilitated agent, reflecting the reduction of inflammatory process and improving analgesia. Conclusion: LLLT assisted dehiscence post saphenectomy showed a substantial improvement to the patient's quality of life, with a cost-effectiveness treatment that can benefit both patients and Institutions as an effective and less invasive therapy.
Predictive role of renal resistive index for clinical outcome after revascularization in hypertensive patients with atherosclerotic renal artery stenosis: a monocentric observational study
Background The present study evaluated the predictive value of renal resistive index (RI) for renal function and blood pressure (BP) outcome in hypertensive patients with unilateral atherosclerotic renal artery stenosis submitted to successful revascularization. Methods In 158 hypertensive patients with atherosclerotic renal artery stenosis RI was acquired. Twelve months after revascularization, they were classified on the basis of renal function and BP outcome as benefit (BP?140/90 mmHg or diastolic BP reduction?>?15 mmHg with the same of reduced drugs; decrease in glomerular filtration rate?>?20%), or failure. Results Regarding renal function outcome, RI in the stenotic and in the contralateral kidney were significantly higher in patients with failure (n?=?20) than in those with benefit (0.72?±?0.11 vs 0.61?±?0.11 and 0.76?±?0.08 vs 0.66?±?0.09, p?0.05). Among different cutpoints generated, RI in the contralateral kidney >0.73 provided the largest area under the curve (0.77), and the highest sensitivity (80%) and specificity (72%). In the multivariate logistic regression analysis, RI in the contralateral kidney >0.73 was an independent predictor of a failure in renal function outcome. Regarding BP outcome, patients with no benefit from revascularization (n?=?60) had similar RI in the stenotic and contralateral kidney (p?=?ns), but presented higher pulse pressure, albuminuria and hypertension duration in comparison to patients with improved BP control. Conclusions RI in the contralateral kidney is an independent predictor of renal function outcome after successful revascularization in hypertensive patients with unilateral atherosclerotic renal artery stenosis, whereas it is not able to predict blood pressure outcome. PMID:24555729
The cognitive underpinnings of coronary-prone behaviors
Lynda H. Powell
Research on the cognitive underpinnings of coronary-prone behaviors is important to the development of sophisticated transactional models to explain coronary-prone behaviors, and to the successful promotion of an enduring change in them. The cognitive literature has been organized around three central coronary-prone behaviors—hostility\\/competitiveness, low self-esteem, and low perceived control—and for each behavior, the literature on basic beliefs, attitudes, overt behaviors,
Survival benefit of coronary-artery bypass grafting accounted for deaths in those who remained untreated
Sobolev, Boris G; Fradet, Guy; Hayden, Robert; Kuramoto, Lisa; Levy, Adrian R; FitzGerald, Mark J
Background Currently there are no direct estimates of mortality reduction afforded by coronary-artery bypass grafting (CABG) that take into account the deaths among patients for whom coronary revascularization was indicated but who did not undergo the treatment. The objective of this analysis was to compare survival after the treatment decision between patients who underwent CABG and those who remained untreated. Methods We used a population-based registry to identify patients with established coronary artery disease who were to undergo first-time isolated CABG. We measured the effect of surgical revascularization on survival after the treatment decision in two cohorts of patients categorized by symptoms, coronary anatomy, and left ventricular function. Results One in 10 patients died during the five years after treatment decision. The hazard of death among patients who underwent CABG was 51 percent of that for the untreated group, the adjusted hazard ratio was 0.51 (95 percent confidence interval, 0.43 to 0.61). The effect was stronger when CABG was performed within the recommended time: adjusted hazard ratios were 0.43 (95 percent confidence interval, 0.35 to 0.53) and 0.58 (95 percent confidence interval, 0.48 to 0.70) for early and late intervention, respectively; chi-square for the difference between hazard ratios was 12.2 (P < 0.001). Conclusion Estimates that account for patients who died before they could undergo a required CABG indicate a significant survival benefit of performing early surgical revascularization even for patients registered to undergo the operation on the non-urgent basis. PMID:18637196
Isolated single coronary artery (RII-B type) presenting as an inferior wall myocardial infarction: a rare clinical entity.
Thummar, Ankur C; Lanjewar, Charan P; Phadke, Milind S; Sharma, Rajiv B; Kerkar, Prafulla G
Isolated single coronary artery without other congenital cardiac anomalies is very rare among the different variations of anomalous coronary patterns. The prognosis in patients with single coronary varies according to the anatomic distribution and associated coronary atherosclerosis. If the left main coronary artery travels between the aorta and pulmonary arteries, it may be a cause of sudden cardiac death. We present multimodality images of a single coronary artery, in which the whole coronary system originated by a single trunk from the right sinus of Valsalva with inter-arterial course of left main coronary artery. This rare type of single coronary artery was classified as RII-B type according to Lipton's scheme of classification. A significant flow-limiting lesions were found in the right coronary artery that was successfully treated with percutaneous coronary intervention. PMID:25443613
Spontaneous coronary artery dissection causing acute coronary syndrome in a young patient without risk factors
Chevli, Parag; Kelash, Fnu; Gadhvi, Pragnesh; Grandhi, Sreeram; Syed, Amer
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction that is more common in younger patients (under age 50) and in women. Although the etiology is not known, some predisposing conditions to SCAD are well known and include Marfan syndrome, pregnancy and peripartum state, drug abuse, and some anatomical abnormalities of the coronary arteries such as aneurysms and severe kinking. We describe a case of SCAD in a young woman who presented with sudden onset of chest pain and was admitted for the treatment of acute coronary syndrome. The coronary angiography showed dissection of the left anterior descending artery. The patient underwent successful percutaneous transluminal coronary angioplasty and stent placement. PMID:25317268
Acute coronary syndrome in a patient with a single coronary artery arising from the right sinus of Valsalva.
Liesting, Crista; Brugts, Jasper Jan; Kofflard, Marcellinus Johannes Maria; Dirkali, Attila
Coronary artery anomalies are usually encountered as coincidental findings during coronary angiography or at autopsy. Life threatening symptoms, such as arrhythmias, syncope, myocardial infarction, or sudden death, can occur in up to 20% of patients. However, the majority of anomalies (80%) are benign and asymptomatic. A single coronary artery (SCA) is one of the most rarely seen coronary anomalies with an incidence of 0.05%. We report the case of a 55-year old male patient who presented with symptoms of chest pain associated with an acute myocardial infarction. Coronary angiography revealed an anomalous left main coronary artery (LMCA) originating from the right coronary ostium, and an occluded distal right coronary artery. The occluded distal right coronary artery was successfully treated by thrombosuction and stenting. In order to confirm the origin and course of the SCA, multi-slice computed tomography (MSCT) of the heart was performed after coronary angiography. MSCT showed that the anomalous LMCA originated from the right coronary artery ostium and then passed the interventricular septum, instead of being intra arterial, and under the right ventricular infundibulum. The anomalous LMCA was classified as R-II S subtype according to Lipton's classification. PMID:22953025
Reduced cerebral embolic signals in beating heart coronary surgery detected by transcranial Doppler ultrasound.
Watters, M P; Cohen, A M; Monk, C R; Angelini, G D; Ryder, I G
Cerebral emboli detected by transcranial Doppler imaging were recorded in 20 patients undergoing multiple-vessel coronary artery bypass surgery, either with or without cardiopulmonary bypass, in a prospective unblinded comparative study. Emboli were recorded continuously from the time of pericardial incision until 10 min after the last aortic instrumentation. The numbers of coronary grafts and of aortic clampings were also documented. Patients undergoing revascularization with cardiopulmonary bypass had more emboli (median 79, range 38-876) per case compared with patients having off-pump surgery (median 3, range 0-18). No clinically detectable neurological deficits were seen in either group. Beating heart surgery is associated with fewer emboli than coronary surgery with cardiopulmonary bypass. Further research is necessary to determine whether a smaller number of emboli alters the incidence of neurological deficit after cardiac surgery. PMID:10844840
Myocardial Revascularization in Dyalitic Patients: In-Hospital Period Evaluation
Miranda, Matheus; Hossne, Nelson Américo; Branco, Joăo Nelson Rodrigues; Vargas, Guilherme Flora; da Fonseca, José Honório de Almeida Palma; Pestana, José Osmar Medina de Abreu; Juliano, Yara; Buffolo, Enio
Background Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high. Objective Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients. Methods Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012. Results High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality. Conclusion Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions. PMID:24270865
Myocardial blood volume and coronary resistance during and after coronary angioplasty.
Indermühle, Andreas; Vogel, Rolf; Meier, Pascal; Zbinden, Rainer; Seiler, Christian
Animal experiments have shown that the coronary circulation is pressure distensible, i.e., myocardial blood volume (MBV) increases with perfusion pressure. In humans, however, corresponding measurements are lacking so far. We sought to quantify parameters reflecting coronary distensibility such as MBV and coronary resistance (CR) during and after coronary angioplasty. Thirty patients with stable coronary artery disease underwent simultaneous coronary perfusion pressure assessment and myocardial contrast echocardiography (MCE) of 37 coronary arteries and their territories during and after angioplasty. MCE yielded MBV and myocardial blood flow (MBF; in ml · min(-1) · g(-1)). Complete data sets were obtained in 32 coronary arteries and their territories from 26 patients. During angioplasty, perfusion pressure, i.e., coronary occlusive pressure, and MBV varied between 9 and 57 mmHg (26.9 ± 11.9 mmHg) and between 1.2 and 14.5 ml/100 g (6.7 ± 3.7 ml/100 g), respectively. After successful angioplasty, perfusion pressure and MBV increased significantly (P < 0.001 for both) and varied between 64 and 118 mmHg (93.5 ± 12.8 mmHg) and between 3.7 and 17.3 ml/100 g (9.8 ± 3.4 ml/100 g), respectively. Mean MBF increased from 31 ± 20 ml · min(-1) · g(-1) during coronary occlusion, reflecting collateral flow, to 121 ± 33 ml · min(-1) · g(-1) (P < 0.01), whereas mean CR, i.e., the ratio of perfusion pressure and MBF, decreased by 20% (P < 0.001). In conclusion, the human coronary circulation is pressure distensible. MCE allows for the quantification of CR and MBV in humans. PMID:21217067
The spectrum of left main coronary artery disease: variables affecting patient selection, management, and death.
Jones, E L; King, S B; Craver, J M; Douglas, J S; Kaplan, J A; Morgan, E A; Brown, E M; Bradford, J M; Hatcher, C R
A total of 178 patients having a diagnosis of left main coronary artery stenosis were divided into three groups as follows: surgical, Group I (n = 135 patients); operable medically treated, Group II (n = 21 patients); and inoperable, Group III (n = 22 patients). Groups 1 and 2 were comparable with regard to clinical profile, extent of anatomic coronary disease, and left ventricular function. Inoperable patients had a much higher incidence of prior myocardial infarction (especially anterior), more severe distal coronary disease, and markedly depressed left ventricular function. The hospital mortality rate for surgical patients was 4% (6/135). The late mortality rate, (median follow-up = 23.4 months) was 7% (9/135). For operable patients, the late mortality rate was 43% (9/21) at 28 months. In the inoperable group, the late death rate at 20 months was 59% (13/22). Actuarial survival at 24 months for the three groups was: 88%, 66%, and 42%, respectively. Of the nine patients who died in the operable group, two had less than 75% obstruction of the left main coronary artery and two had normal left ventricular wall motion. Although patients with higher grades of left main coronary artery stenosis and reduced left ventricular function are at greater risk, patients with less obstruction and good left ventricular function are also at risk and should have myocardial revascularization with some sense of urgency. The population of left main coronary artery stenosis is a heterogeneous one, and comparison of surgical versus medical therapy should exclude inoperable patients. The operative mortality rate has been greatly reduced in recent years (2% in the last 100 cases); this is attributed to careful monitoring in the critical prebypass period, aggressive pharmacologic treatment of increased preload, tachycardia, and hypertension, and improved aurgical technique, with emphasis on careful myocardial preservation. Adherence to these principles makes frequent use of the intra-aortic balloon either before or after revascularization unnecessary. PMID:6765978
Percutaneous vertebral angioplasty before coronary artery bypass grafting
Ikuo Fukuda; Wahei Mihara; Akinobu Sasaki; Seigo Gomi
We report a case of a 63-year-old male with three-vessel coronary heart disease complicated by stenosis of the bilateral vertebral arteries. Triple coronary bypass grafting, using arterial conduits, was successfully performed after percutaneous balloon angioplasty of the left vertebral artery. Precedent angioplasty of a stenotic vertebral artery is safe and protects the brain from ischemia during extracorporeal circulation.
Survival with Total Occlusion of Left Main Coronary Artery
Choh, Joong H.; Wang, Timothy; Golbus, Glenn A.; Leskovac, Thomas M.; Nazarian, Arthur; Ihm, H. Jae; Khazei, A. Hassan
Complete occlusion of the left main coronary artery is considered to be a terminal event in most cases. We describe two patients with this lesion who underwent successful coronary bypass surgery with complete relief of symptoms and long-term survival. The angiographic findings and clinical management of the two patients are discussed. * Images PMID:15227097
Chromosome 9p21 Single Nucleotide Polymorphisms are Not Associated with Recurrent Myocardial Infarction in Patients with Established Coronary Artery Disease
Virani, Salim S.; Brautbar, Ariel; Lee, Vei-Vei; Elayda, MacArthur; Morrison, Alanna C.; Grove, Megan L.; Nambi, Vijay; Frazier, Lorraine; Wilson, James M.; Willerson, James T.; Boerwinkle, Eric; Ballantyne, Christie M.
Background Chromosome 9p21 single-nucleotide-polymorphisms (SNPs) have shown to be associated with coronary heart disease in multiple studies. We aimed to identify whether these SNPs are associated with recurrent myocardial infarction (MI), revascularization, or death in acute-coronary-syndromes (ACS) patients or those undergoing coronary artery bypass grafting (CABG). Methods and Results TexGen registry participants with ACS (n=2,067) or CABG (n=1,176) were evaluated. We assessed whether 9p21 SNPs (rs1333049, rs2383206, rs10757278, rs10757274) were associated with recurrent MI (primary outcome), recurrent revascularization, or death (secondary outcomes) at ? 3.2 years of follow-up. Carriers of risk allele (C) for rs1333049 presented at an earlier age (62 vs. 63.5 years in non-carriers, p=0.0004) with more extensive disease (number of vessels with significant stenosis =1.9 vs. 1.7 in non-carriers, p=0.001) in the ACS group. In adjusted models, C allele was not associated with recurrent MI (HR 1.01, 95%CI 0.74–1.38), recurrent revascularization (HR 0.98, 95%CI 0.78–1.23), or death (HR 0.91, 95%CI 0.69–1.18) in ACS or CABG group (HR 0.64, 95%CI 0.40–1.05 for recurrent MI; HR 0.98, 95%CI 0.61–1.55 for recurrent revascularization; and HR 0.89, 95%CI 0.61–1.30 for death). Results were similar for the other 3 SNPs. Conclusions 9p21 SNPs were not associated with recurrent MI, revascularization, or mortality after ACS or CABG. However, individuals with the rs1333049 C allele may present with earlier and more extensive disease. PMID:22322877
Counseling the Coronary Patient
ERIC Educational Resources Information Center
Semmler, Caryl; Semmler, Maynard
The article discusses counseling sessions designed to a) help the coronary patient adjust to cardiovascular disease, b) diminish patient anxieties and fears, and c) educate the patient and family members on controlling risk factors to deter another coronary attack. (JS)
... from the NHLBI on Twitter. What Is Coronary Heart Disease? Espańol Coronary heart disease (CHD) is a ... Red: Eileen's Story 04/10/2014 Celebrating American Heart Month: NIH Advancing Heart Research 02/06/2014 ...
Directional coronary atherectomy (DCA)
MedlinePLUS Videos and Cool Tools
... the coronary arteries and allow more blood to flow to the heart muscle and ease the pain ... within the coronary artery to keep the vessel open. After the intervention is completed the doctor injects ...
Accelerated coronary atherosclerosis and H syndrome
Shankarappa, Ravindranath K; Ananthakrishna, Rajiv; Math, Ravi S; Yalagudri, Sachin Dhareppa; Karur, Satish; Dwarakaprasad, Ramesh; Nanjappa, Manjunath C; Molho-Pessach, Vered
A 12-year-old boy with insulin dependent diabetes mellitus, presented with acute myocardial infarction. Intracoronary thrombolysis with urokinase restored TIMI III flow in the culprit vessel. After stabilisation with medical therapy, unusual clinical findings in the form of cutaneous hyperpigmentation and hypertrichosis, affecting the lower extremities, were appreciated. These and other phenotypic features were consistent with H syndrome, a recently described autosomal recessive genodermatosis, and confirmed by mutation analysis. Despite being on optimal medical therapy for coronary artery disease, the patient presented 3 months thereafter, with unstable angina which was successfully managed with percutaneous coronary intervention. An unusual occurrence of coronary artery disease with accelerated atherosclerosis in a child with H syndrome is presented herein. Identification of further patients with this novel disorder will clarify the possible association, suggested here, with increased risk for coronary or other vascular events. PMID:22679148
Association between Aspirin Therapy and Clinical Outcomes in Patients with Non-Obstructive Coronary Artery Disease: A Cohort Study
Hwang, In-Chang; Jeon, Joo-Yeong; Kim, Younhee; Kim, Hyue Mee; Yoon, Yeonyee E.; Lee, Seung-Pyo; Kim, Hyung-Kwan; Sohn, Dae-Won; Sung, Jidong; Kim, Yong-Jin
Background Presence of non-obstructive coronary artery disease (CAD) is associated with increased prescription of cardiovascular preventive medications including aspirin. However, the association between aspirin therapy with all-cause mortality and coronary revascularization in this population has not been investigated. Methods and Findings Among the cohort of individuals who underwent coronary computed tomography angiography (CCTA) from 2007 to 2011, 8372 consecutive patients with non-obstructive CAD (1-49% stenosis) were identified. Patients with statin or aspirin prescription before CCTA, and those with history of revascularization before CCTA were excluded. We analyzed the differences of all-cause mortality and a composite of mortality and late coronary revascularization (>90 days after CCTA) between aspirin users (n=3751; 44.8%) and non-users. During a median of 828 (interquartile range 385–1,342) days of follow-up, 221 (2.6%) mortality cases and 295 (3.5%) cases of composite endpoint were observed. Annualized mortality rates were 0.97% in aspirin users versus 1.28% in non-users, and annualized rates of composite endpoint were 1.56% versus 1.48%, respectively. Aspirin therapy was associated with significantly lower risk of all-cause mortality (adjusted HR 0.649; 95% CI 0.492–0.857; p=0.0023), but not with the composite endpoint (adjusted HR 0.841; 95% CI 0.662–1.069; p=0.1577). Association between aspirin and lower all-cause mortality was limited to patients with age ?65 years, diabetes, hypertension, decreased renal function, and higher levels of coronary artery calcium score, low-density lipoprotein cholesterol and high-sensitivity C-reactive protein. Conclusions Among the patients with non-obstructive CAD documented by CCTA, aspirin is associated with lower all-cause mortality only in those with higher risk. PMID:26035823
Platelet neuropeptide Y is critical for ischemic revascularization in mice
Tilan, Jason U.; Everhart, Lindsay M.; Abe, Ken; Kuo-Bonde, Lydia; Chalothorn, Dan; Kitlinska, Joanna; Burnett, Mary Susan; Epstein, Stephen E.; Faber, James E.; Zukowska, Zofia
We previously reported that the sympathetic neurotransmitter neuropeptide Y (NPY) is potently angiogenic, primarily through its Y2 receptor, and that endogenous NPY is crucial for capillary angiogenesis in rodent hindlimb ischemia. Here we sought to identify the source of NPY responsible for revascularization and its mechanisms of action. At d 3, NPY?/? mice demonstrated delayed recovery of blood flow and limb function, consistent with impaired collateral conductance, while ischemic capillary angiogenesis was reduced (?70%) at d 14. This biphasic temporal response was confirmed by 2 peaks of NPY activation in rats: a transient early increase in neuronally derived plasma NPY and increase in platelet NPY during late-phase recovery. Compared to NPY-null platelets, collagen-activated NPY-rich platelets were more mitogenic (?2-fold vs. ?1.6-fold increase) for human microvascular endothelial cells, and Y2/Y5 receptor antagonists ablated this difference in proliferation. In NPY+/+ mice, ischemic angiogenesis was prevented by platelet depletion and then restored by transfusion of platelets from NPY+/+ mice, but not NPY?/? mice. In thrombocytopenic NPY?/? mice, transfusion of wild-type platelets fully restored ischemia-induced angiogenesis. These findings suggest that neuronally derived NPY accelerates the early response to femoral artery ligation by promoting collateral conductance, while platelet-derived NPY is critical for sustained capillary angiogenesis.—Tilan, J. U., Everhart, L. M., Abe, K., Kuo-Bonde, L., Chalothorn, D., Kitlinska, J., Burnett, M. S., Epstein, S. E., Faber, J. E., Zukowska, Z. Platelet neuropeptide Y is critical for ischemic revascularization in mice. PMID:23457218
Coronary bypass using bilateral internal mammary arteries in an achondroplast.
Alassal, Mohamed Abdulwahab; Youssef, Mostafa; Koudieh, Mohammed
Coronary bypass grafting for ischemic heart disease in achondroplastic dwarfs is very rare. Shortage of veins and inadequate vein quality may cause difficulties during surgery. Only 2 cases of coronary bypass surgery in an achondroplastic dwarf, in which the left internal mammary artery and vein grafts were used, have been reported. We describe the case of a 55-year-old male achondroplastic dwarf who had triple-vessel coronary disease and underwent successful coronary bypass surgery using one saphenous vein graft and bilateral internal mammary artery grafts. The anatomic and surgical challenges in achondroplasia are highlighted. PMID:24887865
Coronary magnetic resonance angiography
Matthias Stuber; Robert G. Weiss
Coronary magnetic resonance angiography (MRA) is a pow- erful noninvasive technique with high soft-tissue contrast for the visualization of the coronary anatomy without X-ray exposure. Due to the small dimensions and tortuous na- ture of the coronary arteries, a high spatial resolution and sufficient volumetric coverage have to be obtained. How- ever, this necessitates scanning times that are typically much
Whole blood gene expression testing for coronary artery disease in nondiabetic patients: major adverse cardiovascular events and interventions in the PREDICT trial.
Rosenberg, Steven; Elashoff, Michael R; Lieu, Hsiao D; Brown, Bradley O; Kraus, William E; Schwartz, Robert S; Voros, Szilard; Ellis, Stephen G; Waksman, Ron; McPherson, John A; Lansky, Alexandra J; Topol, Eric J
The majority of first-time angiography patients are without obstructive coronary artery disease (CAD). A blood gene expression score (GES) for obstructive CAD likelihood was validated in the PREDICT study, but its relation to major adverse cardiovascular events (MACE) and revascularization was not assessed. Patients (N = 1,160) were followed up for MACE and revascularization 1 year post-index angiography and GES, with 1,116 completing follow-up. The 30-day event rate was 23% and a further 2.2% at 12 months. The GES was associated with MACE/revascularizations (p < 0.001) and added to clinical risk scores. Patients with GES >15 trended towards increased >30 days MACE/revascularization likelihood (odds ratio = 2.59, 95% confidence interval = 0.89-9.14, p = 0.082). MACE incidence overall was 1.5% (17 of 1,116) and 3 of 17 patients had GES ? 15. For the total low GES group (N = 396), negative predictive value was 90% for MACE/revascularization and >99% for MACE alone, identifying a group of patients without obstructive CAD and highly unlikely to suffer MACE within 12 months. PMID:22396313
Histologic analysis of a covered stent implanted for pseudoaneurysm in a coronary artery
Alston, Evan A.; Brott, Brigitta C.; Athanasuleas, Constantine L.; Anderson, Peter G.; Litovsky, Silvio H.
Covered stents are the standard of care when coronary perforations complicate percutaneous coronary interventions (PCIs) and have also been utilized in the treatment of coronary aneurysms. We present the clinical and histologic features of a patient who developed a coronary perforation and pseudoaneurysm four years following deployment of intracoronary stents. Although the covered stent successfully sealed the perforation, subsequent thrombosis led to a fatal acute myocardial infarction. PMID:23478012
Appropriateness of Percutaneous Coronary Intervention
Chan, Paul S.; Patel, Manesh R.; Klein, Lloyd W.; Krone, Ronald J.; Dehmer, Gregory J.; Kennedy, Kevin; Nallamothu, Brahmajee K.; Douglas Weaver, W.; Masoudi, Frederick A.; Rumsfeld, John S.; Brindis, Ralph G.; Spertus, John A.
Context Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. Objective To assess the appropriateness of PCI in the United States. Design, Setting, and Patients Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication. Main Outcome Measures Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures. Results Of 500 154 PCIs, 355 417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103 245 [20.6%]; non–ST-segment elevation myocardial infarction, 105 708 [21.1%]; high-risk unstable angina, 146 464 [29.3%]), and 144 737 (28.9%) for nonacute indications. For acute indications, 350 469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72 911 PCIs (50.4%) were classified as appropriate, 54 988 (38.0%) as uncertain, and 16 838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (?1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%–16.7%). Conclusions In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals. PMID:21730241
Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart – a possible complication of the Lima-stitch and sequential venous anastomosis
Background Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization. Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB. Case presentation We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography. Conclusions Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery. PMID:24898884
Inflammatory response after myocardial revascularization with or without cardiopulmonary bypass
Luiz A Brasil; Walter J Gomes; Reinaldo Salomăo; Enio Buffolo
Background. Tumor necrosis factor-? has been implicated in complications seen after cardiac operations with cardiopulmonary bypass. The release of tumor necrosis factor-? and its possible effects were studied in patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass.Methods. Twenty patients were studied, 10 with (group 1) and 10 without cardiopulmonary bypass (group 2). Serial blood samples were obtained
Cytokine-mediated deployment of SDF-1 induces revascularization through recruitment of CXCR4+ hemangiocytes
David K Jin; Koji Shido; Hans-Georg Kopp; Isabelle Petit; Sergey V Shmelkov; Lauren M Young; Andrea T Hooper; Hideki Amano; Scott T Avecilla; Beate Heissig; Koichi Hattori; Fan Zhang; Daniel J Hicklin; Yan Wu; Zhenping Zhu; Ashley Dunn; Hassan Salari; Zena Werb; Neil R Hackett; Ronald G Crystal; David Lyden; Shahin Rafii
The mechanisms through which hematopoietic cytokines accelerate revascularization are unknown. Here, we show that the magnitude of cytokine-mediated release of SDF-1 from platelets and the recruitment of nonendothelial CXCR4+VEGFR1+ hematopoietic progenitors, 'hemangiocytes,' constitute the major determinant of revascularization. Soluble Kit-ligand (sKitL), thrombopoietin (TPO, encoded by Thpo) and, to a lesser extent, erythropoietin (EPO) and granulocyte-macrophage colony-stimulating factor (GM-CSF) induced the
A novel platinum chromium everolimus-eluting stent for the treatment of coronary artery disease
Bennett, Johan; Dubois, Christophe
The development of coronary stents represents a major step forward in the treatment of obstructive coronary artery disease since the introduction of percutaneous coronary intervention. The initial enthusiasm for bare metal stents was, however, tempered by a significant incidence of in-stent restenosis, the manifestation of excessive neointima hyperplasia within the stented vessel segment, ultimately leading to target vessel revascularization. Later, drug-eluting stents, with controlled local release of antiproliferative agents, consistently reduced this need for repeat revascularization. In turn, the long-term safety of first-generation drug-eluting stents was brought into question with the observation of an increased incidence of late stent thrombosis, often presenting as myocardial infarction or sudden death. Since then, new drugs, polymers, and platforms for drug elution have been developed to improve stent safety and preserve efficacy. Development of a novel platinum chromium alloy with high radial strength and high radiopacity has enabled the design of a new, thin-strut, flexible, and highly trackable stent platform, while simultaneously improving stent visibility. Significant advances in polymer coating, serving as a drug carrier on the stent surface, and in antiproliferative agent technology have further improved the safety and clinical performance of newer-generation drug-eluting stents. This review will provide an overview of the novel platinum chromium everolimus-eluting stents that are currently available. The clinical data from major clinical trials with these devices will be summarized and put into perspective. PMID:23818756
Quantification and Impact of Untreated Coronary Artery Disease After Percutaneous Coronary Intervention
Généreux, Philippe; Palmerini, Tullio; Caixeta, Adriano; Rosner, Gregg; Green, Philip; Dressler, Ovidiu; Xu, Ke; Parise, Helen; Mehran, Roxana; Serruys, Patrick W.; Stone, Gregg W.
Objectives The purpose of this study was to quantify the extent and complexity of residual coronary stenoses following percutaneous coronary intervention (PCI) and to evaluate its impact on adverse ischemic outcomes. Background Incomplete revascularization (IR) after PCI is common, and most studies have suggested that IR is associated with a worse prognosis compared with complete revascularization (CR). However, formal quantification of the extent and complexity of residual atherosclerosis after PCI has not been performed. Methods The baseline Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score (bSS) from 2,686 angiograms from patients with moderate- and high-risk acute coronary syndrome (ACS) undergoing PCI enrolled in the prospective ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial was determined. The SS after PCI was also assessed, generating the "residual" SS (rSS). Patients with rSS >0 were defined as having IR and were stratified by rSS tertiles, and their outcomes were compared to the CR group. Results The bSS was 12.8 ± 6.7, and after PCI the rSS was 5.6 ± 2.2. Following PCI, 1,084 patients (40.4%) had rSS = 0 (CR), 523 (19.5%) had rSS >0 but ?2, 578 (21.5%) had rSS >2 but ?8, and 501 patients (18.7%) had rSS >8. Age, insulin-treated diabetes, hypertension, smoking, elevated biomarkers or ST-segment deviation, and lower ejection fraction were more frequent in patients with IR compared with CR. The 30-day and 1-year rates of ischemic events were significantly higher in the IR group compared with the CR group, especially those with high rSS. By multivariable analysis, rSS was a strong independent predictor of all ischemic outcomes at 1 year, including all-cause mortality (hazard ratio: 1.05, 95% confidence interval: 1.02 to 1.09, p = 0.006). Conclusions The rSS is useful to quantify and risk-stratify the degree and complexity of residual stenosis after PCI. Specifically, rSS >8.0 after PCI in patients with moderate- and high-risk ACS is associated with a poor 30-day and 1-year prognosis. PMID:22483327
Elective preoperative use of intra aortic balloon counterpulsation in high risk group of coronary artery disease patients to facilitate off pump surgery
Harinder Singh Bedi; Charanbir Singh Sohal; Bhupender Singh Sengar
Background To avoid the deleterious effects of cardio-pulmonary bypass, off pump coronary artery bypass graft surgery (OPCABG) is increasingly\\u000a the procedure of choice in the majority of patients needing myocardial revascularization. However patients at high operative\\u000a risk are sometimes not given the advantage of off pump surgery because of haemodynamic deterioration during displacement of\\u000a the heart to access the target vessels,
Vascular Access Site Complications After Percutaneous Coronary Intervention With Abciximab in the Evaluation of c7E3 for the Prevention of Ischemic Complications (EPIC) Trial
James C. Blankenship; Anne S. Hellkamp; Frank V. Aguirre; S. Lee Demko; Eric J. Topol; Robert M. Califf
Thrombolytic therapy or intense anticoagulation during percutaneous transluminal coronary revascularization (PTCR) increases the risk of vascular access site complications. This study evaluated the association of abciximab, a glycoprotein IIb\\/IIIa receptor blocker, with vascular access site complications after PTCR. Of 2,058 patients who underwent PTCR in the Evaluation of c7E3 for the Prevention of Ischemic Complications (EPIC) trial, major vascular access
Maintenance of Long-Term Clinical Benefit With Sirolimus-Eluting Coronary Stents. Three-Year Results of the RAVEL Trial
Jean Fajadet; Marie-Claude Morice; Christoph Bode
Background—The use of sirolimus-eluting coronary stents has been associated with a nearly complete elimination of restenosis at 6 months and with a very low 1-year incidence of major adverse cardiac events (MACE). This analysis examined whether these beneficial effects persist over the longer term. Methods and Results—This multicenter trial randomly assigned 238 patients to revascularization of single, de novo, native
Traumatic Coronary Artery Fistula Closure with Stent Graft
Safi, Morteza; Ebrahim, Nematollah Pour; Namazi, Mohammad Hasan; Saadat, Habibollah; Vakili, Hosein; Hekmat, Manuchehr
We present a rare case of a symptomatic acquired large coronary fistula and aneurysm secondary to chest trauma that was successfully closed using stent graft. This case is followed by review of the literature. PMID:22891139
The association of 9p21-3 locus with coronary atherosclerosis: a systematic review and meta-analysis
Background Studies suggest that the 9p21-3 locus may influence susceptibility to myocardial infarction. We performed a systematic review and meta-analysis to assess whether this locus is associated with severity of coronary atherosclerosis and adverse clinical outcomes in those with known coronary disease. Methods Multiple electronic databases were searched from inception through August 2012. Studies examining 9p21-3 genotype in patients with known coronary artery disease were included. We extracted the association of the 9p21-3 locus with measures of severity of coronary atherosclerosis [number of diseased vessels, Gensini Score, Duke CAD Prognostic Index (DPI)], angiographic outcomes [change in minimum lumen diameter (?MLD) and number of new lesions at follow-up], and key clinical outcomes (all-cause mortality, recurrent myocardial infarction and the need for coronary revascularization). Relative risks (RR) and weighted mean difference (WMD) were pooled using the random effects models. Results 23 cohorts enrolling 16,860 participants were analyzed. There was no significant difference between HR and LR genotypes in terms of all-cause mortality, recurrent myocardial infarction or the frequency of coronary revascularization. HR genotype was associated with increased risk of triple vessel disease (RR?=?1.34; 95% CI 1.08-1.65; P?=?0.01) and increased baseline Gensini Score (WMD?=?5.30; 95% CI 0.66-9.93; P?=?0.03). However there was no association with DPI (WMD?=?4.00; 95% CI 2.94-10.94; P?=?0.26). HR genotype did not predict ?MLD or number of new lesions at follow-up. Conclusions Patients of coronary atherosclerosis who carry the high risk genotype of the 9p21-3 allele may be more likely to have multi-vessel CAD. However the effect of this allele on CAD progression and disease specific clinical outcomes are not observed possibly due to diminishing genetic risk following dietary modification and therapy. PMID:24906238
A phase II, sham-controlled, double-blinded study testing the safety and efficacy of the coronary sinus reducer in patients with refractory angina: study protocol for a randomized controlled trial
Background A growing population of patients lives with severe coronary artery disease not amenable to coronary revascularization and with refractory angina despite optimal medical therapy. Percutaneous reduction of the coronary sinus is an emerging treatment for myocardial ischemia that increases coronary sinus pressure to promote a transcollateral redistribution of coronary artery in-flow from nonischemic to ischemic subendocardial territories. A first-in-man study has demonstrated that the percutaneous reduction of the coronary sinus can be performed safely in such patients. The COSIRA trial seeks to assess whether a percutaneous reduction of the coronary sinus can improve the symptoms of refractory angina in patients with limited revascularization options. Methods/Design The COSIRA trial is a phase II double-blind, sham-controlled, randomized parallel trial comparing the percutaneously implanted coronary sinus Reducer (Neovasc Inc, Richmond, BC, Canada) to a sham implantation in 124 patients enrolled in Canada, Belgium, England, Scotland, Sweden and Denmark. All patients need to have stable Canadian Cardiovascular Society (CCS) class III or IV angina despite optimal medical therapy, with evidence of reversible ischemia related to disease in the left coronary artery, and a left ventricular ejection fraction >25%. Participants experiencing an improvement in their angina ?2 CCS classes six months after the randomization will meet the primary efficacy endpoint. The secondary objective of this trial is to test whether coronary sinus Reducer implantation will improve left ventricular ischemia, as measured by the improvement in dobutamine echocardiogram wall motion score index and in time to 1 mm ST-segment depression from baseline to six-month post-implantation. Discussion Based on previous observations, the COSIRA is expected to provide a significant positive result or an informative null result upon which rational development decisions can be based. Patient safety is a central concern and extensive monitoring should allow an appropriate investigation of the safety related to the coronary sinus Reducer. Trial registration ClinicalTrials.gov identifier - NCT01205893. PMID:23413981
Effectiveness of Drug-Eluting Stents versus Bare-Metal Stents in Large Coronary Arteries in Patients with Acute Myocardial Infarction
Sim, Doo Sun; Ahn, Youngkeun; Kim, Young Jo; Chae, Shung Chull; Hong, Taek Jong; Seong, In Whan; Chae, Jei Keon; Kim, Chong Jin; Cho, Myeong Chan; Seung, Ki Bae; Park, Seung Jung
This study compared clinical outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in large coronary arteries in patients with acute myocardial infarction (MI). A total of 985 patients who underwent single-vessel percutaneous coronary intervention (PCI) in large coronary arteries (? 3.5 mm) in lesions < 25 mm were divided into DES group (n = 841) and BMS group (n = 144). Clinical outcomes during 12 months were compared. In-hospital outcome was similar between the groups. At six months, death/MI rate was not different. However, DES group had significantly lower rates of target-lesion revascularization (TLR) (1.7% vs 5.6%, P = 0.021), target-vessel revascularization (TVR) (2.2% vs 5.6%, P = 0.032), and total major adverse cardiac events (MACE) (3.4% vs 11.9%, P = 0.025). At 12 months, the rates of TLR and TVR remained lower in the DES group (2.5% vs 5.9%, P = 0.032 and 5.9% vs 3.1%, P = 0.041), but the rates of death/MI and total MACE were not statistically different. The use of DES in large vessels in the setting of acute MI is associated with lower need for repeat revascularization compared to BMS without compromising the overall safety over the course of one-year follow-up. PMID:21468259
Configurations and classifications of composite arterial grafts in coronary bypass surgery.
Yuan, Shi-Min; Shinfeld, Amihay; Raanani, Ehud
The aim of this review is to present the configurations and classifications of composite arterial grafts in coronary bypass surgery. Articles were collected by tracking references cited in the literature with regard to the configurations of composite arterial grafts in coronary bypass surgery. Figures of the configurations were drawn in accordance to the schematic drawings, angiograms, photographs, table contents or written captions of the literature. According to their structural nature, composite arterial grafts can be classified as: (i) alphabetical (Y, T, I, U, K, X and H) and (ii) complex grafts (TY, loop, pi and sling grafts). According to the conduits that form the composite graft, they can be classified as: (i) definite (all standard alphabetical grafts, classic pi and sling grafts); (ii) varying [internal mammary artery (IMA) loop, modified pi graft]; and (iii) indefinite conduit graft (TY graft). According to their application in coronary artery bypass grafting (CABG), they can be divided into complete arterial revascularization for: (i) triple vessel disease (T, Y, K, X, TY, pi and sling grafts); (ii) two vessel disease (U, right Y, and two-thirds right IMA T grafts); and (iii) single vessel disease, mainly the left anterior descending artery with or without the diagonal branch (H, I, IMA loop and left IMA T grafts). According to the CABG method, they can be classified as: (i) for conventional CABG (sling graft); (ii) for minimally invasive direct coronary artery bypass (H graft); and (iii) for both conventional CABG and off-pump coronary artery bypass (T, Y, U, K, I, TY, IMA loop, and pi grafts). Standard Y and T grafts have been accepted as the common figurations of composite arterial grafts to maximum graft length for the bypass of triple vessel disease. Composite arterial grafts overcome the limited availability of arterial conduits for performing total arterial myocardial revascularization, allow a gain in conduit length, and minimize the ascending aorta manipulation. PMID:18268413
Myocardial Revascularization in New York State: Variations in the PCI-to-CABG Ratio and Their Implications
Ko, Wilson; Tranbaugh, Robert; Marmur, Jonathan D.; Supino, Phyllis G.; Borer, Jeffrey S.
Background During the past 2 decades, percutaneous coronary intervention (PCI) has increased dramatically compared with coronary artery bypass grafting (CABG) for patients with coronary artery disease. However, although the evidence available to all practitioners is similar, the relative distribution of PCI and CABG appears to differ among hospitals and regions. Methods and Results We reviewed the published data from the mandatory New York State Department of Health annual cardiac procedure reports issued from 1994 through 2008 to define trends in PCI and CABG utilization in New York and to compare the PCI/CABG ratios in the metropolitan area to the remainder of the State. During this 15-year interval, the procedure volume changes for CABG, for all cardiac surgeries, for non-CABG cardiac surgeries, and for PCI for New York State were ?40%, ?20%, +17.5%, and +253%, respectively; for the Manhattan programs, the changes were similar as follows: ?61%, ?23%, +14%, and +284%. The average PCI/CABG ratio in New York State increased from 1.12 in 1994 to 5.14 in 2008; however, in Manhattan, the average PCI/CABG ratio increased from 1.19 to 8.04 (2008 range: 3.78 to 16.2). The 2008 PCI/CABG ratios of the Manhattan programs were higher than the ratios for New York City programs outside Manhattan, in Long Island, in the northern counties contiguous to New York City, and in the rest of New York State; their averages were 5.84, 5.38, 3.31, and 3.24, respectively. In Manhattan, a patient had a 56% greater chance of receiving PCI than CABG as compared with the rest of New York State; in one Manhattan program, the likelihood was 215% higher. Conclusions There are substantial regional and statewide differences in the utilization of PCI versus CABG among cardiac centers in New York, possibly related to patient characteristics, physician biases, and hospital culture. Understanding these disparities may facilitate the selection of the most appropriate, effective, and evidence-based revascularization strategy. (J Am Heart Assoc. 2012;1:e001446 doi: 10.1161/JAHA.112.001446.) PMID:23130131
[Preventive intraaortic balloon counterpulsation during surgical myocardial revascularization].
Konstantinov, B A; Ziuliaeva, T P; Eremenko, A A; Molochnikov, I O; Iavorovski?, A G
Fifty patients with low myocardial functional reserves (left ventricular ejection fraction less than 40%, disseminated cardiosclerosis, multiple affection of coronary arteries, NYHA class III-IV) after coronary artery bypass surgery (CABS) were examined. All the patients were divided into 2 groups. Preventive intraaortic balloon counterpulsation (IABC) was used in 24 patients (group 1). Group 2 consisted of 26 patients with similar physical state where IABC has not been used. It was revealed that preventive IABC leads to stabilization of the left ventricle function and cardiac output, a decrease in the doses and period of catecholamines administration. The rate of cardiac rhythm disorders in group 1 was 7 times, myocardial infarction -- 2.5 times, respiratory failure -- 5 times, stay at the intensive care unit -- 2 times less compared with those of group 2. Lethality was 12.5% in group 1 and 26.9% in group 2. PMID:16482051
Non-cardiac surgery in patients with prior myocardial revascularization
Patricia M. Cruchley; Joel A. Kaplan; Carl C. Hug; David Nagle; Rhea Sumpter; Donna Finucane
Patients who had undergone aorto-coronary bypass grafts (ACBG) were assessed\\/or the incidence of cardiac complications in\\u000a the postoperative period following subsequent non-cardiac surgery. One hundred and twenty-one patients had 13 complications\\u000a (11 percent). A significantly higher risk of cardiac complications (27 per cent) was found in patients undergoing non-cardiac\\u000a procedures in the first month after ACBG. This remained higher (17
Correlation between Patient-Reported Symptoms and Ankle-Brachial Index after Revascularization for Peripheral Arterial Disease
Je, Hyung Gon; Kim, Bo Hyun; Cho, Kyoung Im; Jang, Jae Sik; Park, Yong Hyun; Spertus, John
Improvement in quality of life (QoL) is a primary treatment goal for patients with peripheral arterial disease (PAD). The current study aimed to quantify improvement in the health status of PAD patients following peripheral revascularization using the peripheral artery questionnaire (PAQ) and ankle-brachial index (ABI), and to evaluate possible correlation between the two methods. The PAQ and ABI were assessed in 149 symptomatic PAD patients before, and three months after peripheral revascularization. Mean PAQ summary scores improved significantly three months after revascularization (+49.3 ± 15 points, p < 0.001). PAQ scores relating to patient symptoms showed the largest improvement following revascularization. The smallest increases were seen in reported treatment satisfaction (all p's < 0.001). As expected the ABI of treated limbs showed significant improvement post-revascularization (p < 0.001). ABI after revascularization correlated with patient-reported changes in the physical function and QoL domains of the PAQ. Twenty-two percent of PAD patients were identified as having a poor response to revascularization (increase in ABI < 0.15). Interestingly, poor responders reported improvement in symptoms on the PAQ, although this was less marked than in patients with an increase in ABI > 0.15 following revascularization. In conclusion, data from the current study suggest a significant correlation between improvement in patient-reported outcomes assessed by PAQ and ABI in symptomatic PAD patients undergoing peripheral revascularization. PMID:25993299
Perioperative myocardial infarction in patients undergoing myocardial revascularization surgery
Pretto, Pericles; Martins, Gerez Fernandes; Biscaro, Andressa; Kruczan, Dany David; Jessen, Barbara
Introduction Perioperative myocardial infarction adversely affects the prognosis of patients undergoing coronary artery bypass graft and its diagnosis was hampered by numerous difficulties, because the pathophysiology is different from the traditional instability atherosclerotic and the clinical difficulty to be characterized. Objective To identify the frequency of perioperative myocardial infarction and its outcome in patients undergoing coronary artery bypass graft. Methods Retrospective cohort study performed in a tertiary hospital specialized in cardiology, from May 01, 2011 to April 30, 2012, which included all records containing coronary artery bypass graft records. To confirm the diagnosis of perioperative myocardial infarction criteria, the Third Universal Definition of Myocardial Infarction was used. Results We analyzed 116 cases. Perioperative myocardial infarction was diagnosed in 28 patients (24.1%). Number of grafts and use and cardiopulmonary bypass time were associated with this diagnosis and the mean age was significantly higher in this group. The diagnostic criteria elevated troponin I, which was positive in 99.1% of cases regardless of diagnosis of perioperative myocardial infarction. No significant difference was found between length of hospital stay and intensive care unit in patients with and without this complication, however patients with perioperative myocardial infarction progressed with worse left ventricular function and more death cases. Conclusion The frequency of perioperative myocardial infarction found in this study was considered high and as a consequence the same observed average higher troponin I, more cases of worsening left ventricular function and death. PMID:25859867
Increased cerebral blood flow after external carotid artery revascularization
Zarins, C.K.; DelBeccaro, E.J.; Johns, L.; Turcotte, J.K.; Dohrmann, G.J.
Ten patients with symptoms of cerebral ischemia were found to have totally occluded internal carotid arteries with significant external carotid artery stenosis or occlusion. Eight patients underwent external carotid endarterectomy, and two patients underwent saphenous vein bypass to the external carotid artery from the subclavian artery. Cerebral blood flow was measured with /sup 133/Xe in six patients preoperatively and in five postoperatively. Four of the six patients had diminished mean flow on the affected side, and three had diminished flow in the contralateral side. All patients had abnormalities in regional cerebral blood flow. Postoperatively, all patients had significant improvement in mean blood flow on the side treated with operation (15% to 39%), and four had improvement of blood flow on the contralateral side (12% to 52%). All had improvement in regional cerebral blood flow. Nine of the 10 patients were relieved of their symptoms. One patient, despite improvement in cerebral blood flow, continued to have diminished cerebral flow and symptoms postoperatively. Subsequent extracranial-intracranial bypass relieved his symptoms and his cerebral blood flow returned to normal. Thus external carotid artery revascularization is effective in increasing total and regional cerebral blood flow and in relieving symptoms of internal carotid artery occlusion and external carotid stenosis. Cerebral blood flow measurement with /sup 133/Xe is useful in preoperative patient selection and objective assessment of operative results.
Platelet neuropeptide Y is critical for ischemic revascularization in mice.
Tilan, Jason U; Everhart, Lindsay M; Abe, Ken; Kuo-Bonde, Lydia; Chalothorn, Dan; Kitlinska, Joanna; Burnett, Mary Susan; Epstein, Stephen E; Faber, James E; Zukowska, Zofia
We previously reported that the sympathetic neurotransmitter neuropeptide Y (NPY) is potently angiogenic, primarily through its Y2 receptor, and that endogenous NPY is crucial for capillary angiogenesis in rodent hindlimb ischemia. Here we sought to identify the source of NPY responsible for revascularization and its mechanisms of action. At d 3, NPY(-/-) mice demonstrated delayed recovery of blood flow and limb function, consistent with impaired collateral conductance, while ischemic capillary angiogenesis was reduced (~70%) at d 14. This biphasic temporal response was confirmed by 2 peaks of NPY activation in rats: a transient early increase in neuronally derived plasma NPY and increase in platelet NPY during late-phase recovery. Compared to NPY-null platelets, collagen-activated NPY-rich platelets were more mitogenic (~2-fold vs. ~1.6-fold increase) for human microvascular endothelial cells, and Y2/Y5 receptor antagonists ablated this difference in proliferation. In NPY(+/+) mice, ischemic angiogenesis was prevented by platelet depletion and then restored by transfusion of platelets from NPY(+/+) mice, but not NPY(-/-) mice. In thrombocytopenic NPY(-/-) mice, transfusion of wild-type platelets fully restored ischemia-induced angiogenesis. These findings suggest that neuronally derived NPY accelerates the early response to femoral artery ligation by promoting collateral conductance, while platelet-derived NPY is critical for sustained capillary angiogenesis. PMID:23457218
Sequential vs simultaneous revascularization in patients undergoing liver transplantation: A meta-analysis
Wang, Jia-Zhong; Liu, Yang; Wang, Jin-Long; Lu, Le; Zhang, Ya-Fei; Lu, Hong-Wei; Li, Yi-Ming
AIM: We undertook this meta-analysis to investigate the relationship between revascularization and outcomes after liver transplantation. METHODS: A literature search was performed using MeSH and key words. The quality of the included studies was assessed using the Jadad Score and the Newcastle-Ottawa Scale. Heterogeneity was evaluated by the ?2 and I2 tests. The risk of publication bias was assessed using a funnel plot and Egger's test, and the risk of bias was assessed using a domain-based assessment tool. A sensitivity analysis was conducted by reanalyzing the data using different statistical approaches. RESULTS: Six studies with a total of 467 patients were included. Ischemic-type biliary lesions were significantly reduced in the simultaneous revascularization group compared with the sequential revascularization group (OR = 4.97, 95%CI: 2.45-10.07; P < 0.00001), and intensive care unit (ICU) days were decreased (MD = 2.00, 95%CI: 0.55-3.45; P = 0.007) in the simultaneous revascularization group. Although warm ischemia time was prolonged in simultaneous revascularization group (MD = -25.84, 95%CI: -29.28-22.40; P < 0.00001), there were no significant differences in other outcomes between sequential and simultaneous revascularization groups. Assessment of the risk of bias showed that the methods of random sequence generation and blinding might have been a source of bias. The sensitivity analysis strengthened the reliability of the results of this meta-analysis. CONCLUSION: The results of this study indicate that simultaneous revascularization in liver transplantation may reduce the incidence of ischemic-type biliary lesions and length of stay of patients in the ICU. PMID:26078582
Postoperative coronary artery spasm after mitral valve replacement?
Pragliola, Claudio; Gaudino, Mario; Farina, Piero; Massetti, Massimo
Introduction Postoperative coronary artery spasm is an infrequent life-threatening event after cardiac surgery which can occur without an underlying coronary disease Presentation of case We report a documented case of a 67-year-old man with normal coronary arteries submitted to mitral valve replacement. Immediately after surgery he had a ST elevation in the inferior leads, and an inferior wall hypokinesia at the trans-oesophageal echo. A coronary angiography demonstrated a focal spasm in the right coronary artery which was successfully treated by intracoronary injection of nitrates. The following postoperative course was uneventful and the left ventricular function returned to normal. Discussion A coronary artery spasm should be suspected whenever a postoperative infarction occurs after valvular surgery especially in absence of associated coronary artery disease. In this cases postoperative coronary angiography allows both the diagnosis and the treatment. Conclusion This case-report summarizes the findings of this rare and potentially life-threatening cause of early postoperative ischemia and highlights the role of early coronary angiography in the cases of suspected myocardial infarction after cardiac surgery PMID:25680533
[Giant aneurysm of the right coronary artery: an unusual treatment].
Rognoni, Andrea; Degiovanni, Anna; Cavallino, Chiara; Lupi, Alessandro; Rosso, Roberta; Veia, Alessia; Rametta, Francesco; Bongo, Angelo Sante
Coronary artery aneurysm (CAA) is an uncommon disease observed in only 0.15-4.9% of patients undergoing coronary angiography. CAA are defined as dilated coronary artery sections exceeding by 1.5 times the diameter of normal adjacent segments or of the patient's largest coronary vessel. Occasionally, CAA enlarge enough to be called giant CAA. We report the case of a 78-year-old man, with known chronic ischemic cardiomyopathy and a history of prior coronary artery bypass surgery (with a left internal mammary artery graft to the left anterior descending coronary artery and saphenous venous graft to the obtuse marginal branch), who was referred to our cardiology department for progressive dyspnea. Echocardiography showed severe mitral regurgitation suggesting replacement; coronary angiography revealed three-vessel coronary artery disease, left internal mammary artery patency, saphenous vein graft occlusion and an aneurysm of the mid right coronary artery. Cardiac magnetic resonance confirmed this finding, showing a giant CAA (65 x 75 mm) with a large endoluminal thrombus. Treatment is not standardized and may include medical therapy, percutaneous treatment and surgical intervention; our patient underwent percutaneous coil embolization. One-month angiographic follow-up showed successful obliteration. The patient underwent surgical mitral valve replacement without any complications. At 9-month clinical follow-up, he was asymptomatic; transthoracic echocardiography showed an ejection fraction of 44% without prosthetic mitral regurgitation. PMID:25959761
[Off-pump coronary artery bypass: analysis of 1080 patients].
Monassier, F; Mattei, C; Gavra, G; Dallemand, R; Lallemant, P; Olteane, C; Semenescu, A; Durasnel, P; Monassier, J P; Bischoff, N
A consecutive cohort including 1080 patients undergoing "off-pump" myocardial revascularization was reviewed. An average of 2.22 bypass/patients was performed. The death-rate during the first 30 days after surgery was 0.65%. Four cases needed cross-over to on-pump. The postoperative events were: need of inotropic drugs (2.7%), atrial fibrillation (12.4%), myocardial infarction (6.6%). The extubation was performed before the first postoperative 24 h in 91.9% of cases. The majority of patients was discharged from hospital before 8 days after surgery. Off pump coronary artery bypass surgery exhibit good results for most of the patients even if they present multiple vessel disease and high operating risk. PMID:17183823
An appraisal of symptom relief after coronary bypass grafting.
Frick, M. H.
Subjective symptomatic improvement is experienced by 90% of patients after coronary bypass surgery. Objective exercise testing reduces this incidence to 70%. An analysis of the multifactorial genesis of pain relief based on data of non-randomized trials reveals that graft patency plays a dominant but not unique role in causing improved symptomatology. In a number of cases, intra-operative myocardial infarctions seem to explain the pain relief but may also have opposite effects. Changes in left ventricular function operate bidirectionally but data on this variable in relation to changes in symptomatology are not amenable for detailed analysis. Progression in native vessel lesions apparently opposes pain relief and has its greatest impact in connection with graft closure. Residual post-operative angina is evidently related also to incomplete revascularization. PMID:64978
Arbab-Zadeh, Armin; Nakano, Masataka; Virmani, Renu; Fuster, Valentin
In the United States alone, more than 400,000 Americans die annually from coronary artery disease and more than 1,000,000 suffer acute coronary events, i.e., myocardial infarction and sudden cardiac death.1 Considering the aging of our population and increasing incidence of diabetes and obesity, the morbidity from coronary artery disease, and its associated costs, will place an increasing, substantial burden on our society.2 Between 2010 and 2030, total direct medical costs spent in the US for cardiovascular diseases are projected to triple from 273 to 818 billion dollars.2 Although effective treatments are available and considerable efforts are ongoing to identify new strategies for the prevention of coronary events, predicting such events in an individual has been challenging.3 In hopes of improving our ability to determine the risk of coronary events, it is prudent to review our knowledge of factors that lead to acute coronary events. PMID:22392862
Assessment of coronary thrombolysis
Geltman, E.M.; Abendschein, D.R.; Devries, S.R.
The efficacy of coronary thrombolysis may be assessed by several invasive and noninvasive means, including coronary angiography, contrast and radionuclide angiography, thallium 201 or /sup 99m/Tc-pyrophosphate scintigraphy, positron emission tomography, cardiac ultrasonography, electrocardiography, and analysis of plasma creatine kinase activity. Each technique has its own strengths and limitations, but when used in concert these methods may provide insight into the physiology of coronary reperfusion and the efficacy of reperfusion in individual patients and populations. 104 references.
Embedding a randomized clinical trial into an ongoing registry infrastructure: Unique opportunities for efficiency in design of the Study of Access site For Enhancement of Percutaneous Coronary Intervention for Women (SAFE-PCI for Women)
Hess, Connie N.; Rao, Sunil V.; Kong, David F.; Aberle, Laura H.; Anstrom, Kevin J.; Gibson, C. Michael; Gilchrist, Ian C.; Jacobs, Alice K.; Jolly, Sanjit S.; Mehran, Roxana; Messenger, John C.; Newby, L. Kristin; Waksman, Ron; Krucoff, Mitchell W.
Women are at higher risk than men for bleeding and vascular complications after percutaneous coronary intervention (PCI). Compared with femoral access, radial access reduces these complications but may be more challenging in women because of higher rates of radial artery spasm, tortuosity, and occlusion as well as lower rates of procedure success. Whether the safety advantages of radial versus femoral access in women undergoing PCI are outweighed by reduced effectiveness has not been studied. The Study of Access site For Enhancement of PCI for Women is a prospective, randomized clinical trial comparing radial with femoral arterial access in women undergoing PCI. In conjunction with the US Food and Drug Administration?s Critical Path Cardiac Safety Research Consortium, this study embeds the randomized clinical trial into the existing infrastructure of the National Cardiovascular Data Registry™ CathPCI Registry™ through the National Institute of Health?s National Cardiovascular Research Infrastructure. The primary efficacy end point is a composite of bleeding (Bleeding Academic Research Consortium types 2, 3, or 5) or vascular complication requiring intervention occurring at 72 hours after PCI or by hospital discharge. The primary feasibility end point is procedure success. Secondary end points include procedure duration, contrast volume, radiation dose, quality of life, and a composite of 30-day death, vascular complication, or unplanned revascularization. PMID:24016489
Is the advantage of coronary bypass graft surgery over percutaneous coronary intervention in diabetic patients with severe multivessel disease influenced by the status of insulin requirement?
Lee, Beom Jun; Herbison, Peter; Wong, Cheuk-Kit
Several studies have shown that coronary artery bypass graft surgery (CABG) is superior to percutaneous coronary intervention (PCI) in patients with diabetes and multi-vessel disease. Whether this advantage of CABG over PCI is confined to diabetics who require insulin is unknown. We review the published literature comparing CABG with PCI in diabetics including 8 cohorts and 4,786 patients. There was a lower rate for all-cause mortality (Relative risk (RR): 0.78, 95% confidence interval (CI): 0.62–0.99), and for major adverse cardiac and cerebrovascular events (MACCE, RR: 0.59, 95% CI: 0.47–0.75) for CABG compared to PCI. Composite outcome of mortality, myocardial infarction and stoke was similar between CABG and PCI (RR: 0.87, 95% CI: 0.54–1.42). Visual inspection of the forest plots showed that in most analyses, the point estimates of the RR are similar between the insulin requiring group and non-insulin requiring group. On meta-regression, there was no interaction between status of insulin requirement and revascularization strategies (P > 0.05 for all). The presented data on the still unpublished analysis of the FREEDOM trial showed similar results. Thus, in the current era, CABG is superior to PCI with lower mortality and MACCE rates, but the state of insulin requirement had no effect on the outcomes from the two revascularization strategies. PMID:24748887
Is the advantage of coronary bypass graft surgery over percutaneous coronary intervention in diabetic patients with severe multivessel disease influenced by the status of insulin requirement?
Lee, Beom Jun; Herbison, Peter; Wong, Cheuk-Kit
Several studies have shown that coronary artery bypass graft surgery (CABG) is superior to percutaneous coronary intervention (PCI) in patients with diabetes and multi-vessel disease. Whether this advantage of CABG over PCI is confined to diabetics who require insulin is unknown. We review the published literature comparing CABG with PCI in diabetics including 8 cohorts and 4,786 patients. There was a lower rate for all-cause mortality (Relative risk (RR): 0.78, 95% confidence interval (CI): 0.62-0.99), and for major adverse cardiac and cerebrovascular events (MACCE, RR: 0.59, 95% CI: 0.47-0.75) for CABG compared to PCI. Composite outcome of mortality, myocardial infarction and stoke was similar between CABG and PCI (RR: 0.87, 95% CI: 0.54-1.42). Visual inspection of the forest plots showed that in most analyses, the point estimates of the RR are similar between the insulin requiring group and non-insulin requiring group. On meta-regression, there was no interaction between status of insulin requirement and revascularization strategies (P > 0.05 for all). The presented data on the still unpublished analysis of the FREEDOM trial showed similar results. Thus, in the current era, CABG is superior to PCI with lower mortality and MACCE rates, but the state of insulin requirement had no effect on the outcomes from the two revascularization strategies. PMID:24748887
Comparison of clinical outcomes between culprit vessel only and multivessel percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel coronary diseases
Ryu, Kwang Sun; Park, Hyun Woo; Park, Soo Ho; Shon, Ho Sun; Ryu, Keun Ho; Lee, Dong Gyu; Bashir, Mohamed EA; Lee, Ju Hee; Kim, Sang Min; Lee, Sang Yeub; Bae, Jang Whan; Hwang, Kyung Kuk; Kim, Dong Woon; Cho, Myeong Chan; Ahn, Young Keun; Jeong, Myung Ho; Kim, Chong Jin; Park, Jong Seon; Kim, Young Jo; Jang, Yang Soo; Kim, Hyo Soo; Seung, Ki Bae
Background The clinical significance of complete revascularization for ST segment elevation myocardial infarction (STEMI) patients during admission is still debatable. Methods A total of 1406 STEMI patients from the Korean Myocardial Infarction Registry with multivessel diseases without cardiogenic shock who underwent primary percutaneous coronary intervention (PPCI) were analyzed. We used propensity score matching (PSM) to control differences of baseline characteristics between culprit only intervention (CP) and multivessel percutaneous coronary interventions (MP), and between double vessel disease (DVD) and triple vessel disease (TVD). The major adverse cardiac event (MACE) was analyzed for one year after discharge. Results TVD patients showed higher incidence of MACE (14.2% vs. 8.6%, P = 0.01), any cause of revascularization (10.6% vs. 5.9%, P = 0.01), and repeated PCI (9.5% vs. 5.7%, P = 0.02), as compared to DVD patients during one year after discharge. MP reduced MACE effectively (7.3% vs. 13.8%, P = 0.03), as compared to CP for one year, but all cause of death (1.6% vs. 3.2%, P = 0.38), MI (0.4% vs. 0.8%, P = 1.00), and any cause of revascularization (5.3% vs. 9.7%, P = 0.09) were comparable in the two treatment groups. Conclusions STEMI patients with TVD showed higher rate of MACE, as compared to DVD. MP performed during PPCI or ad hoc during admission for STEMI patients without cardiogenic shock showed lower rate of MACE in this large scaled database. Therefore, MP could be considered as an effective treatment option for STEMI patients without cardiogenic shock.
The pharmacoeconomic impact of amlodipine use on coronary artery disease.
De Portu, Simona; Menditto, Enrica; Scalone, Luciana; Bustacchini, Silvia; Cricelli, Claudio; Mantovani, Lorenzo Giovanni
The most frequent cause of mortality and morbidity in industrialized countries is coronary artery disease (CAD), which in Europe alone is responsible for around two million deaths per year. In 2001 it accounted for about 260,000 hospital discharges in Italy. The costs of CAD treatment in Italy--which were borne by the Italian state, the third-party payer--amounted to 800 million euros. We propose to assess the pharmacoeconomic implications of using amlodipine besylate treatment in Italy for patients with coronary artery disease. The study is based on a post-hoc cost-effectiveness analysis that compared standard care supplemented by amlodipine besylate with ordinary standard care over a 36-month time horizon. The clinical outcome data were based on the prospective randomized evaluation of vascular effect of norvasc trial (PREVENT). Direct medical costs referred to the purchase costs of amlodipine besylate and the cost of National Health Service (NHS) hospitalization. The costs were discounted back at an annual rate of 5%. Patients administered amlodipine besylate exhibited a significant risk reduction with respect to any major vascular event or procedure when compared to the placebo group. The reduction mainly referred to unstable angina events and revascularization procedures. We estimated that the total cost of adding amlodipine besylate to standard care amounted to 139,050 euros per 1000 patients treated for 36 months. This represents a cost of 1780 euros per patient remaining free of any vascular event. Results were sensitive to both clinical and economic variables. The incremental costs of the alternative therapy ranged from 296 euros to 5066 per patient free of any event in, respectively, the best and worst scenario. Amlodipine besylate therapy can be a cost-effective strategy for CAD treatment in Italy. Our economic evaluation demonstrated, first, that by reducing vascular events and the need for revascularization procedures savings were achieved in hospital expenditure, and, second, that such savings could significantly offset drug costs. PMID:16814560
Percutaneous Closure of a Coronary Artery-to-Vein Graft Anastomotic Pseudoaneurysm Presenting as Acute Coronary Syndrome after Recent Coronary Artery Bypass Grafting
Sharma, Suresh; Gupta, Kamal; Wiley, Mark; Parashara, Deepak
Pseudoaneurysm formation has been reported in degenerated coronary artery saphenous vein bypass grafts, as well as in native coronary arteries after interventional procedures or blunt trauma. In contrast, pseudoaneurysm formation arising from the anastomotic site of native coronary vessels soon after coronary artery bypass grafting is rare, and neither the clinical presentation of this phenomenon nor its treatment is well described. We present the case of a 63-year-old man, a recent coronary artery bypass grafting patient, who presented with acute coronary syndrome due to a large and expanding pseudoaneurysm of the saphenous vein-to-ramus intermedius artery graft anastomosis. After several attempts, we successfully treated the pseudoaneurysm by means of percutaneous coil embolization. To our knowledge, this is the first report of acute coronary syndrome secondary to a pseudoaneurysm at the coronary artery–saphenous vein graft anastomosis. In addition, this appears to be the first report of the percutaneous treatment of such a pseudoaneurysm by means of coil embolization. PMID:26175645
Combination of low molecular weight heparins with antiplatelet agents in non-ST elevation acute coronary syndromes: an update.
Cohen, Marc
This article reviews the use of low molecular weight heparin (LMWH) and antiplatelet agents in the treatment of unstable angina and non-ST segment elevation myocardial infarction (NSTEMI), which together account for 1 million hospitalisations annually in the US alone. Mortality and recurrent myocardial infarction (MI) in these conditions is currently approximately 8 to 16% at 1 month, and there is a need to optimise treatment further. Since their introduction, LMWHs have been shown to be successful and well tolerated in the treatment of unstable angina and NSTEMI, but differences have been seen in their efficacy compared with the parent compound, unfractionated heparin (UFH). A meta-analysis of all LMWHs, grouped, versus UFH showed equivalent efficacy and safety. The LMWHs dalteparin sodium and nadroparin calcium have independently been shown to be as effective as UFH. However, enoxaparin sodium has been shown to have greater clinical efficacy than UFH in patients with unstable angina (UA)/NSTEMI. One area of new research is patients with UA/NSTEMI who later undergo percutaneous coronary interventions (PCI), and early data suggest enoxaparin can be safely used as an anticoagulant instead of UFH in these patients. There is a wealth of data for glycoprotein (GP) IIb/IIIa receptor antagonists (abciximab, eptifibatide, lamifiban, and tirofiban), although some are conflicting. Recent meta-analyses suggest that some benefit is conferred by using these compounds, particularly in patients who undergo PCI. Recent trials have focussed on combining GP IIb/IIIa antagonists with LMWH, and although data is still scant, the ACUTE (Anti-thrombotic Combination Using Tirofiban and Enoxaparin) and ACUTE II studies indicate the safety and potential clinical benefit of combining enoxaparin with tirofiban in patients with UA/NSTEMI not undergoing PCI, compared with UFH and tirofiban. The NICE (National Investigators Collaborating on Enoxaparin) 4 study collected data on the combination of enoxaparin and abciximab in patients undergoing PCI, and both safety and efficacy data compared well with historical data collected on the use of UFH with abciximab. The more recent NICE 3 study extended this finding to the combination of enoxaparin with abciximab, tirofiban or eptifibatide. The safety of two doses of dalteparin and abciximab had also been investigated, with the higher dose the efficacious, and also with safety, in patients undergoing PCI. In addition, a GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes) IV substudy found that dalteparin had equivalent safety to UFH when co-administered with abciximab in patients not undergoing PCI. The NICE 3 and 4 trials were not randomised comparisons, and as such there results must be interpreted with caution. Recently, the CRUISE (Coronary Revascularisation Utilizing Integrelin [eptifibatide] and Single-bolus Enoxaparin) and INTERACT (Integrelin and Enoxaparin randomised assessment of Acute Coronary Syndromes Treatment) studies have provided evidence for both the safety and efficacy of enoxaparin combined with eptifibatide in non-ST elevation patients with acute coronary syndromes. A further study (SYNERGY [Superior Yield of the New strategy of Enoxaparin, Revascularization and GlYcoprotein IIb/IIIa inhibitors]) will investigate the efficacy of the combination of enoxaparin with abciximab versus that of UFH and abciximab in a large cohort of 8000 patients. The use of GP IIb/IIIa agents and LMWH in patients with UA/STEMI has led to their use in those with ST-elevation MI, and studies indicate LMWH is efficacious and can be used safely as an adjunct to thrombolysis. New studies will investigate the use of these agents in patients with STEMI not undergoing thrombolysis and we await the results of these studies. PMID:12149045
In-hospital and nine-month outcome of treatment of coronary bifurcational lesions with sirolimus-eluting stent.
Ge, Lei; Tsagalou, Eleutheria; Iakovou, Ioannis; Sangiorgi, Giuseppe M; Corvaja, Nicola; Airoldi, Flavio; Chieffo, Alaide; Montorfano, Matteo; Michev, Iassen; Colombo, Antonio
Between April 2002 and May 2004, 174 consecutive patients who underwent percutaneous coronary intervention of bifurcational lesions with sirolimus-eluting stents were identified. Two strategies were used: stenting only 1 branch (group 1S, n = 57) or stenting both branches (group 2S, n = 117). The incidence of major adverse cardiac events was evaluated in the hospital and at 9-month follow-up. There were no statistically significant differences between the 2 groups with regard to the incidence of target lesion revascularization (5.4% vs 8.9%, p = 0.76), target vessel revascularization (5.4% vs 11.1%, p = 0.51), and cumulative major adverse cardiac events (18.9% vs 23.3%, p = 0.76) at 9 months. PMID:15757605
Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients
Erik W. L. Jansen; Cornelius Borst; Jaap R. Lahpor; Paul F. Gründeman; Frank D. Eefting; Arno Nierich; Etienne O. Robles de Medina; Johan J. Bredée
Objective: Cardiopulmonary bypass and global cardiac arrest enable safe coronary artery bypass grafting but have adverse effects. In off-pump coronary bypass grafting, invasiveness is reduced, but anastomosis suturing is jeopardized by cardiac motion. Therefore the key to successful off-pump coronary bypass grafting is effective local cardiac wall stabilization. Methods: We prospectively assessed the safety and efficacy of the Octopus tissue
Biodegradable-polymer-based drug-eluting stent for left main coronary artery disease.
Gutiérrez-Chico, J L; Jochheim, D; Mehilli, J
Percutaneous coronary interventions (PCI) have gained widespread acceptation among cardiologists and among the general population for a variety of clinical indications, comprising from stable angina to ST-elevation acute myocardial infarction, due to the undisputed clinical benefit they provide and to their large availability and accessibility. Nonetheless PCI in the left main coronary artery (LMCA) is still controversial. Traditionally the revascularization of the LMCA has been one of those exceptions in which surgery was preferred to PCI, although PCI still found a slot in non-surgically-suitable cases or as bailout intervention. Some evidence has been recently generated, that challenges this traditional approach, and also about the clinical advantages of new-generation intracoronary devices, among them the drug-eluting stents with biodegradable polymers in abluminal coating. This scenario opens new horizons for the treatment of LMCA disease, in which a more prominent role of PCI can be anticipated. PMID:24096250
Visualization of Coronary Arteries from Intravenous Angiograms
NASA Technical Reports Server (NTRS)
Selzer, Robert H.
Under most circumstances, the coronary arteries are not satisfactorily visualized in intravenous angiograms. The objective of this study is to develop computer image enhancement methods that will improve the quality of the latent coronary images to a degree sufficient to detect an obstructive lesion. Such a technique, if successful, could be used as a first step alternative to conventional coronary angiography for individuals with ambiguous noninvasive cardiac tests. The determination of no lesion from the intravenous procedure would relieve the need for the conventional angiogram, while verification of an obstructive lesion could be followed by a conventional angiogram. The nature of the imaging problem and a description of the methods and initial processing results are described in this paper.
Stroke prevention in asymptomatic carotid artery disease: revascularization of carotid stenosis is not the solution.
Hart, Robert G; Ng, Kuan H
Asymptomatic carotid stenosis (ACS) exceeding 50% is present in about 2% of 60?year?old patients and an even higher fraction of older individuals. The major independent risk factors include advancing age, male sex, tobacco smoking, and a history of vascular disease. The best available evidence does not support either population screening for ACS or routine carotid revascularization when ACS is discovered. There is an urgent need to identify patients with ACS and a sufficiently high risk of ipsilateral stroke (despite contemporary medical management) to warrant invasive treatment. The mainstays of medical management are antiplatelet therapy (usually low?dose aspirin), high?dose statins, blood pressure control, and smoking cessation. Patients with ACS should be periodically educated about symptoms of transient ischemic attack and stroke that require emergent medical attention. Current guidelines vary widely in recommendations regarding revascularization (ie, endarterectomy or carotid stenting). The benefits of revascularization strategies remain uncertain for patients with ACS who receive contemporary medical management. PMID:25883075
Single Nucleotide Polymorphisms in Cholesteryl Ester Transfer Protein Gene And Recurrent Coronary Heart Disease or Mortality in Patients with Established Atherosclerosis
Virani, Salim S.; Lee, Vei-Vei; Brautbar, Ariel; Grove, Megan L.; Nambi, Vijay; Alam, Mahboob; Elayda, MacArthur; Wilson, James M.; Willerson, James T.; Boerwinkle, Eric; Ballantyne, Christie M.
It is not known whether genetic variants in the cholesteryl-ester-transfer-protein (CETP) gene are associated with recurrent coronary heart disease events or mortality in secondary prevention patients. Among 3717 acute coronary syndrome (ACS) or coronary artery bypass grafting (CABG) patients enrolled in a prospective genetic registry; we evaluated whether CETP gene variants previously shown to be associated with reduced CETP activity and high-density-lipoprotein-cholesterol increase ("A" allele for both TaqIB [rs708272] and rs12149545) are associated with a reduction in recurrent myocardial infarction [MI], recurrent revascularization or death. At 4.5 years of follow-up; 439 recurrent MI, 698 recurrent revascularizations and 756 deaths occurred. Using an additive model of inheritance, the "A" allele for rs708272 was not associated with recurrent MI (HR 0.95, 95% CI 0.78-1.17 for AG; HR 0.89, 95% CI 0.67-1.19 for AA; compared with GG genotype), recurrent revascularization (HR 1.13, 95% CI 0.95-1.33 for AG; HR 1.05, 95% CI 0.84-1.32 for AA) or mortality (HR 1.02, 95% CI 0.86-1.19 for AG; HR 1.11, 95% CI 0.91-1.37 for AA) in the overall cohort. Similar results were seen for the "A" allele for rs12149545. In the CABG subgroup, AG genotype for rs708272 was associated with an increased mortality (HR 1.38, 95% CI 1.06-1.79) compared to GG genotype. Results remained consistent using dominant model of inheritance. In conclusion, genetic CETP variants were not associated with recurrent MI or recurrent revascularization in overall cohort with a possible mortality increase in CABG patients. PMID:23891427
Coronary Artery Bypass Grafting
Liubov Ben-Noun
Long-term psychosocial outcomes were examined in 132 patients 7 to 22 years M = 9.4 years after coronary artery bypass grafting. The control group comprised 145 medically treated patients with coronary heart disease of 7 to 22 year duration M = 9.2. Significantly more medically than surgically treated patients were scored in the clinically significant range for anxiety, and for
Prognosis of patients with stable coronary artery disease (from the CORONOR study).
Bauters, Christophe; Deneve, Michel; Tricot, Olivier; Meurice, Thibaud; Lamblin, Nicolas
There are limited data on the prognosis of patients with stable coronary artery disease (CAD) in modern clinical practice. We conducted a multicenter study enrolling 4,184 outpatients with stable CAD defined as previous myocardial infarction (>1 year ago), previous coronary revascularization (>1 year ago), and/or ?50% coronary stenosis by angiography. Clinical follow-up was performed after 2 years. All cases of death were adjudicated and the mortality rate was compared with expected mortality of persons of the same age and gender in the same geographical area. Mean age was 66.9±11.6 years; 77.7% were men. There was a wide prescription of secondary prevention drugs: antithrombotic drugs, 99.3%; ? blockers, 79.4%; statins, 92.2%; and antagonists of the angiotensin system, 81.9%. Two-year follow-up was obtained for 99.2% of the patients. There were 271 deaths (3.3/100 patient-years). The mortality rate was similar to the expected mortality in the general population (p=0.93). Most deaths were noncardiovascular (1.8/100 patient-years). Among cardiovascular deaths, the leading causes were heart failure death (0.4/100 patient-years) and sudden death (0.4/100 patient-years); in contrast, there were few deaths related to vascular causes (stroke, 0.2/100 patient-years and myocardial infarction, 0.1/100 patient-years). Age, diabetes, multivessel CAD, the absence of previous coronary revascularization, previous hospitalization for decompensated heart failure, a low ejection fraction, a low estimated glomerular filtration rate, and the absence of statin treatment were independent predictors of mortality. In conclusion, the mortality rate of patients with stable CAD in modern clinical practice is similar to that of the general population and is mostly due to noncardiovascular causes. PMID:24507170
How to balance risks and benefits in the management of CKD patients with coronary artery disease.
Marenzi, Giancarlo; Cosentino, Nicola; Guastoni, Carlo
Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease (CAD), which remains the most common cause of morbidity and mortality in CKD patients. Although the management of CAD is more challenging in patients with CKD than in the general population, and coupled with concerns about further deterioration of renal function and therapy-related toxic effects, CKD patients and those receiving dialysis have not traditionally been included in randomized trials evaluating either medical or revascularization therapies. Thus, only scant data from small prospective studies or retrospective analyses of controlled trials and registries are available, and to date no optimal treatment approach has been defined for this subgroup of patients. However, they potentially have much to gain from the pharmacological, interventional, and surgical strategies used in the general population. Thus, the objective of this review is to summarize the current evidence regarding the management of CAD in CKD patients, in particular with respect to uncertainties regarding coronary revascularization options, and their risk-benefit relationship in such a high-risk population. PMID:25712237
Intravascular ultrasound-guided unprotected left main coronary artery stenting in the elderly
Tan, Qiang; Wang, Qingsheng; Liu, Dongtian; Zhang, Shuangyue; Zhang, Yang; Li, Yang
Objectives: To investigate whether intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) could improve clinical outcomes compared with angiography-guided PCI in the treatment of unprotected left main coronary artery stenosis (ULMCA) in the elderly. Methods: This controlled study was carried out between October 2009 and September 2012, in Qinhuangdao First Hospital, Hebei Province, China. One hundred and twenty-three consecutive patients with ULMCA, aged 70 or older, were randomized to an IVUS-guided group and a control group. The occurrence of major adverse cardiac events (MACE): death, non-fatal myocardial infarction, or target lesion revascularizations) were recorded after 2 years of follow-up. Results: The IVUS-guided group had a lower rate of 2-year MACE than the control group (13.1% versus 29.3%, p=0.031). The incidence of target lesion revascularization was lower in the IVUS-guided group than in the control group (9.1% versus 24%, p=0.045). However, there were no differences in death and myocardial infarction in the 2 groups. On Cox proportional hazard analysis, distal lesion was the independent predictor of MACE (hazard ratio [HR]: 1.99, confidence interval [CI]: 1.129-2.367; p=0.043); IVUS guidance was independent factor of survival free of MACE (HR: 0.414, CI: 0.129-0.867; p=0.033). Conclusion: The use of IVUS could reduce MACE in elderly patients undergoing ULMCA intervention. PMID:25935174
Placing COURAGE in context: review of the recent literature on managing stable coronary artery disease.
Coylewright, Megan; Blumenthal, Roger S; Post, Wendy
Coronary artery disease (CAD) is the leading cause of death in the United States, but prevention and intervention efforts are lowering mortality. This progress is being undercut by rising rates of obesity and diabetes, and adherence to evidence-based prevention efforts is less than ideal. Many patients with CAD who are asymptomatic or have minimal symptoms undergo percutaneous coronary intervention (PCI) each year, even though PCI has not been demonstrated to improve survival for this group. Motivated by the recent controversy surrounding the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, we reviewed randomized clinical trials with follow-up published in the past decade comparing medical management with revascularization for stable CAD to provide a context for the COURAGE trial. We searched for relevant studies published from January 1, 1997, until the date of electronic publication of the COURAGE study results, March 26, 2007; references cited in the COURAGE publication were also reviewed. Evidence shows that PCI does not decrease mortality or risk of myocardial infarction over optimal medical or lifestyle therapy in patients with chronic stable CAD. In published studies, early benefits in angina control afforded by revascularization wane over time; this could change with modern interventional therapies. The final word is not that medical therapy is superior for all patients, but that optimizing medical and lifestyle therapy is appropriate as an initial management strategy for most patients who do not have unstable or disabling symptoms. It is essential that systems are set in place to make the medical management of patients with CAD second nature; this focus could be one of the most powerful results of the COURAGE trial. PMID:18613996
Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes
Marino, Barbara Campos Abreu; Nascimento, Guilherme Abreu; Rabelo, Walter; Marino, Marcos Antônio; Marino, Roberto Luiz; Ribeiro, Antonio Luiz Pinho
Background Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation. Objective Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment. Methods We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year. Results Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44–12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53–44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75–9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35–29.38]; p = 0.019) emerged as predictors of a secondary outcome. Conclusion Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up. PMID:25651344
Isolated Perforation of Left Coronary Cusp after Blunt Chest Trauma
Maini, Rohit; Dadu, Razvan T.; Addison, Daniel; Cunningham, Luke; Hamzeh, Ihab; Wall, Matthew; Lakkis, Nasser; Tabbaa, Rashed
Left coronary cusp perforation is an extremely rare consequence of blunt chest trauma. A 22-year-old male presented after a motor vehicle accident with dyspnea. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) showed moderate to severe aortic regurgitation with prolapsing right coronary cusp. In the operating room he was found to have a left coronary cusp tear near the annulus and an enlarged right cusp. The patient recovered well after successful aortic valve replacement with a mechanical valve. Traumatic aortic regurgitation with left cusp perforation is serious and surgical intervention may be lifesaving if performed timely. PMID:25802765
Drug-eluting coronary stents – focus on improved patient outcomes
Jaffery, Zehra; Prasad, Amit; Lee, John H; White, Christopher J
The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. Subsequently, neointimal hyperplasia within the stent leading to in-stent restenosis emerged as a major obstacle in long-term success of percutaneous coronary intervention. Recent introduction of drug-eluting stents is a major breakthrough to tackle this problem. This review article summarizes stent technology, reviews progress of drug-eluting stents and discusses quality of life, patient satisfaction, and acceptability of percutaneous coronary intervention. PMID:22915977
Prognostic differences between routine invasive and conservative strategies for the management of high-risk, non-ST segment acute coronary syndromes: Experience from two consecutive periods in a single center
Julio Núńez; Juan Sanchis; Eduardo Núńez; Vicent Bodi; Vicente Bertomeu-González; Maria J. Bosch; Enrique Santas; Lorenzo Fácila; Francisco J. Chorro; Cristina Gómez; Luciano Consuegra; Angel Llŕcer
BackgroundThe optimal revascularization strategy for non-ST elevation acute coronary syndromes (NSTE-ACS) remains controversial, especially in a real world context. The objective of this work was to assess differences at 1 year in all-cause mortality and the composite endpoint of mortality or acute myocardial infarction (MI) between two management strategies for NSTE-ACS: a conservative strategy (CS) versus a routine invasive strategy (RIS).
Impact of sirolimus-eluting stents on outcome in diabetic patients: A SIRIUS (SIRolImUS-coated Bx Velocity balloon-expandable stent in the treatment of patients with de novo coronary artery lesions) substudy
Issam Moussa; Martin B. Leon; Donald S. Baim
Background—Randomized clinical trials have shown that a sirolimus-eluting stent significantly reduces restenosis after percutaneous coronary revascularization. Diabetic patients are known to have a higher risk of restenosis compared with nondiabetic patients. The purpose of this analysis was to determine the impact of sirolimus-eluting stents on outcomes of diabetic compared with nondiabetic patients. Methods and Results—The SIRIUS (SIRolImUS-coated Bx Velocity balloon-expandable
Intrathecal morphine for off-pump coronary artery bypass grafting
Samuel Metz; Nanette Schwann; Wael Hassanein; Brian Yuskevich; Todd Nixon
Objective: To determine if preinduction intrathecal morphine is associated with successful intraoperative extubation in patients undergoing off-pump coronary artery bypass grafting.Design: A retrospective noncontrolled chart review of all patients undergoing off-pump coronary artery bypass grafting.Setting: Single university hospital.Participants: One hundred twelve patients.Interventions: One hundred twelve of 150 patients received preinduction intrathecal morphine as part of routine anesthetic care for off-pump
Case report - Cardiac general Myocardial revascularization for situs inversus totalis and dextrocardia
Pramod Bonde; G. F. Campalani
Situs inversus totalis with dextrocardia is rare and presentation with coronary artery disease in the ninth decade of life is even rarer. Here we describe a case where a patient underwent coronary stenting and subsequently coronary bypass surgery for the same. q 2003 Elsevier B.V. All rights reserved.
Impact of diabetes on long term follow-up of elderly patients with chronic total occlusion post percutaneous coronary intervention
Liu, Wei; Wagatsuma, Kenji; Nii, Hideo; Toda, Mikihito; Amano, Hideo; Uchida, Yasuto
Background The prognosis of elderly patients with chronic total occlusion (CTO) and diabetes mellitus (DM) treated with percutaneous coronary intervention (PCI) is not known. Objective To investigate the effect of diabetes on long-term follow-up of CTO after PCI in elderly patients. Methods A total of 153 elderly patients (age > 65 years old) with CTO lesions which were successfully treated with PCI were enrolled. Fifty one patients with diabetes and 102 without diabetes were compared for long-term outcomes (mean follow up: 36 ± 12 months). Major adverse cardiac events (MACE) which include death, myocardial infarction or target lesion revascularization (TLR) were considered as a combined endpoint. Results The combined endpoint occurred in 29.4% of diabetes patients, and 11.3% of the patients without diabetes (P < 0.05). The Cox proportional hazards model identified: drug eluting stent (DES) or bare metal stent (BMS) (HR: 0.13, 95% confidence interval (95% CI): 0.03–0.62, P = 0.004), DM (HR: 6.69, 95% CI: 1.62–15.81, P = 0.01) and final minimal lumen diameter (MLD) (HR: 0.37, 95% CI: 0.13–0.90, P = 0.03 ) as independent predictors of MACE, DM with renal impairment (HR: 6.64, 95% CI: 1.32–33.36, P = 0.02), HBA1C on admission (HR: 1.79, 95% CI: 1.09–2.94, P = 0.02), as independent predictors of MACE at long term follow-up. Conclusions The study demonstrates that DM is a predictive factor for MACE in elderly CTO patients treated with PCI, type of stent, final minimal lumen diameter and DM with renal impairment, and HBA1C level on admission are predictors of MACE. PMID:23610569
Early outcome of treatment of ostial de novo left anterior descending coronary artery lesions with drug-eluting stents.
Tsagalou, Eleftheria; Stankovic, Goran; Stancovic, Goran; Iakovou, Ioannis; Melzi, Gloria; Cosgrave, John; Ge, Le; Michev, Iassen; Chieffo, Alaide; Airoldi, Flavio; Carlino, Mauro; Montorfano, Matteo; Colombo, Antonio
We investigated early and mid-term clinical and angiographic outcomes of patients who had de novo ostial left anterior descending coronary artery (LAD) lesions that were treated with drug-eluting stents (DESs) or bare metal stents (BMSs). We identified 43 consecutive patients who underwent percutaneous intervention for isolated de novo ostial LAD lesions with implantation of DESs and compared them with 43 patients who had similar lesions that were treated with BMSs. All stents were successfully implanted. There were no significant differences with respect to major in-hospital complications between the 2 groups. One patient in the BMS group died during hospitalization. Non-Q-wave myocardial infarction occurred in 2 patients (4.7%) in the DES and in 1 patient (2.3%) in the BMS group. At 9-month follow-up, 3 patients (7%) in the DES group and 11 (25.6%) in the BMS group underwent target lesion revascularization (p = 0.038); major adverse cardiac events were less frequent in the DES than in the BMS group (9.3% vs 32.6%, p = 0.015). Angiographic follow-up was available in 82% of patients in the DES group and 75% of those in the BMS group (p = 0.6) and showed lower binary restenotic rates (5.7% vs 31.3%, p = 0.01) and smaller late loss (0.30 +/- 0.81 vs 1.23 +/- 0.93 mm, p = 0.0001) in the DES group. In conclusion, DES implantation in de novo ostial LAD lesions appears safe and effective and is associated with a significant decrease in restenotic rates compared with historical experience with BMSs. PMID:16442360
Coronary artery ectasia in Egyptian patients with coronary artery disease.
Waly, H M; Elayda, M A; Lee, V V; el-Said, G; Reul, G J; Hall, R J
We conducted a retrospective study of 45 Egyptian patients with coronary artery ectasia who underwent coronary bypass grafting at our institution between 1980 and 1995. We examined the anatomic distribution and type of coronary ectasia and its association with coronary risk factors in these patients, and evaluated the severity of their coronary artery disease. We compared these findings with those from a group of 230 Egyptian patients who did not have coronary ectasia. These patients also underwent coronary artery bypass grafting between 1980 and 1995 at our institution. Obesity was present in 60% of the patients who had coronary artery ectasia, compared with 42% of patients who did not have ectasia (P < 0.01). Coronary artery ectasia was not related to any coronary risk factors other than obesity. However, patients who had ectasia did have a higher rate of triple-vessel coronary artery disease than did patients without ectasia (82% vs 67%, P < 0.05). Of the coronary vessels affected by ectasia, 43% were left anterior descending arteries. Diffuse disease was noted in 84% of all ectatic segments. We conclude that in this patient population, 2 conditions had a positive correlation with coronary ectasia: obesity and the severity of coronary artery disease. Images PMID:9456489
Treatment of ostial lesions of the left anterior descending coronary artery with Palmaz-Schatz coronary stent
Nicoletta B. De Cesare; Antonio L. Bartorelli; Stefano Galli; Alessandro Loaldi; Franco Fabbiocchi; Paolo Sganzerla; Piero Montorsi; Maurizio D. Guazzi
We evaluated acute and long-term clinical and angiographic results of elective Palmaz-Schatz coronary stent implantation for left anterior descending coronary artery (LAD) ostial stenosis in 23 consecutive patients. Eight patients had stable angina, 14 had unstable angina, and 1 had recent myocardial infarction. Sixteen patients had single-vessel, 5 had double-vessel, and 2 had triple-vessel disease. Clinical success without major complications
Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study
Christine M Logar; Lisa M Pappas; Nirupama Ramkumar; Srinivasan Beddhu
BACKGROUND: Surgical treatment of peripheral vascular disease (PVD) in dialysis patients is controversial. METHODS: We examined the post-operative morbidity and mortality of surgical revascularization or amputation for PVD in a retrospective analysis of United States Renal Data System. Propensity scores for undergoing amputation were derived from a multivariable logistic regression model of amputation. RESULTS: Of the Medicare patients initiated on
Up-regulation of vascular endothelial growth factor mrna and angiogenesis after transmyocardial laser revascularization
Keith A Horvath; Elaine Chiu; Dipen C Maun; Jon W Lomasney; Rodney Greene; William H Pearce; David A Fullerton
Background. Angiogenesis has been proposed as a potential mechanism whereby transmyocardial laser revascularization (TMLR) has provided clinical relief of angina. Experimental work has found histologic evidence supporting this, as well as an improved response when angiogenic growth factors have been added to TMLR. The purpose of this study was to demonstrate that the molecular response to TMLR was an increase
Septic Coronary Artery Embolism Treated with Aspiration Thrombectomy: Case Report and Review of Literature
Sarwar, Nosheen; Eftekhari, Hossein; Lotfi, Amir
Coronary embolization is a potentially fatal sequela of endocarditis. We report a case of Candida endocarditis with septic embolism to the left anterior descending coronary artery. This embolism was successfully treated with aspiration thrombectomy followed by balloon angioplasty. The treatment of acute coronary syndrome in the presence of septic embolism is controversial. Aspiration thrombectomy has been performed in this situation before, and it appears to be safer and more feasible than is thrombolysis or percutaneous transluminal angioplasty. PMID:25120402
Concomitant surgical procedures for coronary artery disease and intraperitoneal double cancers: Report of a case
Masahiko Taniguchi; Wataru Kamiike; Toshiki Takahashi; Kazuhiro Iwase; Namiko Ishikawa; Toyokazu Aono; Norihide Fukushima; Keishi Kadoba; Kazuhiro Taniguchi; Hikaru Matsuda
Concomitant surgical procedures for coronary artery disease and double cancers are reported. A 61-year-old man with severe\\u000a triple-vessel coronary disease was found to have early gastric cancer and advanced rectal cancer. We successfully performed\\u000a a concomitant coronary artery bypass graft using an extracorporeal ultrafiltration membrane and curative surgery for both\\u000a cancers. Concomitant surgery thus appears to be a benefical and
Symetis valve implantation in failing freestyle with close proximity between coronary Ostia and annulus.
Nagendran, Jeevan; Catrip, Jorge; Diamantouros, Pantelis; Teefy, Patrick; Kiaii, Bob; Chan, Ian; Goela, Aashish; Holzhey, David M; Chu, Michael W A
Transcatheter treatment of patients with degenerated aortic valve stentless prosthesis and low proximal coronary ostia to the aortic annulus remain a challenge because of the elevated risk for coronary obstruction. Newer generation transcatheter aortic valve devices that engage and pull the aortic valve calcium towards the aortic annulus may be beneficial in these patients. We present a case of successful treatment of a degenerated tubular stentless prosthesis with low coronary ostia with a Symetis Acurate TA prosthesis. PMID:25841857
Coronary Fistulas: A Case Series
Fennich, Nada; Elouali, Fedoua; Saghi, Ghita; Bouzammour, Nadia; Haddour, Leila; Zarzur, Jamila; Cherti, Mohamed
Coronary artery fistula is an uncommon finding during angiographic exams. We report a case series of five patients with congenital coronary fistulas. The first patient was 56 years old and had a coronary fistula associated with a partial atrio ventricular defect, the second patient was 54 years old and had two fistulas originating from the right coronary artery with a severe atherosclerotic coronary disease, the third patient was 57 years old with a fistula originating from the circumflex artery associated with a rheumatic mitral stenosis, the fourth patient was 50 years old and had a fistulous communication between the right coronary artery and the right bronchial artery, and the last patient was 12 years old who had bilateral coronary fistulas draining into the right ventricle with an aneurismal dilatation of the coronary arteries. Angiographic aspects of coronary fistulas are various; management is controversial and depends on the presence of symptoms. PMID:24501660
[Calcification in culprit lesions of coronary artery disease].
Wada, A; Yamanaka, O; Yamagami, S; Hayashi, Y; Nakayama, R; Kanoh, T
Coronary calcification, a type of coronary atherosclerosis, has recently been closely examined in clinical cardiology because its presence may influence the selection of interventional therapy. In addition, plaque instability is one of the most important factors in the mechanism of acute coronary syndrome, and calcium deposit is frequently detected in advanced lesions. However, little is known about the clinical significance of coronary calcification. The incidence of calcium deposits was investigated in the culprit lesions (culprit coronary calcification) of patients with serious coronary artery disease to discover any cardioprotective effect. Initial coronary angiography was performed in 179 consecutive patients with acute myocardial infarction with Q wave on electrocardiography (AMI group; male 139, female 40, mean age 60.2 +/- 10 yr) and in 119 consecutive patients with stable effort angina pectoris (SAP group; male 78, female 41, mean age 63.8 +/- 8 yr) for which balloon plasty or bypass surgery was necessary from 1990 to 1997. Culprit coronary calcification was defined positive if the calcification deposit was present cinefluoroscopically within 5 mm from the culprit point. The culprit point was defined as the narrowest point after successful intracoronary thrombolytic therapy or the latest point to be dilated during a balloon inflation in direct or rescue percutaneous transluminal coronary angioplasty in the AMI group, and the narrowest point of the culprit lesion in the SAP group. There was no statistical difference in clinical background between the 2 groups other than male dominance in the AMI group and high incidence of family history of ischemic heart disease in the SAP group (p < 0.05). Culprit coronary calcification in patients over 50 years old was less frequently positive in the AMI group than the SAP group (26% vs 66%, p < 0.005, respectively). In younger patients under 50 years old, the incidence of culprit coronary calcification was low (14-15%) in both groups. Culprit coronary calcification was frequently positive in the right or the left anterior descending coronary artery in the SAP group (p < 0.005). There was no incidental sex difference of culprit coronary calcification. This comparison suggests that if a plaque contains cinefluoroscopically visible calcification, it may be regarded as less vulnerable or having a history of chronic process of atherosclerosis which results in protecting plaque rupture. PMID:10654247
MedlinePLUS Videos and Cool Tools
... cholesterol and cells and other substances in the wall of the artery forming a plaque. If this ... heart muscle and cause angina. If the inner wall of a coronary artery becomes damaged, the inner ...
Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death ... both men and women. CAD happens when the arteries that supply blood to heart muscle become hardened ...
Wolfgang Koenig
The notion that fibrinogen is strongly, consistently, and independently related to coronary risk has been widely accepted.\\u000a The evidence is based on numerous prospective epidemiological studies and clinical observations. However, the reasons why\\u000a fibrinogen is elevated in coronary disease and in atherosclerosis are only incompletely understood. All cells involved in\\u000a the atherogenetic process are able to produce cytokines which induce
Coronary artery bypass grafting
Kenji Takazawa; Yasuyuki Hosoda; Taira Yamamoto; Shiori Kawasaki; Shiro Sasaguri
Objectives: The aim of this study was to analyze the long-term results of coronary artery bypass grafting in Japanese patients who were\\u000a followed more than 10 years after surgery, and, without resorting to actuarial methods, to determine the factors that influence\\u000a long-term survival.Subjects and Methods: From January 1984 through December 1986, 376 patients received coronary artery bypass grafting at the
Off-pump coronary artery bypass grafting using skeletonized in situ arterial grafts
Suzuki, Tomoaki; Nota, Hiromitsu; Kuroyanagi, Satoshi; Kinoshita, Takeshi; Takashima, Noriyuki; Hayakawa, Masato; Naito, Shiho
Skeletonization is an advanced technique of graft harvesting for coronary artery bypass grafting (CABG), and while it requires meticulous attention, it has many advantages. For example, skeletonization of internal thoracic artery (ITA) can minimize sternal ischemia and lower the risk of mediastinitis, and is longer and larger than pedicled ITA. In this article we describe the surgical techniques demonstrated in our video, which details our techniques of skeletonization of arterial grafts and off-pump coronary artery bypass (OPCAB) exclusively using these in situ grafts. Our method of right gastroepiploic artery (GEA) skeletonization has only three technical steps. The first step is to pass thin vessel loops under the GEA. The second step is to unroof the tissue surrounding the GEA. The last step is to seal and sever all the branches. Skeletonization of the GEA not only prevents vasospasm but also leads to GEA dilatation, and facilitates inspection and makes sequential anastomosis easier. Bilateral use of the skeletonized ITA and use of the skeletonized GEA can cover most coronary artery target sites without any manipulation of the ascending aorta. In our consecutive series of over 1,000 patients, the stroke rate was 0.5%. Our method helps to make the technique simple and secure in this technically demanding operation, and we believe that OPCAB with these grafts provides the best possible coronary revascularization. PMID:23977635
Impact of Multiple Complex Plaques on Short-and Long-Term Clinical in Patients Presenting with ST-Segment Elevation Myocardial Infarction (From the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial)
Keeley, Ellen C.; Mehran, Roxana; Brener, Sorin J.; Witzenbichler, Bernhard; Guagliumi, Giulio; Dudek, Dariusz; Kornowski, Ran; Dressler, Ovidiu; Fahy, Martin; Xu, Ke; Grines, Cindy L.; Stone, Gregg W.
It is not known whether the extent and severity of non-culprit coronary lesions correlate with outcomes in patients with STEMI referred for primary PCI. We sought to quantify complex plaques in ST-segment elevation myocardial infarction (STEMI) patients referred for primary percutaneous coronary intervention (PCI) and to determine their effect on short- and long-term clinical outcomes by examining the core laboratory database for plaque analysis from the HORIZONS-AMI study. Baseline demographic, angiographic, and procedural details were compared between patients with single vs. multiple complex plaques undergoing single vessel PCI. Multivariable analysis was performed for predictors of long-term major adverse cardiac events (MACE), a combined end point of death, reinfarction, ischemic target vessel revascularization, or stroke, and for death alone. Single vessel PCI was performed in 3,137 patients (87%): 2,174 (69%) had multiple complex plaques and 963 (31%) had a single complex plaque. Compared to those with a single complex plaque, patients with multiple complex plaques were older (p<0.0001) and had more comorbidities. The presence of multiple complex plaques was an independent predictor of 3-year MACE (hazard ratio [HR]: 1.58; 95% confidence interval [CI]: 1.26–1.98, p<0.0001), and death alone (HR: 1.68; 95% CI: 1.05–2.70, p=0.03). In conclusion, multiple complex plaques are present in the majority of STEMI patients undergoing primary PCI and their presence is an independent predictor of short- and long-term MACE, including death. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI]; NCT00433966) PMID:24703369
Coronary Artery Imaging in Children
Coronary artery problems in children usually have a significant impact on both short-term and long-term outcomes. Early and accurate diagnosis, therefore, is crucial but technically challenging due to the small size of the coronary artery, high heart rates, and limited cooperation of children. Coronary artery visibility on CT and MRI in children is considerably improved with recent technical advancements. Consequently, CT and MRI are increasingly used for evaluating various congenital and acquired coronary artery abnormalities in children, such as coronary artery anomalies, aberrant coronary artery anatomy specific to congenital heart disease, Kawasaki disease, Williams syndrome, and cardiac allograft vasculopathy. PMID:25741188
Coronary artery disease in congenital single coronary artery in adults: A Dutch case series
Said, Salah AM; de Voogt, Willem G; Bulut, Suat; Han, Jacques; Polak, Peter; Nijhuis, Rogier LG; op den Akker, Jeroen W; Slootweg, Andries
AIM: To assess the current diagnostic and therapeutic management and the clinical implications of congenital single coronary artery (SCA) in adults. METHODS: We identified 15 patients with a SCA detected from four Dutch angiography centers in the period between 2010 and 2013. Symptomatic patients who underwent routine diagnostic coronary angiography (CAG) for suspected coronary artery disease and who incidentally were found to have isolated SCA were analyzed. RESULTS: Fifteen (7 females) with a mean age of 58.5 ± 13.78 years (range 43-86) had a SCA. Conventional CAG demonstrated congenital isolated SCA originating as a single ostium from the right sinus of Valsalva in 6 patients and originating from the left in 9 patients. Minimal to moderate coronary atherosclerotic changes were found in 4, and severe stenotic lesions in another 4 patients. Seven patients were free of coronary atherosclerosis. Runs of non-sustained ventricular tachycardia were documented in 2 patients, one of whom demonstrated transmural ischemic changes on presentation. Myocardial perfusion scintigraphic evidence of transmural myocardial ischemia was found in 1 patient due to kinking and squeezing of the SCA with an interarterial course between the aorta and pulmonary artery. Multi-slice computed tomography (MSCT) was helpful to delineate the course of the anomalous artery relative to the aorta and pulmonary artery. Percutaneous coronary intervention was successfully performed in 3 patients. Eight patients were managed medically. Arterial bypass graft was performed in 4 patients with the squeezed SCA. CONCLUSION: SCA may be associated with transient transmural myocardial ischemia and aborted sudden death in the absence of coronary atherosclerosis. The availability and sophistication of MSCT facilitates the delineation of the course of a SCA. We present a Dutch case series and review of the literature. PMID:24772259
Coronary artery ectasia--a variant of occlusive coronary arteriosclerosis.
Swanton, R H; Thomas, M L; Coltart, D J; Jenkins, B S; Webb-Peploe, M M; Williams, B T
In a study of 1000 consecutive coronary arteriograms, 12 patients (all men) had coronary artery ectasia. Ectasia was found most frequently in the circumflex or right coronary artery. Only 1 patient had ectasia in the left anterior descending coronary artery. In 11 patients, ectasia of one artery was associated with severe stenosis or occlusion of other vessels, typical of arteriosclerosis. Histology from an ectatic segment in one of this group showed changes of severe arteriosclerosis with extensive intimal fibrosis and destruction of the media. One patient had a mixed collagen vascular disease. Measurement of coronary sinus flow in 2 patients with coronary artery ectasia showed flows in the range of patients with non-ectatic coronary artery disease. At cardiac surgery flows down the graft to ectatic arteries were in the same range as in grafts to non-ectatic vessels. Patients with coronary artery ectasia should be anticoagulated. Images PMID:646906
Altered coronary flow properties in diffuse coronary artery ectasia
Ömer Akyürek; Berkten Berkalp; Tamer Say?n; Deniz Kumbasar; Celal Kervanc?o?lu; Dervi? Oral
Objectives The purpose of this study was to investigate coronary blood flow properties in patients with diffuse coronary artery ectasia (CAE) associated with exercise-induced myocardial ischemia.Methods Seventeen patients with diffuse CAE and without coexisting coronary artery stenosis were enrolled in the study (CAE group). CAE was defined as luminal dilatation 1.5 to 2 times that of the adjacent normal coronary
Coronary anomalies: left main coronary artery aneurysm.
Varda, Rajsekhar; Chitimilla, Santosh Kumar; Lalani, Aslam
Coronary artery aneurysm is one of the rarest anomalies that we see in our medical practice and they are mostly associated with obstructive lesions due to atherosclerotic changes. Management of these aneurysm patients (conservative or surgical repair) usually depends on obstructive lesions and associated symptoms. We are presenting a case of left main aneurysm measuring around 14 × 28?mm with other obstructive leisons. It was treated with surgical repair in view of obstructive lesions and symptoms. PMID:24860680
Compression of the ostium of left main coronary artery caused by aortic root intramural hematoma after blunt thoracic trauma
Wang, Hua; Jiang, Lingyun; Zhang, Li; Zhang, Hongming
We reported a case of compression of the ostium of left main coronary artery caused by aortic root intramural hematoma after blunt thoracic trauma treated with percutaneous coronary intervention (PCI). A 46-year-old man visited our hospital because of exertional chest discomfort and dyspnea for 4 months. He was diagnosed as compression of the ostium of left main coronary artery caused by aortic root intramural hematoma, severe stenosis in the ostium of the left main coronary artery. The percutaneous coronary intervention was conducted, and a drug-eluting stent was implanted successfully. The symptoms were improved and the patient had a good recovery after PCI surgery.
Comparison of hybrid procedure and open surgical revascularization for multilevel infrainguinal arterial occlusive disease
Zhou, Min; Huang, Dian; Liu, Chen; Liu, Zhao; Zhang, Min; Qiao, Tong; Liu, Chang-Jian
Objective To compare outcomes of hybrid (combined surgical and endovascular) procedures (HYBRID) with open surgical reconstructions (OPEN) in patients with multilevel infrainguinal artery occlusive diseases. Design Case series study with retrospective analysis of prospectively collected nonrandomized data. Methods Between 2008 and 2012, 64 patients underwent OPEN and 43 underwent HYBRID. Patient characteristics, technique success, clinical improvement, and procedure-related morbidity were reviewed and compared. Patency rates and limb salvages were analyzed and compared using Kaplan–Meier life tables. Cox regression analyses were used to assess the influence of various risk factors on primary patency. Results HYBRID patients were older and presented with worse New York Heart Association function compared with OPEN patients. The increase in the ankle-brachial index and improvement of Ruthford category after procedures were equivalent between two groups, but HYBRID patients had shorter hospital length of stay (7.6±12.0 versus 15.5±17.3; P= 0.018) and less overall perioperative morbidity (12% versus 28%; P=0.042) compared with OPEN patients. No statistically significant difference in 36-month primary (47.1%±7.1% versus 50.1%±9.4%; P=0.418), assisted primary (57.0%±7.9% versus 62.4%±9.2%; P=0.517), or secondary (82.0%±6.8% versus 83.1%±7.3%; P=0.445) patency was seen between the two groups. Limb salvage rates of HYBRID vs OPEN at 3 years were similar (76.3%±9.3% versus 80.4%±8.2%; P=0.579). Critical limb ischemia was a negative predictor of long-term patency of patients in both the HYBRID and OPEN groups (P=0.012 and P<0.001, respectively), and the presence of diabetes and renal insufficiency were another two independent predictors of decreased primary patency for HYBRID (P=0.017 and P=0.019, respectively). Conclusion Multilevel infrainguinal artery occlusive diseases could be treated by hybrid procedure, with shorter hospitalization, less perioperative morbidity, and similar early- and long-term efficacy compared with open revascularization. A hybrid procedure should be considered for patients with high surgical risk, but critical limb ischemia, diabetes, and renal insufficiency could compromise its long-term patency. PMID:25284992
Integrative physiology of coronary microcirculation.
Kajiya, F; Goto, M
Coronary microvessels play a crucial role for mechanoenergetic interaction between blood flow and myocardial function, which is not uniform transmurally. Thus, highly organized vascular regulations are required for matching local blood flow with myocardial energy requirement. Recently, new technologies to investigate in vivo coronary microcirculation with new knowledge of the signaling molecules for vascular regulation have revolutionized our abilities to understand the integrative regulation of coronary microcirculation. In this review, the mechanical aspects of the interaction between coronary blood flow and myocardium, coronary arte-rial tree and its roles in myocardial blood flow regulation, hierarchical and dynamic control of coronary flow, capillary network and function, function of venous drainage system, and molecular and cellular aspects of integrative coronary blood flow regulation are discussed, focusing on their integrational roles in maintaining coronary microvascular function and cell signaling. PMID:10529484
Coronary CT Angiography: Native Vessels
Stephan Achenbach
\\u000a Visualization of the coronary arteries has been the major focus of cardiac CT in the past years. Noninvasive "coronary CT\\u000a angiography" has tremendous clinical potential for detecting or ruling out coronary artery stenoses in selected patients.\\u000a In addition, imaging of coronary atherosclerotic plaque may play a potential role in risk stratification. However, spatial\\u000a resolution and temporal resolution of CT imaging,
Two Cases of Super-Giant Coronary Aneurysms after Kawasaki Disease
Lee, Joowon; Kwon, Bo Sang; Bae, Eun Jung; Noh, Chung Il
Acute giant coronary aneurysm after Kawasaki disease (KD) is a catastrophic complication that can be fatal and very difficult to manage. However, no fixed consensus has been reached for the management of super-giant coronary aneurysms in the acute setting. Here, we report the successful management of young children with super-giant coronary aneurysms after KD. Based on our experience, hemodynamic stabilization to prevent further coronary dilation or rupture and strict anticoagulation to avoid thrombus formation are mandatory in the management of this condition. PMID:24497892
Long term survival after coronary endarterectomy in patients undergoing combined coronary and valvular surgery – a fifteen year experience
Kumar, Sanjay; Agarwala, Sandeep; Talbot, Charlie; Nair, R Unnikrishnan
Background Coronary Endarterectomy (CE) in patients undergoing coronary artery bypass graft (CABG) surgery has been shown to be beneficial in those with diffuse coronary artery disease. There are no published data on its role and benefit in patients undergoing more complex operations. We present our experience with CE in patients undergoing valve surgery with concomitant CABG. Materials and methods Between 1989 and 2003, 237 patients underwent CABG with valve surgery under a single surgeon at our institution. Of these, 41 patients needed CE. Data was retrospectively obtained from hospital records and database. Further follow-up was obtained by telephone interview. All variables were analyzed by univariate analysis for significant factors relating to hospital mortality. Morbidity and long term survival was also studied. There were 29 males and 12 females with a mean age of 67.4 ± 8.1 and body mass index of 26.3 ± 3.3. Their mean euroscore was 7.6 ± 3.2 and the log euro score was 12.2 ± 16.1. Results Thirty-two patients were discharged from the intensive therapy unit within 48 hours after surgery. Average hospital stay was 12.7 ± 10.43 days. Thirty day mortality was 9.8%. Six late deaths occurred during the 14 year follow up. Ten year survival was 57.2% (95% CL 37.8%–86.6%). Three of the survivors had Class II symptoms, with one requiring nitrates. None required further percutaneous or surgical intervention. We compared the result with the available mortality figure from the SCTS database. Conclusion Compared to the SCTS database for these patients, we have observed that CE does not increase the mortality in combined procedures. By accomplishing revascularization in areas deemed ungraftable, we have shown an added survival benefit in this group of patients. PMID:18366756
Endovascular revascularization of renal artery stenosis: Technical and clinical results
Ruth L. Bush; Sasan Najibi; M. Julia MacDonald; Peter H. Lin; Elliot L. Chaikof; Louis G. Martin; Alan B. Lumsden
Purpose: The natural history of renal artery stenosis is progression with subsequent deterioration of kidney function and development of renovascular hypertension. Percutaneous transluminal renal angioplasty is effective in the treatment of nonostial lesions but less effective for ostial stenoses. Because of the poor technical success experienced with percutaneous transluminal renal angioplasty, stenting of ostial stenoses is becoming the standard of
Improving outcomes for acute coronary syndrome patients in the hospital setting: successful implementation of the American Heart Association "Get With The Guidelines" program by Phase I cardiac rehabilitation nurses.
Flynn, Frances M; Cafarelli, Mary; Petrakos, Karen; Christophersen, Patricia
A treatment gap exists between published guidelines for secondary prevention of cardiovascular disease and application of these guidelines in clinical practice. The "Get With The Guidelines" program is a quality initiative developed by the American Heart Association to help acute care providers bridge this gap, thereby decreasing morbidity and mortality from cardiovascular disease. This article describes how cardiac rehabilitation nurses successfully implemented the program using a prospective case-management model in the acute care setting. An overview of the program including purpose, benefits, tools, and resources is provided along with start-up considerations, potential barriers, training needs, and keys to success. PMID:17545819
Coronary Plaque Boundary Enhancement in IVUS Image by Using a Modified Perona-Malik Diffusion Filter
Anam, S.; Uchino, E.; Suetake, N.
We propose a modified Perona-Malik diffusion (PMD) filter to enhance a coronary plaque boundary by considering the conditions peculiar to an intravascular ultrasound (IVUS) image. The IVUS image is commonly used for a diagnosis of acute coronary syndrome (ACS). The IVUS image is however very grainy due to heavy speckle noise. When the normal PMD filter is applied for speckle noise reduction in the IVUS image, the coronary plaque boundary becomes vague. For this problem, we propose a modified PMD filter which is designed in special reference to the coronary plaque boundary detection. It can then not only reduce the speckle noise but also enhance clearly the coronary plaque boundary. After applying the modified PMD filter to the IVUS image, the coronary plaque boundaries are successfully detected further by applying the Takagi-Sugeno fuzzy model. The accuracy of the proposed method has been confirmed numerically by the experiments. PMID:25506357
Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease
Patrick W. Serruys; Marie-Claude Morice; A. Pieter Kappetein; Antonio Colombo; David R. Holmes; Michael J. Mack; E. Stahle; Ted E. Feldman; Marcel van den Brand; Eric J. Bass; Nic Van Dyck; K. Leadly; Keith D. Dawkins; Friedrich W. Mohr
BACKGROUND Percutaneous coronary intervention (PCI) involving drug-eluting stents is increasingly used to treat complex coronary artery disease, although coronary-artery bypass grafting (CABG) has been the treatment of choice historically. Our trial compared PCI and CABG for treating patients with previously untreated three-vessel or left main coronary artery disease (or both). METHODS We randomly assigned 1800 patients with three-vessel or left
Comparison of 30-day and 5-year outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients aged?50 years (the Coronary aRtery diseAse in younG adultS Study).
Biancari, Fausto; Gudbjartsson, Tomas; Heikkinen, Jouni; Anttila, Vesa; Mäkikallio, Timo; Jeppsson, Anders; Thimour-Bergström, Linda; Mignosa, Carmelo; Rubino, Antonino S; Kuttila, Kari; Gunn, Jarmo; Wistbacka, Jan-Ola; Teittinen, Kari; Korpilahti, Kari; Onorati, Francesco; Faggian, Giuseppe; Vinco, Giulia; Vassanelli, Corrado; Ribichini, Flavio; Juvonen, Tatu; Axelsson, Tomas A; Sigurdsson, Axel F; Karjalainen, Pasi P; Mennander, Ari; Kajander, Olli; Eskola, Markku; Ilveskoski, Erkki; D'Oria, Veronica; De Feo, Marisa; Kiviniemi, Tuomas; Airaksinen, K E Juhani
Data on the outcome of young patients after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are scarce. Data on 2,209 consecutive patients aged?50 years who underwent CABG or PCI were retrospectively collected from 15 European institutions. PCI and CABG had similar 30-day mortality rates (0.8% vs 1.4%, p=0.27), late survival (at 5 years, 97.8% vs 94.9%, p=0.082), and freedom from stroke (at 5 years, 98.0% and 98.0%, p=0.731). PCI was associated with significantly lower freedom from major adverse cardiac and cerebrovascular events (at 5 years, 73.9% vs 85.0%, p<0.0001), repeat revascularization (at 5 years, 77.6% vs 92.5%, p<0.0001), and myocardial infarction (at 5 years, 89.9% vs 96.6%, p<0.0001) compared with CABG. These findings were confirmed in propensity score-adjusted and matched analyses. Freedom from major adverse cardiac and cerebrovascular events after PCI was particularly low in diabetics (at 5 years, 58.0% vs 75.9%, p<0.0001) and in patients with multivessel disease (at 5 years, 63.6% vs 85.1%, p<0.0001). PCI in patients with ST elevation myocardial infarction was associated with significantly better 5-year survival (97.5% vs 88.8%, p=0.001), which was driven by its lower 30-day mortality rate (1.5% vs 6.0%, p=0.017). In conclusion, patients aged?50 years have an excellent immediate outcome after either PCI or CABG with similar long-term survival when used according to the current clinical practice. PCI was associated with significantly lower freedom from myocardial infarction and repeat revascularization. PMID:24878127
The left internal thoracic artery and radial artery composite graft in off-pump coronary artery bypass grafting.
Tanaka, Hiroyuki; Narisawa, Takashi; Mori, Nobutaka; Masuda, Mikio; Kishi, Daijirou; Suzuki, Takashi; Takaba, Toshihiro
Arterial multivessel bypass grafting without extra corporeal circulation and manipulation of the ascending aorta should be a good surgical option for the treatment of coronary artery disease. An internal thoracic artery (ITA)-radial artery (RA) composite graft was used for this purpose. Between July 2000 and October 2001, we employed the LITA-RA composite graft for off-pump coronary artery bypass in 15 cases. Mean patient age was 71.3 +/- 5.8 years old. Left main trunk disease was present in six patients and triple-vessel disease in four patients. Preoperative concomitant disease was renal dysfunction in three cases, cerebrovascular disease in four and diabetes mellitus in five cases. Two patients had a so-called bad aorta. Twelve elective operations and three urgent operations were carried out for unstable angina. Two to four (mean 2.6 +/- 0.7) anastomoses were performed per patient. Complete revascularization was achieved in 12 out of 15 patients. Mean operating time was 335 +/- 53 min. Mean intraoperative blood loss was 595 +/- 375 ml and nine patients underwent the operation without blood transfusion. There was no PMI, no brain disorder, and no death. Postoperative coronary angiography in all patients documented a good patency rate (LITA 15/15, RA 21/21, right gastroepiploic artery (RGEA) 2/2, and saphenous vein graft (SVG) 0/2). LITA-RA composite grafting in off-pump coronary artery bypass enables arterial multivessel revascularization using an aortic no touch technique. This can be done with minimum postoperative complications and without risk of cerebral infarction even in patients at high risk for extracorporeal circulation (ECC). PMID:12472383
Recombinant human complement C5a receptor antagonist reduces infarct size after surgical revascularization
Robert D. Riley; Hiroki Sato; Zhi-Qing Zhao; Vinod H. Thourani; James E. Jordan; Adolfo X. Fernandez; Xin-Liang Ma; Duncan R. Hite; Dean F. Rigel; Theodore C. Pellas; Jane Peppard; Kurt A. Bill; Rodney W. Lappe; Jakob Vinten-Johansen
Objectives: This study tested the hypothesis that a recombinant human C5a antagonist, CGS 32359, attenuates neutrophil activation and reduces infarct size in a porcine model of surgical revascularization. Methods: CGS 32359 (0.16-16 ?mol\\/L) dose-dependently inhibited superoxide production by human C5a-activated porcine neutrophils (18 ± 3.7 vs 1.6 ± 0.5 nmol\\/5 min\\/5 × 106 neutrophils; P < .05) and reduced neutrophil
[Coronary artery disease in women].
Niemelä, Matti; Kervinen, Kari; Romppanen, Hannu; Vikman, Saila
Although the rate of coronary artery disease mortality has decreased over the last decades, it is still the leading cause of death in Finland. Coronary artery disease appears in women with a delay of ten years as compared with men. For women, diabetes and smoking increase the risk of developing the disease more than for men. Women's coronary arteries are smaller in size, which previously impaired the results of invasive treatment. Treatment outcome with current techniques is equal independently of gender. In spite of this, women in an acute attack of coronary artery disease are less frequently directed to coronary angiography. PMID:19432079
The Association between Antidepressant Medications and Coronary Heart Disease in Brazil: A Cross-Sectional Analysis on the Brazilian Longitudinal Study of Adult Health (ELSA-Brazil)
Kemp, Andrew H.; Brunoni, Andre R.; Bittencourt, Marcio S.; Nunes, Maria A.; Benseńor, Isabela M.; Lotufo, Paulo A.
Background: Recent studies have highlighted associations between use of antidepressant medications and coronary heart disease (CHD). Tricyclic antidepressants (TCA) are not recommended in patients with CHD as they may increase morbidity and mortality. However, this class of antidepressants is freely prescribed in public health pharmacies, while access to other classes of antidepressants is restricted in Brazil. Here, we examine the associations between antidepressant use and prevalent CHD in a large cohort from Brazil. Methods: Participants included 14,994 civil servants aged 35–74?years from the baseline assessment of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). CHD (n?=?710) included stable angina, myocardial infarction, and coronary revascularization. Univariate (unadjusted) and multivariate (adjusted) logistic regression analyses were conducted to estimate odds ratios and confidence intervals. Results: After full adjustment for covariates, TCA use (n?=?156) was associated with a twofold increase in prevalent CHD, relative to non-use (n?=?14,076). Additional sensitivity analysis revealed a threefold association for myocardial infarction (OR: 2.96, 95% CI: 1.41–6.21) and coronary revascularization (OR: 2.92, 95% CI: 1.28–6.66). There were no significant associations between antidepressant use and stable angina pectoris. Conclusion: Findings highlight a strong association between TCA use and prevalent CHD. While the cross-sectional design is an important limitation of the present study, findings have important implications for the treatment of cardiac patients in Brazil. PMID:25657993
Small Islets Transplantation Superiority to Large Ones: Implications from Islet Microcirculation and Revascularization
Li, Wenjuan; Zhao, Ruxing; Liu, Jidong; Tian, Meng; Lu, Yiran; He, Tianyi; Cheng, Meng; Liang, Kai; Li, Xia; Wang, Xiangdong; Sun, Yu; Chen, Li
Pancreatic islet transplantation is a promising therapy to regain glycemic control in diabetic patients. The selection of ideal grafts is the basis to guarantee short-term effectivity and longevity of the transplanted islets. Contradictory to the traditional notion, recent findings implied the superiority of small islets for better transplantation outcomes rather than the large and intact ones. However, the mechanisms remain to be elucidated. Recent evidences emphasized the major impact of microcirculation on islet ?-cell mass and function. And potentials in islet graft revascularization are crucial for their survival and preserved function in the recipient. In this study, we verified the distinct histological phenotype and functionality of small islets versus large ones both in vitro and in vivo. With efforts to exploring the differences in microcirculation and revascularization of islet grafts, we further evaluated local expressions of angiotensin and vascular endothelial growth factor A (VEGF-A) at different levels. Our findings reveal that, apart from the higher density of insulin-producing ?-cells, small islets express less angiotensin and more angiotrophic VEGF-A. We therefore hypothesized a logical explanation of the small islet superiority for transplantation outcome from the aspects of facilitated microcirculation and revascularization intrinsically in small islets. PMID:24829922
Small islets transplantation superiority to large ones: implications from islet microcirculation and revascularization.
Li, Wenjuan; Zhao, Ruxing; Liu, Jidong; Tian, Meng; Lu, Yiran; He, Tianyi; Cheng, Meng; Liang, Kai; Li, Xia; Wang, Xiangdong; Sun, Yu; Chen, Li
Pancreatic islet transplantation is a promising therapy to regain glycemic control in diabetic patients. The selection of ideal grafts is the basis to guarantee short-term effectivity and longevity of the transplanted islets. Contradictory to the traditional notion, recent findings implied the superiority of small islets for better transplantation outcomes rather than the large and intact ones. However, the mechanisms remain to be elucidated. Recent evidences emphasized the major impact of microcirculation on islet ? -cell mass and function. And potentials in islet graft revascularization are crucial for their survival and preserved function in the recipient. In this study, we verified the distinct histological phenotype and functionality of small islets versus large ones both in vitro and in vivo. With efforts to exploring the differences in microcirculation and revascularization of islet grafts, we further evaluated local expressions of angiotensin and vascular endothelial growth factor A (VEGF-A) at different levels. Our findings reveal that, apart from the higher density of insulin-producing ? -cells, small islets express less angiotensin and more angiotrophic VEGF-A. We therefore hypothesized a logical explanation of the small islet superiority for transplantation outcome from the aspects of facilitated microcirculation and revascularization intrinsically in small islets. PMID:24829922
Results of distal revascularization in elderly patients for critical ischemia of the lower limbs.
Illuminati, G; Calio, F G; Bertagni, A; Piermattei, A; Vietri, F; Martinelli, V
Thirty eight patients over 75 years of age were operated upon of 40 distal arterial revascularizations for critical ischaemia of the lower limbs. Arterial reconstruction was proposed to ambulatory, self sufficient patients, with a patent artery of the leg or the foot in continuity with pedal arch, at arteriography. The revascularized artery was the peroneal in 14 cases, the anterior tibial in 11, the posterior tibial in 9, the dorsalis pedis in 5, and the external plantar artery in 1 case. Postoperative mortality was 2.6%. No postoperative arterial occlusion occurred and no postoperative amputation needed to be performed. The mean follow-up of 37 patients surviving operation was 21 months (ext. 2-52 months). At 36 months interval, patients' survival was 43%, primary patency rate was 57%, and limb salvage rate was 76%, at life-table analysis. Distal revascularization enables a good number of elderly patients in critical ischaemia of the lower limb, to enjoy an active, independent life, with a viable limb. PMID:10352735
Timing and selection for renal revascularization in an era of negative trials: what to do?
Textor, Stephen C; McKusick, Michael M; Misra, Sanjay; Glockner, James
Management of atherosclerotic renal artery stenosis has become more complex with advances in both medical therapy and endovascular procedures. Results from recent trials fail to demonstrate major benefits of endovascular stenting in addition to optimal medical therapy. The general applicability of these results to many patients is limited by short-term follow-up and selection biases in recruitment. Many patients at highest risk were excluded from these studies and some were included with trivial lesions. Identification of patients with hemodynamically significant lesions remains a challenge and has led to more stringent criteria for Doppler ultrasound, measurement of translesional gradients and quantitative angiography. Although many patients can now be managed with medical therapy, it should be recognized that long-term reduction in antihypertensive drug requirements and recovery of kidney function are limited to those undergoing renal revascularization. As with any major vascular lesion, follow-up for disease stability and/or progression is essential. The ambiguity of present trial data may lead some to overlook selected subgroups that would benefit from restoring renal blood supply through revascularization. Further studies to more precisely identify kidneys that can recover function and/or are beyond meaningful recovery are essential. Considering the comorbid risks for the atherosclerotic population, it will remain imperative for clinicians to consider the hazards, costs and benefits carefully for each patient to determine the role and timing for both medical therapy and revascularization. PMID:19917333
A thromboembolic model for the efficacy and safety evaluation of combined mechanical and pharmacologic revascularization strategies
Gounis, Matthew J; Nogueira, Raul G; Mehra, Manik; Chueh, Juyu; Wakhloo, Ajay K
Background and purpose Recanalization strategies mediated by intra-arterial fibrinolytic therapy in combination with mechanical clot disruption may be a more effective treatment approach than either therapy used alone. There are few preclinical animal models to evaluate these strategies. Here we report on a model to simultaneously evaluate both of these treatment approaches. Methods Allogeneic clot was injected through the 6 F guide catheter after creating >50% luminal stenosis of the common carotid arteries of New Zealand White rabbits. The stenosis was released after 1?h, allowing sufficient time for clot–vessel wall interaction. Occlusion was confirmed and each vessel was assigned to receive either balloon angioplasty alone, intra-arterial tissue plasminogen activator (tPA, Alteplase, Genentech, San Francisco, California, USA), tPA delivery through prototype balloon infusion wire (NIT Therapeutics, Pittsburgh, Pennsylvania, USA), partial stent deployment or partial stent deployment with locally delivered tPA. The negative control received no treatment. Results In vivo revascularization Thrombolysis in Cerebral Infarction (TICI) score revealed that the balloon infusion wire achieved a stable and higher revascularization score of TICI 2B, with a lower dose of tPA in comparison with other treatment strategies. All treatment strategies resulted in endothelial denudation and exposure of the internal elastic lamina. Conclusions The proposed animal model permits reliable and consistent thromboembolic occlusion of the target vasculature and allows for an assessment of both pharmacologic and mechanical revascularization strategies for acute ischemic stroke. PMID:22962414
The process of change in hemodynamics after revascularization in the ischemic brain.
Shidoh, Satoka; Akiyama, Takenori; Horiguchi, Takashi; Ohira, Takayuki; Yoshida, Kazunari
In patients with a high-degree of internal carotid artery stenosis, cerebral hemodynamics and metabolism are compromised during ischemia. Revascularization improves cortical hemodynamics and oxygen metabolism during functional activity, but the process by which it occurs is still controversial. Therefore, using functional near-infrared spectroscopy (fNIRS), we investigated the process by which cerebral hemodynamics improve after revascularization surgery. Eight patients with severe carotid artery stenosis were examined using fNIRS during a motor task before and after surgery. We evaluated postoperative changes in total hemoglobin and deoxyhemoglobin (HbR), at 2 weeks after surgery, and again at 3 months after surgery. Parameters measured were the TTP (time to peak) value, defined as the time taken to reach 70% of the maximum total hemoglobin concentration, and the increase in HbR during the motor task. TTP was higher in four patients preoperatively, but this was no longer evident in two of the patients at 2 weeks after surgery. An increase in HbR during the task was observed in six patients before surgery, and was maintained at 2 weeks after surgery. However, in three of these patients, this increase was no longer evident 3 months later. These changes observed using fNIRS suggest that the increase in cerebral blood flow after revascularization surgery is followed by improvement in parenchymal vasodilation and neuronal oxygen metabolism. PMID:26103116
Clinical Characteristics of Coronary Drug-Eluting Stent Fracture: Insights from a Two-Center DES Registry
Park, Kyung Woo; Park, Jin Joo; Chae, In-Ho; Seo, Jae-Bin; Yang, Han-Mo; Lee, Hae-Young; Kang, Hyun-Jae; Cho, Young-Seok; Yeon, Tae-Jin; Chung, Woo-Young; Koo, Bon-Kwon; Oh, Byung-Hee; Park, Young-Bae; Kim, Hyo-Soo
Stent fracture (SF) has been implicated as a risk factor for in-stent restenosis, but its incidence and clinical characteristics are not well established. Therefore we investigated the conditions associated with stent fracture and its clinical presentation and outcome. Between 2004 and 2007, consecutive cases of SF were collected from the Seoul National University Hospital. Clinical characteristics and outcome of patients with fractured stents were compared with a ten-fold cohort of age and gender matched controls (n = 236). A total of 4,845 patients received percutaneous coronary intervention and 3,315 patients (68.4%) underwent angiographic follow-up. Twenty-eight fractured stents were observed in 24 patients. The incidence of SF was 0.89% for sirolimus-eluting stents (SES) and 0.09% for paclitaxel-eluting stents. Chronic kidney disease, stent implantation in the right coronary artery (RCA), and SES use were independent predictors of drug-eluting stent fracture by multivariate analysis. SF was significantly associated with binary restenosis (11.4% vs 41.7%, P < 0.001) and increased risk of target lesion revascularization (8.1% vs 33.3%, P = 0.001). Patients with SF but without significant restenosis showed excellent outcome despite only medical treatment. In conclusion, SF is associated with increased rates of restenosis and repeat revascularization. Significant risk factors include chronic kidney disease, RCA intervention, and SES use. PMID:21218030
Minimally invasive coronary artery bypass grafting using the inferior J-shaped ministernotomy in high-risk patients.
Del Giglio, Mauro; Dell'Amore, Andrea; Aquino, Tommaso; Calvi, Simone; Calli, Morena; Marri, Claudio; Boni, Francesco; Lamarra, Mauro
In the last years the population of patients referred for coronary surgery has changed toward a high-risk profile. In selected cases minimally invasive approach could be a good option to reduce mortality and morbidity. Between September 2005 and September 2007, twenty-one consecutive patients underwent minimally invasive bypass surgery using the J-shaped inferior mini-sternotomy approach. All patients had a EuroSCORE higher than 6. The operative mortality was 0%. Conversion to on-pump surgery was not necessary. The mean operation time was 89+/-18 min, the mean ventilation time was 2.4+/-2.2 h, the mean intensive care unit stay was 47.2+/-36.5 h. In four patients a hybrid approach to achieve a complete revascularization was used. After six months from the operation the graft patency was evaluated with the 64-slice computed tomography. In high-risk coronary patients the use of the minimally invasive technique appeared a good option to achieve low morbidity and mortality. Through a mini-sternotomy approach, single- or double-vessel revascularization can be performed safely off-pump even in high-risk patients without compromising the accuracy of the anastomosis. Nevertheless, a further investigation is required to evaluate the long-term results in a larger cohort of patients. PMID:18276661
Percutaneous coronary intervention in two patients with a solitary coronary artery from the right coronary sinus of Valsalva
AlFaleh, Hussam F.
Two patients with a common coronary artery arising from the right sinus of Valsalva, who underwent coronary angiography and percutaneous coronary intervention following an acute coronary syndrome, are presented. The anatomic description based on previously published classification schemes is described. The clinical implications of this rare coronary anomaly and interventional considerations are addressed. PMID:22048514
Coronary microcatheter mapping of coronary arteries during radiofrequency ablation in children
Hasim Olgun; Tevfik Karagoz; Alpay Celiker
Introduction Radiofrequency catheter ablation (RFCA) is a safe and effective treatment option for children with refractory supraventricular\\u000a tachycardias. RFCA of right-sided accessory pathways (APs) continues to be challenging, resulting in lower success rates and\\u000a higher recurrence rates. One of the reasons for a prolonged or failed procedure is mapping error and changes in cardiac anatomy.\\u000a The right coronary artery (RCA) runs
Visualization of Discrete Microinfarction After Percutaneous Coronary Intervention Associated With Mild Creatine Kinase-MB Elevation
Mark J. Ricciardi; Edwin Wu; Charles J. Davidson; Kelly M. Choi; Francis J. Klocke; Robert O. Bonow; Robert M. Judd; Raymond J. Kim
Background—Mild elevations in creatine kinase-MB (CK-MB) are common after successful percutaneous coronary interventions and are associated with future adverse cardiac events. The mechanism for CK-MB release remains unclear. A new contrast-enhanced MRI technique allows direct visualization of myonecrosis. Methods and Results—Fourteen patients without prior infarction underwent cine and contrast-enhanced MRI after successful coronary stenting; 9 patients had procedure-related CK-MB elevation,
Myocardial infarction determined by technetium-99m pyrophosphate single-photon tomography complicating elective coronary artery bypass grafting for angina pectoris
Burns, R.J.; Gladstone, P.J.; Tremblay, P.C.; Feindel, C.M.; Salter, D.R.; Lipton, I.H.; Ogilvie, R.R.; David, T.E.
The incidence of acute myocardial infarction (AMI) complicating coronary artery bypass grafting (CABG) has previously been based on concordance of electrocardiographic, enzymatic and scintigraphic criteria. Technetium-99m pyrophosphate (Tc-PPi) single-photon emission computed tomography now enables detection of AMI with high sensitivity and specificity. Using this technique, perioperative AMI was detected in 12 of 58 patients (21%) undergoing successful elective CABG for stable angina pectoris. Stepwise multivariate logistic regression analysis was performed to compare the predictive value of preoperative (New York Heart Association class, left ventricular ejection fraction and use of beta blockers) and intraoperative (number of grafts constructed, use of internal mammary anastomoses, use of sequential saphenous vein grafts, smallest grafted distal vessel lumen caliber and aortic cross-clamp time) variables. Preoperative New York Association class (p = 0.04) and smallest grafted distal vessel lumen caliber (p = 0.03) were significant multivariate predictors of perioperative AMI. Only 1 perioperative patient with AMI (and 1 pyrophosphate-negative patient) developed new Q waves. Serum creatine kinase-MB was higher in patients with AMI by repeated measures analysis of variance (p = 0.0003). Five AMIs occurred in myocardial segments revascularized using sequential saphenous vein grafts, and 7 in segments perfused by significantly stenosed epicardial vessels with distal lumen diameter and perfusion territory considered too small to warrant CABG. At 6-month follow-up, the mean left ventricular ejection fraction increased from 0.61 to 0.65 in Tc-PPI-negative patients (p = 0.01), but not in perioperative patients with AMI.
Total myocardial revascularization for situs inversus totalis with dextrocardia: a case report
Abbasali Karimi; Abbas SalehiOmran; Hossein Ahmadi; Parin Yazdanifard
We report our experience of two patients suffering from severe coronary artery disease and situs inversus totalis with dextrocardia. The surgeon, standing on the right side of the patients, performed coronary artery bypass grafting by harvesting the right internal mammary artery in lieu of the left one.
Immediate Postoperative Complications in Patients Undergoing CABG; Investigating the Role of Prior Coronary Stenting
Negargar, Sohrab; Anvari, Shahriar; Abbasi, Kyomars; Enamzadeh, Elgar
Introduction: Approximately 15 to 30% of patients undergoing percutaneous coronary intervention (PCI) will require repeated revascularization. There is an ongoing debate concerning the impact of prior PCI on subsequent coronary artery bypass graft (CABG) surgery. This study sought to compare immediate post-CABG complications between patients with and without previous coronary stenting. Methods: A total of 556 CABG candidates including 73 patients with previous coronary stenting and 483 patients without prior stenting were enrolled in this retrospective-prospective study. Demographic information, cardiac markers (CK-MB, Troponin T), and postoperative data including inotrope administration, intra-aortic balloon pump (IABP) use, bleeding, pathological electrocardiography (ECG) changes, and overall complications were compared between the two groups. Results: The mean age of the patients in stented group was significantly higher than that in unstented group (63.49±7.71 vs. 61.37±9.80 years, p=0.05). The mean serum level of Troponin T 12 h postoperation was significantly higher in the same group (323.26±33.16 vs. 243.30±11.52 ng/dL; p=0.03). Comparing the stented and unstented groups, the rates of inotrope use (17.8% vs. 7.2%; p=0.003), significant bleeding (15.1% vs. 4.3%; p=0.001), and overall complications (32.9% vs. 11.6%; odds ratio: 3.74 with 95% confidence interval of 2.13-6.55, p<0.001) were significantly higher in the former group. The association between overall complications and prior stenting was independent (odd ratio: 3.06). No significant connections were found between postoperative complications and stent number or type. Conclusion: A positive history of previous coronary stenting significantly increases the risk of immediate post-CABG complications. PMID:25610554
Does stent design affect the long-term outcome after coronary stenting?
Elbaz, Meyer; El Mokhtar, Elyes; Fourcade, Joelle; Mourali, Sami; Hobeika, Robert; Carrié, Didier; Puel, Jacques
The purpose of our study was to determine the clinical, angiographic, and procedural variables that predict the risk for 2-year target lesion revascularization (TLR) and other clinical events in a large cohort of patients treated with coronary stenting. Between March 1996 and March 1999, 1,340 patients were prospectively enrolled. They underwent at least one stenting procedure with one of the four coronary stent types used during this time period in our institution: Wiktor-I, Nir, Bard XT, or Tenax. Clinical follow-up was obtained for 99.1% of eligible patients (mean, 19.38 +/- 4.97 months). The overall TLR rate was 10.7% at 24 months. Two variables were independently associated with the long-term outcome: MLD post stenting and stent type. Implantation of silicon carbide-coated stents was associated with a twofold decrease in 24-month TLR (P < 0.01). The major adverse cardiac event rate at 2 years was 20.8%. Multivariate analysis showed that three parameters were predictive: diabetes (P < 0.002), recent onset of symptoms (P < 0.03), and high diffusion of coronary atherosclerosis as assessed by Gensini score (P < 0.0069). In conclusion, stent type, and particularly passive silicon carbide coating, appears to affect the 24-month TLR rate but not other major cardiac events. PMID:12112881
Proteomic profiling of oxidative stress in human victims of traffic-related injuries after lower limb revascularization and indication for secondary amputation.
Lin, Chih-Hung; Wang, Pei-Wen; Pan, Tai-Long; Bazylak, Grzegorz; Liu, Eric Kar-Wai; Wei, Fu-Chan
Microsurgical replantation and revascularization are frequently performed to salvage devascularized severe lower-extremity fractures in the human victims of road traffic-related injuries. However, some patients require secondary amputation within 1 week of successful revascularization due to tissue necrosis and sepsis. Enhanced efforts to understand the underlying molecular mechanism of such events are needed and should characterized in depth. Thus, functional proteomics were applied in this study to evaluate the role of oxidative stress in acute injury following microsurgery in a set of human subjects surviving serious road traffic accidents. Changes in the levels of protein volume and the accompanying content in protein carbonylation were visualized using two-dimensional electrophoresis (2-DE) and immunoblot analysis. Since oxidation of some acute-phase proteins not only causes them to lose their function as antioxidants but also initiates the intracellular stress signaling pathway that regulates cytokine and chemokine responses, how cytokine expression correlated with oxidative stress was also evaluated via protein array assays. It was observed that the growth-regulated oncogene protein family (GRO), the range of IL-6, IL-8, IL-10 and monocyte chemotactic protein-1 (MCP-1), which are responsible for neutrophil and monocyte aggregation with subsequent cytotoxic effects, were significantly elevated in the plasma of amputees subjects, whilst the level of chemokine recruiting leucocytes into inflammatory sites (RANTES) was diminished in the salvaged group of patients. Our results suggest that severely oxidative injury during revascularization perturbs the normal redox balance and induces carbonylation of specific proteins, thereby activating pro-inflammatory factors leading to severe tissue damage. The dissimilar 2-DE protein and cytokine profiles revealed here might reflect distinct etiologies resulting in oxidative damage to tissues and may serve as pivotal indicators of local necrosis and the subsequent need for secondary amputation of limbs. We believe that the combination of proteomic and cytokine profile results presented in this work offers more reliable information and defines more sophisticated criteria in clinical practice than currently used C-reactive protein levels (CRP) or white blood cells counts (WBC) for predicting secondary amputation requirements in patients requiring limb salvage surgery. PMID:19716253
Coronary CT Angiography in the Quantitative Assessment of Coronary Plaques
Coronary computed tomography angiography (CCTA) has been recently evaluated for its ability to assess coronary plaque characteristics, including plaque composition. Identification of the relationship between plaque composition by CCTA and patient clinical presentations may provide insight into the pathophysiology of coronary artery plaque, thus assisting identification of vulnerable plaques which are associated with the development of acute coronary syndrome. CCTA-generated 3D visualizations allow evaluation of both coronary lesions and lumen changes, which are considered to enhance the diagnostic performance of CCTA. The purpose of this review is to discuss the recent developments that have occurred in the field of CCTA with regard to its diagnostic accuracy in the quantitative assessment of coronary plaques, with a focus on the characterization of plaque components and identification of vulnerable plaques. PMID:25162010
Oblique aortic valve replacement and coronary artery bypass grafting for severely calcified narrow aortic root with unstable angina
Toru Ishida; Kiyoharu Nakano; Akihiko Gomi; Hayao Nakatani; Tokuya Sato; Naoki Saegusa
We report an 84-year-old woman diagnosed with aortic stenosis and regurgitation with a severely calcified narrow aortic root\\u000a and left main coronary artery trunk stenosis with triple-vessel coronary artery disease. Emergency aortic valve replacement\\u000a and triple coronary artery bypass grafting were successful. The aortic annulus was small and heavily calcified, and the ascending\\u000a aorta, the sinus of valsalva and the
What Is Coronary Artery Bypass Grafting (CABG)?
... Medical Illustrations: Jill Rhead, MA What is Coronary Artery Bypass Grafting (CABG)? What Can Happen When Blockages ... Condition be Like After CABG? WHAT IS CORONARY ARTERY BYPASS GRAFTING (CABG)? Coronary artery bypass grafting or " ...
AANA journal course: update for nurse anesthetists--anesthetic considerations for minimally invasive direct vision coronary artery bypass grafting.
Creager, N; Kraska, S; Struebing, V L
A recently developed procedure known as MIDCAB (minimally invasive direct vision coronary artery bypass) offers a select group of patients with coronary artery disease an alternative to coronary artery bypass grafting with cardiopulmonary bypass. Compared with customary coronary artery bypass graft surgery, the MIDCAB procedure has a smaller modified incision, requires less operative time, eliminates the risk of cardiopulmonary bypass, and is, as the name implies, far less invasive. Single or multiple vessels are revascularized while the heart remains warm and beating. Movement of the beating heart is dampened in the area of the targeted bypass vessel with the use of mechanical stabilizers by the surgeon. The heart rate may be pharmacologically slowed by the anesthetist. The combination of slowed heart rate and mechanical tamponade by the stabilizers may lead to profound hemodynamic and ischemic changes that may be poorly tolerated in a patient with multiple vessel disease and concurrent disease processes. Extubation and recovery times are far shorter for MIDCAB procedures, leading to earlier discharge and substantial cost savings. The surgical techniques for cardiac bypass surgery have evolved dramatically during the past few years. It is the unique combination of anesthetic monitoring, quick response to hemodynamic changes, and manipulation of physiologic parameters that makes providing anesthesia for minimally invasive cardiac bypass surgery exceptionally challenging. PMID:10497458
Transient left ventricular cavitary dilation during dipyridamole-thallium imaging as an indicator of severe coronary artery disease
Lette, J.; Lapointe, J.; Waters, D.; Cerino, M.; Picard, M.; Gagnon, A. (Maisonneuve Hospital, Montreal, Quebec (Canada))
Transient left ventricular (LV) cavitary dilation during dipyridamole-thallium imaging was reported in 45 of 510 (9%) consecutive patients referred for dipyridamole-thallium imaging. Clinical and hemodynamic effects observed during dipyridamole infusion were not predictive of transient cavitary dilation on the thallium images. Coronary angiography was performed in 32 of the 45 patients: 75% had either left main, 3-vessel or high-risk 2-vessel coronary artery disease. Although 25 of 45 patients (56%) with transient cavitary dilation were either asymptomatic or had only grade 1/4 effort angina, 16 of 25 patients (64%) not referred for coronary revascularization sustained a cardiac event during a mean follow-up of 12 months. Most events were cardiac deaths (75%) and 87% of events occurred within 4 months of the test. Noncardiac surgery was performed in 187 of the 510 patients. The postoperative cardiac event rate was 2% in the 101 patients with normal scans or fixed defects, 19% in 75 patients with reversible perfusion defects and 58% in 12 patients with reversible cavitary dilation (p less than 0.0001). Thus, transient LV dilation during dipyridamole-thallium imaging is a marker of severe underlying coronary artery disease, denotes a poor prognosis and predicts a high risk of postoperative cardiac complications in patients who undergo noncardiac surgery.
A Comparison of Risk Factors for Calcified Atherosclerotic Plaque in the Coronary, Carotid, and Abdominal Aortic Arteries
Wagenknecht, Lynne E.; Langefeld, Carl D.; Freedman, Barry I.; Carr, J. Jeffery; Bowden, Donald W.
The extent of shared risk factors for calcified atherosclerotic plaque (CAP) of the coronary, carotid, and abdominal aortic arteries is unknown. CAP was measured by computed tomography in 1,125 individuals in families affected with diabetes. Statistical methods adjusted for the lack of independence between observations. CAP scores were standardized, and tests of interaction were conducted to compare risk factor relations across vascular beds. The average age of the cohort was 61 years, and 84% had diabetes. The correlation in CAP scores across vascular beds ranged from 0.59 to 0.72. Age, albumin/creatinine ratio, hemoglobin A1c, diabetes, hypertension, and lipid-lowering therapy were correlated with quantity of CAP in all vascular beds (all p < 0.05); no differences in the strength of these relations were noted. In contrast, other significant correlates differed in the strength of their relations with CAP. The risk factor pack-years of smoking was most strongly correlated with CAP in the abdominal aorta (p < 0.005). Male gender, previous myocardial infarction, and coronary revascularization were most strongly correlated with CAP in the coronary arteries (p < 0.0001). In summary, CAPs of the coronary, carotid, and abdominal aortic arteries generally share common risk factors, even though several of these factors have a greater impact on CAP in one vascular bed than another. PMID:17493948
Functional Relevance of Coronary Artery Disease by Cardiac Magnetic Resonance and Cardiac Computed Tomography: Myocardial Perfusion and Fractional Flow Reserve
Andreini, Daniele; Bertella, Erika; Mushtaq, Saima; Guaricci, Andrea Igoren; Pepi, Mauro
Coronary artery disease (CAD) is one of the leading causes of morbidity and mortality and it is responsible for an increasing resource burden. The identification of patients at high risk for adverse events is crucial to select those who will receive the greatest benefit from revascularization. To this aim, several non-invasive functional imaging modalities are usually used as gatekeeper to invasive coronary angiography, but the diagnostic yield of elective invasive coronary angiography remains unfortunately low. Stress myocardial perfusion imaging by cardiac magnetic resonance (stress-CMR) has emerged as an accurate technique for diagnosis and prognostic stratification of the patients with known or suspected CAD thanks to high spatial and temporal resolution, absence of ionizing radiation, and the multiparametric value including the assessment of cardiac anatomy, function, and viability. On the other side, cardiac computed tomography (CCT) has emerged as unique technique providing coronary arteries anatomy and more recently, due to the introduction of stress-CCT and noninvasive fractional flow reserve (FFR-CT), functional relevance of CAD in a single shot scan. The current review evaluates the technical aspects and clinical experience of stress-CMR and CCT in the evaluation of functional relevance of CAD discussing the strength and weakness of each approach. PMID:25692133
[Off-pump beating heart coronary artery bypass. Technical points of view and surgical results].
Matei, C; Gavra, G; Billaud, P; Dallemand, R; Semenescu, A; Lallemant, P; Réal, P; Jacquemin, L; el Belghiti, R; Monassier, J P; Bischoff, N
A consecutive series of 746 patients undergoing heart beating myocardial revascularization was reviewed. An average of 2.30 grafts/patients was performed. The rate of mortality in the first 30 postoperative days was 0.28%. Two cases had to be terminated on-pump. We used the inotropic drugs in 0.6% of cases. The postoperative events were: atrial fibrillation (12.6%), myocardial infarction (0.3%). The rate of transfusion was 7.4%. The extubation was performed in the first 24 h postoperatively in 94.7% of cases. The majority of patients (91.3%) left the hospital in the first 8 d postoperatively. Off pump coronary artery bypass grafting gives good result for the most of the patients even for those with multiple vessel disease and high operating risk. PMID:12515102
Percutaneous coronary angioplasty of unprotected left main stem: a case report.
Carosio, G; Taverna, G; Ballestrero, G; Reale, M
We describe the case of a 60-year-old man with unstable angina and a critical stenosis of an unprotected left main stem. The patient was also affected with oligophrenia and Paget's disease that contraindicated surgical revascularization. We performed a percutaneous transluminal coronary angioplasty in the cardiac surgery operating room, preparing a femoro-femoral cardiopulmonary bypass by means of a portable X-ray system. The final results were good and they were confirmed by an angiographic control performed three months later as well as during the six-month follow-up. Angioplasty of the unprotected left main stem is feasible and adequate technologic support can reduce the risks for the patient. PMID:9887394
Peripheral arterial disease and revascularization of the diabetic foot.
Forsythe, R O; Brownrigg, J; Hinchliffe, R J
Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised--treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches. PMID:25469642
Balloon catheter coronary angioplasty
Angelini, P.
The author has produced a reference and teaching book on balloon angioplasty. Because it borders in surgery and is performed on an awake patient without circulatory assistance, it is a complex and demanding procedure that requires thorough knowledge before it is attempted. The text is divided into seven sections. The first section describes coronary anatomy and pathophysiology, defines the objectives and mechanisms of the procedure and lists four possible physiologic results. The next section describes equipment in the catheterization laboratory, catheters, guidewires and required personnel. The following section is on the procedure itself and includes a discussion of examination, testing, technique and follow-up. The fourth section details possible complications that can occur during the procedure, such as coronary spasms, occlusion, thrombosis, perforations and ruptures, and also discusses cardiac surgery after failed angioplasty. The fifth section details complex or unusual cases that can occur. The sixth and seventh sections discuss radiation, alternative procedures and the future of angioplasty.
Low-molecular-weight heparin (Fragmin) during instability in coronary artery disease (FRISC). FRISC Study Group.
Swahn, E; Wallentin, L
This study evaluated whether the low-molecular-weight (LMW) heparin dalteparin sodium (Fragmin) had protective effects against cardiac events in aspirin-treated patients with unstable coronary artery syndromes. Patients (n = 1,506) with unstable angina or non-Q-wave myocardial infarction were randomized to double-blind, placebo-controlled treatment with LMW heparin. The treatment was given as subcutaneous injections: 120 U/kg body weight/12 hours during the first 5-7 days and 7,500 U once daily during the following 35-45 days. The primary endpoint, death or myocardial infarction after 6 days, showed a 3% (4.7%-1.7%) absolute and a 65% relative reduction in the LMW heparin group. There was a 6.8% (15.5%-8.7%) absolute and a 47% relative reduction of urgent revascularization or need for heparin or nitroglycerin infusions in combination with the primary endpoint. After 40 days there was an absolute reduction of death or myocardial infarction of 2.8% (10.7%-7.9%) and its combination with incapacitating angina was reduced by 5.9% (30.7%-24.8%). The survival analysis indicated a reactivation of the instability soon after lowering the dose at 5-7 days. With long-term follow-up, 3-4 months after termination of LMW heparin, the differences between groups were no longer statistically significant. However, the cumulative reduction in death, myocardial infarction, and revascularization because of incapacitating angina of 5.1% (25.3%-20.4%) was maintained. No cerebral and few major bleeds occurred. Compliance was adequate. Thus, subcutaneous LMW heparin protects against cardiac events in the acute phase of unstable coronary artery disease. The subcutaneous regimen also allows prolongation of treatment in the outpatient setting, which might maintain the initial benefits over a longer period. PMID:9296466
Mark W. Majesky
Lineage mapping studies have shown an extracardiac origin for the coronary vasculature. Mesothelial cells arising from septum\\u000a transversum mesenchyme contact the developing myocardium via a transient structure called the proepicardial organ (PEO). Proepicardial\\u000a cells first extend over the surface of the heart to form the epicardial layer. Then, a subset of epicardial cells transform\\u000a from epithelial to mesenchymal cells, migrate
Christopher J. O'Donnell; Udo Hoffmann
Because coronary artery disease (CAD) is the most frequent cause of death in industrialized nations (1) and the available tools for prediction of CAD onset are imperfect, there is a need for new methods to screen apparently\\u000a healthy individuals to identify those at increased risk. Current risk prediction of CAD is based on the patient's age and\\u000a sex as well
Clinical and angiographic outcomes in patients with previous coronary artery bypass graft surgery treated with primary balloon angioplasty for acute myocardial infarction
Gregg W. Stone; Bruce R. Brodie; John J. Griffin; Lorelei Grines; Judith Boura; William W. O'Neill; Cindy L. Grines
OBJECTIVESWe sought to characterize the presenting characteristics of patients with previous coronary artery bypass graft surgery (CABG) and acute myocardial infarction (AMI) and to determine the angiographic success rate and clinical outcomes of a primary percutaneous transluminal coronary angioplasty (PTCA) strategy.BACKGROUNDPatients who have had previous CABG and AMI comprise a high risk group with decreased reperfusion success and increased mortality
Selective Coronary Angiography Using a Percutaneous Femoral Technique
Bourassa, M. G.; Lespérance, J.; Campeau, L.; Bois, M. A.; Saltiel, J.
Successful use, in 650 patients over a period of two years, of a percutaneous femoral technique of selective coronary angiography is described. This technique is carried out with the use of mouldable, manually preshaped polyethylene catheters. Preparation of the material and the different steps of the technique are discussed. Excellent flexibility and plastic memory of this catheter material allow easy, rapid and consistent percutaneous insertion and removal of catheters and intubation of the coronary arteries. ImagesFIG. 3FIG. 4FIG. 5FIG. 6 PMID:20311550
Effect of a shortened-duration Eptifibatide infusion (75 mg) as adjunctive therapy for percutaneous coronary intervention on in-hospital cardiovascular outcomes and bleeding.
Nei, Scott D; Armon, Jeffrey J; Dierkhising, Ross A; Bell, Malcolm R; Mathew, Verghese; Barsness, Gregory W; Ou, Narith N
A retrospective cohort analysis was conducted on patients who underwent percutaneous coronary intervention (PCI) before and after a practice change which reduced the infusion duration of eptifibatide from 18 hours to the time required for completion of a single vial of 75 mg initiated during PCI. Primary end points were inhospital cardiovascular events, target vessel revascularization, and major or minor bleeding. The secondary end point was drug cost. A total of 1,647 patients received the standard-duration infusion (18 hours), and 1,237 received the short-duration infusion. The median infusion times were 18.1 hours (interquartile range 17.7 to 18.7) and 6.6 hours (interquartile range 5.6 to 11.3) in the standard- and short-duration groups, respectively. No differences were found for the rate of inhospital cardiovascular events (2.0% vs 1.9%, respectively; p = 0.78) or inhospital revascularization (0.2% vs 0.3%, respectively; p = 0.68). Also, no statistically significant difference was observed in major bleeding (standard 4.3% vs short 4.4%; p = 0.94) or minor bleeding (standard 3.3% vs short 2.3%; p = 0.09). In conclusion, using a shortened infusion reduced eptifibatide use by an average of 1.6 vials at cost savings of $823 per patient and resulted in no difference in inhospital cardiovascular events, revascularization, or bleeding. PMID:25604931
Coronary fistula between the left anterior descending coronary artery and the pulmonary artery: Two case reports
Ibrahim, Mohamed F.; Sayed, Sameh; Elasfar, Abdelfatah; Sallam, Ayman; Fadl, Mazin; Al Baradai, Abdulaziz
Coronary artery fistulae are rare congenital or acquired connections between the coronary vessels and the cardiac chambers or other vascular structures. We present two consecutive cases of coronary fistulae between the proximal left anterior descending artery (LAD) and the main pulmonary artery. Both cases where admitted with history of acute coronary syndromes and had multivessel coronary disease along with coronary pulmonary fistulae. The two cases were managed by coronary artery bypass grafting (CABG) and repair of the fistulae. PMID:24174833
Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy.
Holden, A; Hill, A; Jaff, M R; Pilmore, H
A prospective analysis of renal artery stent revascularization with distal embolic protection in a high-risk patient population with ischemic nephropathy is presented. A total of 63 patients (median age 70.2 years, range 54-86 years) had significant atherosclerotic stenosis of 83 renal arteries documented on pre-procedural imaging. All patients had baseline chronic renal insufficiency with a documented deterioration in renal function in the 6 months before revascularization. The endovascular technique used in all patients involved primary passage of an embolic filter into the distal main renal artery followed by primary stent deployment with a balloon expandable stainless steel stent. The filter baskets were recaptured and contents submitted for pathological analysis. At 6 months post-intervention, 97% of patients demonstrated stabilization or improvement in renal function. Only 3% of patients had an inexorable decline in renal function, unchanged by the intervention. After a mean follow up of 16.0 months (6-27), 94% of patients demonstrated stabilization or improvement in renal function. One patient suffered an acute post-procedural deterioration in renal function. In total, 60% of the filter baskets contained embolic material. This study confirms the technical feasibility of renal artery stent deployment with adjuvant embolic protection. The excellent results for renal preservation at 6 months post-intervention also suggest that a distal embolic protection device may improve the impact of percutaneous renal revascularization on progressive deterioration in renal function. The postulated mechanism is through the prevention of atheromatous embolization and the embolic yield from the distal filters supports this hypothesis. Patients most likely to receive the greatest benefit are those with mild baseline chronic renal insufficiency and a recent decline in renal function. PMID:16837918
Maintaining retinal astrocytes normalizes revascularization and prevents vascular pathology associated with oxygen induced retinopathy
Dorrell, Michael I.; Aguilar, Edith; Jacobson, Ruth; Trauger, Sunia A.; Friedlander, Jeffrey; Siuzdak, Gary; Friedlander, Martin
Astrocytes are well known modulators of normal developmental retinal vascularization. However, relatively little is known about the role of glial cells during pathological retinal neovascularization (NV), a leading contributor to vision loss in industrialized nations. We demonstrate that the loss of astrocytes and microglia directly correlates with the development of pathological NV in a mouse model of oxygen induced retinopathy (OIR). These two distinct glial cell populations were found to have cooperative survival effects in vitro and in vivo. The intravitreal injection of myeloid progenitor cells, astrocytes, or astrocyte-conditioned media rescued endogenous astrocytes from degeneration that normally occurs within the hypoxic, vaso-obliterated retina following return to normoxia. Protection of the retinal astrocytes and microglia was directly correlated with accelerated revascularization of the normal retinal plexuses and reduction of pathological intravitreal NV normally associated with OIR. Using astrocyte-conditioned media, several factors were identified which may contribute to the observed astrocytic protection and subsequent normalization of the retinal vasculature, including VEGF and bFGF. Injection of VEGF or bFGF at specific doses rescued the retinas from developing OIR-associated pathology, an effect which was also preceded by protection of endogenous glia from hypoxia-induced degeneration. Together, these data suggest that vascular-associated glia are also required for normalized revascularization of the hypoxic retina. Methods developed to target and protect glial cells may provide a novel strategy by which normalized revascularization can be promoted and the consequences of abnormal NV in retinal vascular diseases can be prevented. PMID:19544395
Chronic coronary occlusions: age, morphology and chance of reopening.
Vallbracht, C; Unverdorben, M; Kadel, C; Oster, H; Otto, J; Kober, G; Kaltenbach, M
In chronic coronary occlusions the chance of successful reopening by angioplasty can be judged from the age of the occlusion. Often, however, time since occlusion cannot be accurately assessed. Therefore we determined whether the chance of reopening can be predicted from angiographic morphology. In cineangiograms from 60 consecutive patients with chronic coronary occlusions morphological details in at least two projections were evaluated in relation to the rate of success and the estimated age of occlusion. Morphological features associated with a higher rate of success (type A) were a clearcut proximal stump, absence of side branches at the site of occlusion, absence of bridging collaterals, and only slight filling of the distal part of the vessel. Features associated with a low success rate (type B) were absence of proximal stump, side branches at the site of occlusion, bridging collaterals, and rapid high-contrast filling of the distal part of the vessel. 48/60 (80%) of occlusions could be classified as type A or type B. The success rate was 17/21 (81%) in type A versus 5/27 (18.5%) in type B (P < 0.0002). The estimated age of type B occlusions was higher than that of type A medians 8 and 4 months (P < 0.002). Thus in chronic coronary occlusions the likelihood of successful reopening can be judged in many patients from morphological features. Images Figure 1 Figure 2 PMID:9155755
Excessive Daytime Sleepiness is Associated with Longer Culprit Lesion and Adverse Outcomes in Patients with Coronary Artery Disease
Lee, Chi-Hang; Ng, Wai-Yee; Hau, William; Ho, Hee-Hwa; Tai, Bee-Choo; Chan, Mark Y.; Richards, A. Mark; Tan, Huay-Cheem
Study Objectives: We assessed whether excessive daytime sleepiness was associated with coronary plaque phenotype and subsequent adverse cardiovascular events. Methods: Prospective cohort study. Intravascular ultrasound (IVUS) examination of the culprit coronary stenosis was performed. The Epworth Sleepiness Scale (ESS) questionnaire was administered, and the patients were divided into 2 groups—(1) sleepier and (2) less sleepy—based on the ESS score. Adverse cardiovascular outcomes were defined as cardiac death, myocardial infarction, stroke, unplanned revascularization, or heart failure admission. Results: One hundred seventeen patients undergoing urgent or non-urgent coronary angiography were recruited. Compared with the less sleepy group (ESS ? 10, n = 87), the sleepier group (ESS > 10, n = 30) had higher serum levels of total cholesterol and of low-density-lipoprotein cholesterols (p < 0.05 for both). The IVUS examinations indicated coronary stenoses were longer in the sleepier group than in the less sleepy group (p = 0.011). The cumulative incidence of adverse cardiovascular events at 16-month follow-up was higher in the sleepier than the less sleepy group (12.5% versus 6.9%, p = 0.03). Cox regression analysis adjusting for age and smoking showed increased hazard of adverse cardiovascular events in sleepier group as compared to less sleepy group (HR = 3.44, 95% CI 1.01-11.72). Conclusion: In patients presenting with coronary artery disease, excessive daytime sleepiness based on ESS > 10 was associated with longer culprit lesions and future adverse cardiovascular events. Citation: Lee CH; Ng WY; Hau W; Ho HH; Tai BC; Chan MY; Richards AM; Tan HC. Excessive daytime sleepiness is associated with longer culprit lesion and adverse outcomes in patients with coronary artery disease. J Clin Sleep Med 2013;9(12):1267-1272. PMID:24340288
Internal carotid artery surgical revascularization in a pediatric patient with Schimke immuno-osseous dysplasia.
Westbroek, Erick M; Mukerji, Nitin; Kalanithi, Paul; Steinberg, Gary K
Schimke immuno-osseous dysplasia (SIOD) is a rare autosomal recessive disorder characterized by spondyloepiphyseal dysplasia, episodic lymphopenia, renal failure, and cerebrovascular disease secondary to arteriosclerosis and myointimal hyperplasia. In this paper the authors report the first known application of internal carotid artery (ICA) surgical revascularization to relieve a high-grade focal stenosis of the ICA in a pediatric patient, a 6-year-old boy with SIOD. The clinical presentation, imaging features, operative technique, and postoperative course are described and the molecular genetics, pathophysiology, and treatment considerations in SIOD are discussed. PMID:25431900
Segmental myocardial wall motion during minimally invasive coronary artery bypass grafting using open and endoscopic surgical techniques.
Mierdl, S; Byhahn, C; Lischke, V; Aybek, T; Wimmer-Greinecker, G; Dogan, S; Viehmeyer, S; Kessler, P; Westphal, Klaus
Current options for minimally invasive surgical treatment of single-vessel coronary artery disease include beating heart procedures without cardiopulmonary bypass (CPB) via mini-thoracotomy (MIDCAB) and totally endoscopic robot-assisted techniques (TECAB) with CPB. Both procedures are associated with potential myocardial stress before revascularization, such as single-lung ventilation (SLV), temporary coronary artery occlusion, cardiac luxation, intrathoracic carbon dioxide insufflation, and extended CPB and operating time. In this echocardiographic study we sought to evaluate the extent of intraoperative segmental wall motion abnormalities (SWMA) during MIDCAB and TECAB surgery and to identify factors affecting SWMA. Forty-six patients with single-vessel coronary artery disease were studied. Sixteen patients were operated using the MIDCAB technique and 30 patients with TECAB. In both groups sequential transesophageal echocardiograms were recorded during the entire procedure. Hemodynamic data and oxygenation variables were acquired simultaneously. In both groups, mild but obvious perioperative SWMA were identified and noted to increase during the course of the operation. These SWMA were more pronounced in the TECAB group. Independent of operating time, these changes disappeared completely after revascularization. No significant hemodynamic compromise was observed. We conclude that MIDCAB and TECAB techniques are associated with significant perioperative SWMA. The appearance of more profound SWMA in the TECAB group compared with the MIDCAB patients might have been the result of intrathoracic CO(2) insufflation, as SLV was used in both groups. No persistent SWMA or post-CPB SWMA were apparent in either group. More extensive intraoperative ventricular SWMA was detected in the TECAB group, suggesting that a more frequent risk for right ventricular dysfunction may exist during TECAB procedures. PMID:15673848
Coronary centerline extraction from CT coronary angiography images using a minimum cost path approach
Metz, C. T.; Schaap, M.; Weustink, A. C.; Mollet, N. R.; Walsum, T. van; Niessen, W. J. [Department of Medical Informatics and Department of Radiology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam (Netherlands); Department of Radiology and Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam (Netherlands); Department of Medical Informatics and Department of Radiology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam (Netherlands); Department of Medical Informatics and Department of Radiology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam (Netherlands) and Faculty of Applied Sciences, Delft University of Technology, Lorentzweg 1, 2628 CJ Delft (Netherlands)
Purpose: The application and large-scale evaluation of minimum cost path approaches for coronary centerline extraction from computed tomography coronary angiography (CTCA) data and the development and evaluation of a novel method to reduce the user-interaction time. Methods: A semiautomatic method based on a minimum cost path approach is evaluated for two different cost functions. The first cost function is based on a frequently used vesselness measure and intensity information, and the second is a recently proposed cost function based on region statistics. User interaction is minimized to one or two mouse clicks distally in the coronary artery. The starting point for the minimum cost path search is automatically determined using a newly developed method that finds a point in the center of the aorta in one of the axial slices. This step ensures that all computationally expensive parts of the algorithm can be precomputed. Results: The performance of the aorta localization procedure was demonstrated by a success rate of 100% in 75 images. The success rate and accuracy of centerline extraction was quantitatively evaluated on 48 coronary arteries in 12 images by comparing extracted centerlines with a manually annotated reference standard. The method was able to extract 88% and 47% of the vessel centerlines correctly using the vesselness/intensity and region statistics cost function, respectively. For only the proximal part of the vessels these values were 97% and 86%, respectively. Accuracy of centerline extraction, defined as the average distance from correctly automatically extracted parts of the centerline to the reference standard, was 0.64 mm for the vesselness/intensity and 0.51 mm for the region statistics cost function. The interobserver variability was 99% for the success rate measure and 0.42 mm for the accuracy measure. Qualitative evaluation using the best performing cost function resulted in successful centerline extraction for 233 out of the 252 coronaries (92%) in 63 additional CTCA images. Conclusions: The presented results, in combination with minimal user interaction and low computation time, show that minimum cost path approaches can effectively be applied as a preprocessing step for subsequent analysis in clinical practice and biomedical research.
Acute STEMI in the setting of a single coronary artery anomaly.
McCarthy, Cian; Khider, Wisam; Caplice, Noel
We report a case of a patient admitted with an acute ST elevation myocardial infarction following occlusion of his right coronary artery, successfully treated with thrombectomy and percutaneous coronary intervention (PCI). Coronary angiography and multislice CT revealed a single right coronary artery with two anomalous branches (constituting the left coronary system); one branch passed between the pulmonary trunk and the aorta before dividing into three separate branches, while the other anomalous branch passed anterior to the pulmonary trunk, consistent with a Yamanaka R-IIIC classification. The course of this Yamanaka R-IIIC subtype is unusual as both anomalous branches combine to form a dual origin left anterior descending artery. The course of these anomalous branches places the patient at an increased risk of future myocardial ischaemia, infarction and sudden cardiac death. As symptoms typically develop on exertion, this cohort may benefit from exercise myocardial perfusion imaging to identify high-risk patients. PMID:25972382
La valutazione funzionale dopo rivascolarizzazione miocardica Risk stratification after myocardial revascularisation
Salvatore Pirelli; Bianca Maria Fadin
Risk stratification after coronary revascular- ization. S. Pirelli, B.M. Fadin. Coronary angioplasty could be applied to broad groups of coronary patients with high rates of success and low rates of complication. Although multiple clinical, angiographic and procedural factors have beeen associated with an in- creased incidence of restenosis, the ability to predict the risk of restenosis in individual patients remains
Rare vascular perforation complicating radial approach to percutaneous coronary angioplasty.
Farooqi, Fahad; Alexander, John; Sarma, Aditya
A transradial arterial approach to coronary angiography and percutaneous coronary intervention has become increasingly embraced by cardiologists as it is associated with decreased vascular complications and allows early mobilisation of patients when compared with transfemoral arterial access. Major vascular complication post-transradial access is uncommon. We describe a very rare case of perforation of the costocervical trunk (a branch of the right subclavian artery at the site of the thoracic inlet) presenting shortly after percutaneous transradial coronary intervention. The resulting rapidly expanding cervical haematoma caused airway compromise necessitating emergent intubation in the catheter laboratory recovery area. Transfemoral catheter coil embolisation of the feeder artery was successful in obliterating blood flow to the perforated vessel with eventual resolution of the neck haematoma. PMID:23362057
[Extra-coronary atherosclerosis in documented coronary patients].
Hodara, M; Bonithon-Kopp, C; Courbon, D; Guérin, F; Richard, J
The prevalence and severity of extracoronary atherosclerosis in 728 patients (572 men and 156 women; average age 59 years) referred for coronary angiography and who had a history of coronary disease for at least 2 years, were assessed by ultrasonography. This population was divided into 3 groups: Group I, 115 patients without lesions at coronary angiography: Group II, 76 patients with mild coronary stenosis ang Group III, 537 patients with at least one severe coronary artery stenosis, a group which included 294 cases of single vessel disease. The authors observed a strong correlation between the presence, severity and diffusion of the coronary artery disease and ultra sonographic signs of peripheral arterial disease: the frequency increased regularly from 45% in Group I to 88% in patients with triple vessel disease in Group III. About two thirds of patients in Group III had carotid or lower limb atherosclerosis and half of them had atherosclerosis or aneurysm of the abdominal aorta. Severe peripheral lesions were not common but all the aortic aneurysms were observed in Group III. Similarly, simultaneous disease in all three peripheral arterial territories ranged from 12% in Group I to 51% in Group III. The risk of finding peripheral arterial disease was increased in patients with coronary artery disease compared with normal subjects. For each peripheral localisation, the risk was two-fold in cases of mild coronary disease and three or four-fold in patients with triple vessel disease in whom the risk of finding at least one severe peripheral lesion was multiplied by ten. The authors conclude that the prevalence and severity of ultrasonographic peripheral atherosclerosis in documented coronary patients was closely related to the presence, severity and diffusion of the coronary lesions. PMID:9749246
Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements
Schwarz, E; Hager, P; Uebis, R; Hanrath, P; Klues, H
Only a few cases of a single coronary ostium and retroaortic course of the coronary artery have been described. Almost all cases reported so far had additional coronary artery or valvar disease. However, myocardial ischaemia may be caused by the coronary malformation alone. A 40 year old woman with severe myocardial ischaemia in the absence of clinically relevant coronary atherosclerosis is described. To clarify the origin and mechanisms of ischaemia, intracoronary Doppler, pressure and ultrasound studies were performed using microtransducers. In its outer portion along the course behind the ascending aorta, coronary blood flow velocities were increased, there was an external elliptical compression, and distal coronary flow reserve was reduced. Furthermore, an overshoot in diastolic pressure above aortic pressure was detectable within this portion. Dobutamine stimulation exaggerated the observed intracoronary haemodynamics and induced myocardial ischaemia. The intracoronary diagnostic procedures performed were helpful in clarifying the pathophysiological mechanisms of functional coronary obstruction and ischaemia in this malformation. Bypass surgery was successfully performed with symptomatic improvement.?? Keywords: coronary anomaly; Doppler; intravascular ultrasound; single coronary ostium; congenital disorders PMID:9875097
The Coronary Patient in Industry
NASA Technical Reports Server (NTRS)
Schuster, B.
The coronary patient, as he pertains to industry particularly NASA, is discussed. Concepts of precoronary care, acute attacks which may develop while on the job, and the return of the cardiac patient to work are covered. Major emphasis was on the prevention of sudden death due to coronary disease.
Coronary Arteriovenous Fistulae: A Review
Challoumas, Dimitris; Pericleous, Agamemnon; Dimitrakaki, Inetzi A.; Danelatos, Christos; Dimitrakakis, Georgios
Coronary arteriovenous fistulae are a coronary anomaly, presenting in 0.002% of the general population. Their etiology can be congenital or acquired. We present a review of recent literature related to their epidemiology, etiology, pathophysiology, clinical presentation, diagnostic approach, and therapeutic management. PMID:24940026
Comparison of Coronary Computed Tomographic Angiographic Findings in Asymptomatic Subjects With Versus Without Diabetes Mellitus.
Park, Gyung-Min; Lee, Jae-Hwan; Lee, Seung-Whan; Yun, Sung-Cheol; Kim, Young-Hak; Cho, Young-Rak; Gil, Eun Ha; Kim, Tae-Seok; Kim, Chan Joon; Cho, Jung Sun; Park, Mahn-Won; Her, Sung Ho; Yang, Dong Hyun; Kang, Joon-Won; Lim, Tae-Hwan; Koh, Eun Hee; Lee, Woo Je; Kim, Min-Seon; Lee, Ki-Up; Kim, Hong-Kyu; Choe, Jaewon; Park, Joong-Yeol
There are limited data on the impact of diabetes mellitus (DM) on the risk of subclinical atherosclerosis. Therefore, we sought to investigate the impact of DM on the risk of subclinical atherosclerosis in asymptomatic subjects. We analyzed 2,034 propensity score-matched asymptomatic subjects who underwent coronary computed tomographic angiography (mean age 55.9 ± 8.2 years; men 1,725 [84.8%]). Coronary artery calcium score, degree and extent of coronary artery disease (CAD), and clinical outcomes were assessed. High-risk CAD was defined as at least 2-vessel coronary disease with proximal left anterior descending artery involvement, 3-vessel disease, or left main disease. Compared with subjects without DM, those matched with DM had higher coronary artery calcium score (89.9 ± 240.4 vs 62.8 ± 179.5, p = 0.004) and more significant CAD (?50% diameter stenosis, 15.2% vs 10.2%, p = 0.001), largely in the form of 1-vessel disease (10.8% vs 7.3%, p = 0.007). However, there were no significant differences between matched pairs in significant CAD in the left main or proximal left anterior descending artery (5.3% vs 3.8%, p = 0.138), multivessel disease (4.4% vs 2.9%, p = 0.101), and high-risk CAD (4.3% vs 2.7%, p = 0.058). During the follow-up period (median 21.8, interquartile range 15.2 to 33.4 months), there was no significant difference in the composite of all-cause death, myocardial infarction, acute coronary syndrome, and coronary revascularization between 2 groups (hazard ratio 1.438, 95% confidence interval 0.844 to 2.449, p = 0.181). In asymptomatic subjects, those matched with DM have more subclinical atherosclerosis, mainly confined to non-high-risk CAD, than those matched without DM, and there are no differences in high-risk CAD and clinical outcomes. PMID:26037293
Outcome of open versus endovascular revascularization for chronic mesenteric ischemia: review of comparative studies.
Assar, A N; Abilez, O J; Zarins, C K
Chronic mesenteric ischemia is a rare disorder that has traditionally been treated with open surgical revascularization (OR). Endovascular revascularization (ER) has recently gained popularity as an alternative modality of treatment; however, OR is still predominantly used. This study aimed at comparing the outcomes of these two treatment modalities. The literature was searched using the MEDLINE database through the PubMed search engine for relevant articles that compared the outcomes after OR and ER for chronic mesenteric ischemia. Review of the selected articles revealed that patients had lower postoperative mortality and morbidity, and shorter intensive care unit and hospital stay after ER. However, early and long-term symptomatic relief and significantly lower restenosis rate were characteristic of OR. Although no level 1 evidence governs the treatment of chronic mesenteric ischemia, the durability and efficacy of OR is such that this modality should remain the procedure of choice for patients who are fit or whose fitness could be improved before surgery. For unfit patients, or those with short life expectancy, ER is preferable owing to its minimally invasive nature and reduced postoperative mortality and morbidity. Randomized controlled studies are needed to compare the long-term durability and efficacy of ER to those of OR. PMID:19455085
Off-pump coronary artery bypass with multiple arterial conduits
Daniel Navia; Mariano Vrancic; Guillermo Vaccarino; Fernando Piccinini; Eduardo Iparraguirre; Marcelo Casas; Jorge Thierer
Objective: to analyze intra-hospital results in patients undergoing elective off-pump total arterial revascularization and identify morbidity and mortality predictors using this surgical strategy. Methods: From May 1999 to February 2004, 203 myocardial revascularization procedures with total arterial revascularization without cardiopulmonary bypass (off-pump) were carried out in patients with multivessel disease (three vessels 81.7 %, one vessel disease was excluded). We
One-stage combined thoracic ancient schwannomas total removal and coronary artery bypass.
Ceberut, Kadri; Naseri, Erdinc; Celik, Atac; Muslehiddinoglu, Ahmet; Ergin, Ismail
Ancient schwannoma is a rare variant of neural tumors though rarely seen in the thorax. The combination with coronary artery diseases is also rare. Here we describe a 66 year-old male who had undergone one-stage combined surgery for thoracic ancient schwannomas removal and coronary artery disease. The masses were, respectively, 13?cm in the middle mediastinum and 5?cm in diameter originating from the intercostal nerve. The tumors were successfully removed using sternotomy, and then a coronary artery bypass grafting was performed. Here we discuss this rare tumor in relation to the relevant literature. PMID:21961014
Spontaneous coronary artery dissection in a 22-year-old man on lisdexamfetamine.
Afzal, Aasim M; Sarmast, Syed A; Weber, Nicholas A; Schussler, Jeffrey M
Spontaneous coronary artery dissection (SCAD) is a rare cause of coronary events and sudden cardiac death. SCAD can present with a wide spectrum of clinical presentations and as an entity remains underrecognized. Several risk factors, such as female gender, peripartum and early postpartum state, and atherosclerotic disease, have been attributed to SCAD. Amphetamine use has been attributed to an increased risk for coronary artery events. We present a case of a 22-year-old man on lisdexamfetamine and no other significant medical history who presented with SCAD and was successfully treated with medical management. PMID:26130892
Spontaneous coronary artery dissection in a 22-year-old man on lisdexamfetamine
Afzal, Aasim M.; Sarmast, Syed A.; Weber, Nicholas A.
Spontaneous coronary artery dissection (SCAD) is a rare cause of coronary events and sudden cardiac death. SCAD can present with a wide spectrum of clinical presentations and as an entity remains underrecognized. Several risk factors, such as female gender, peripartum and early postpartum state, and atherosclerotic disease, have been attributed to SCAD. Amphetamine use has been attributed to an increased risk for coronary artery events. We present a case of a 22-year-old man on lisdexamfetamine and no other significant medical history who presented with SCAD and was successfully treated with medical management. PMID:26130892
Optimal treatment of coronary-to-pulmonary artery fistula: surgery, coil or stent graft?
Lipiec, Piotr; Peruga, Jan Zbigniew; Jaszewski, Ryszard; Paw?owski, Witold; Kasprzak, Jaros?aw
We report a case of a 57-year-old man with typical angina due to a coronary artery-to-pulmonary artery fistula, which was evident on transthoracic and transesophageal echocardiography with color Doppler flow mapping. The diagnosis was confirmed by coronary angiography. The patient underwent surgical ligation of the fistula. However, repeated transesophageal echocardiography and coronary angiography revealed persistence of the fistula with significant left-to-right shunt. The orifice of the fistula was then obliterated by stent-graft implantation, which was proven successful by angiography and echocardiography. PMID:24570733
Aborted sudden cardiac death associated with an anomalous right coronary artery.
Diaz, Rienzi A; Valdés, Julio
Coronary artery anomalies arising from the opposite sinus of Valsalva and having an interarterial course between the aorta (AO) and pulmonary artery (PA) are the second most common cause of sudden cardiac death among young athletes, after hypertrophic cardiomyopathy. The right coronary artery (RCA) originating from the AO above the left sinus of Valsalva (LSV) is an extremely rare anomaly. We report the first case of a RCA arising from the AO above the LSV that subsequently runs between the AO and the PA, discovered by a 64-slice multidetector coronary CT, in a patient who was successfully resuscitated from ventricular fibrillation (VF) cardiac arrest while running in a marathon race. PMID:26153291
Transcatheter Embolization of a Coronary Fistula Originating from the Left Anterior Descending Artery by Using N-Butyl 2-Cyanoacrylate
Karagoz, Tevfik; Celiker, Alpay [Hacettepe University, Faculty of Medicine, Section of Pediatric Cardiology (Turkey)], E-mail: firstname.lastname@example.com, E-mail: email@example.com; Cil, Barbaros; Cekirge, Saruhan [Hacettepe University, Faculty of Medicine, Department of Radiology (Turkey)
In this report, we describe a successful percutaneous transcatheter n-butyl 2-cyanoacrylate embolization of a coronary fistula originating from the left anterior descending artery in an adolescent with unexpected recurrent attacks of myocardial ischemia.
Oral azithromycin in extended dosage schedule for chronic, subclinical Chlamydia pneumoniae infection causing coronary artery disease: a probable cure in sight? Results of a controlled preliminary trial
Dogra, Jaideep
Purpose Two mega trials have raised the question as to whether the hypothesis that infection plays a role in atherosclerosis is still relevant. This controlled preliminary trial investigated an extended dose of azithromycin in the treatment of Chlamydia pneumoniae infection causing coronary artery disease (CAD). Patients and methods Forty patients with documentary evidence of CAD were screened for immunoglobulin G titers against C. pneumoniae and grouped into either the study group (patients with positive titer, n = 32) or control group (patients with negative titer, n = 8). Cases who met inclusion criteria could not have had coronary artery bypass graft surgery or percutaneous coronary intervention in the preceding 6 months. Informed consent was obtained from every patient. Baseline blood samples were analyzed for red blood cell indices, serum creatinine, and liver function tests, and repeated every 2 months. A primary event was defined as the first occurrence of death by any cause, recurrent myocardial infarction, coronary revascularization procedure, or hospitalization for angina. Patients in the study group received 500 mg of oral azithromycin once daily for 5 days, which was then repeated after a gap of 10 days (total of 24 courses in the 1-year trial period). The control group did not have azithromycin added to their standard CAD treatment. Results In the study group, 30 patients completed the trial. Two patients had to undergo percutaneous coronary intervention in the initial first quarter of the 1-year trial period. In the control group, one patient died during the trial, one had to undergo coronary artery bypass graft surgery, and one had percutaneous coronary intervention. Conclusion The patients tolerated the therapy well and there was a positive correlation between azithromycin and secondary prevention of CAD. PMID:22807637
A 15-cm aneurysm of the right coronary artery presenting as a pericardial cyst
Burnside, Nathan; Nzewi, Onyekwelu C.; Sidhu, Pushpinder Singh
We report an unusual case of a giant right coronary artery aneurysm, measuring 15 cm in diameter, in a 76-year old woman. The aneurysm was initially identified when the patient was investigated for signs of congestive cardiac failure with a computed tomography scan of her thorax; at this stage, the lesion was misdiagnosed as a large pericardial cyst. The aneurysm was successfully excised at surgery and her heavily diseased right coronary artery was secured with a saphenous vein graft. PMID:22228289
Fatal fungal infection complicating aortic dissection following coronary artery bypass grafting
D. M Rassl; S. K Suvarna; G. J Cooper
The case of a 52-year-old man with severe coronary atheroma\\/ischaemic heart disease, who underwent successful triple vessel coronary artery bypass grafting is described. One month later this was complicated by aortic dissection arising at the aortic cannulation site. An emergency resection and Dacron graft placement were performed. Five weeks later he represented with haemoptysis. Despite inconclusive investigations the patient went
Acute Coronary Stenosis in a Young Man with Behçet's Syndrome
Enver Erbilen; Sinan Albayrak; Erim Gulcan; Figen Taser; Serkan Bulur; Hakan Ozhan; Mehmet Yazici
Objective: To present a case of myocardial infarction due to Behçet's syndrome. Clinical Presentation and Intervention: A 27-year-old man who was known to have Behçet's syndrome for 1 year presented with retrosternal fluctuating chest pain, which radiated to the epigastrium 5 h prior to admission. Coronary angiography showed total occlusion of the left anterior descending coronary artery, which was successfully
Unprotected Left Main Percutaneous Coronary Intervention in Acute Coronary Syndromes with Extracorporeal Life Support Backup
Staudacher, Dawid L.; Langner, Oliver; Biever, Paul; Benk, Christoph; Zehender, Manfred; Bode, Christoph; Wengenmayer, Tobias
Background. Left main PCI is superior to coronary bypass surgery in selected patients. Registry data, however, suggest significant early adverse event rates associated with unprotected left main PCI. We aimed to evaluate safety of an extracorporeal life support (ECLS) as backup system during PCI. Methods. We report a registry study of 16 high-risk patients presenting with acute coronary syndromes undergoing unprotected left main PCI with an ECLS backup. Results. Seven patients (43.8%) presented with an acute myocardial infarction while 9 patients (56.3%) had unstable angina. Unprotected left main PCI could be successfully performed in all 16 patients. Mortality or thromboembolic event rates were zero within the index hospital stay. General anesthesia was necessary only in 5 patients (31.3%). Access site bleeding requiring transfusion was encountered in 4 patients (25.0%). Three patients (18.8%) developed access site complications requiring surgical intervention. All patients were ECLS-free after 96 hours. Conclusions. Unprotected left main PCI could be safely and effectively performed after ECLS implantation as backup in acute coronary syndromes in our patient collectively. Vascular access site complications however need to be considered when applying ECLS as backup system. PMID:25810950
Risk score model for the assessment of coronary artery disease in asymptomatic patients with type 2 diabetes.
Park, Gyung-Min; An, Hyonggin; Lee, Seung-Whan; Cho, Young-Rak; Gil, Eun Ha; Her, Sung Ho; Kim, Young-Hak; Lee, Cheol Whan; Koh, Eun Hee; Lee, Woo Je; Kim, Min-Seon; Lee, Ki-Up; Kang, Joon-Won; Lim, Tae-Hwan; Park, Seong-Wook; Park, Seung-Jung; Park, Joong-Yeol
No model has been developed to predict significant coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) in asymptomatic type 2 diabetes. Therefore, we sought to develop a model for the prediction of significant CAD on CCTA in these patients. We analyzed 607 asymptomatic patients with type 2 diabetes who underwent CCTA. The cardiac event was defined as a composite of cardiac death, nonfatal myocardial infarction, acute coronary syndrome, and coronary revascularization. Significant CAD (diameter stenosis ?50%) in at least one coronary artery on CCTA was observed in 188 (31.0%). During the follow-up period (median 4.3 [interquartile range, 3.7-4.8] years), 71 patients had 83 cardiac events. Clinical risk factors for significant CAD were age, male gender, duration of diabetes, hypertension, current smoking, family history of premature CAD, previous history of stroke, ratio of total cholesterol to high-density lipoprotein cholesterol, and neuropathy. Using these variables, we formulated a risk score model, and the scores ranged from 0 to 17 (area under the curve?=?0.727, 95% confidence interval?=?0.714-0.739, P?0.001). Patients were categorized into low (?3), intermediate (4-6), or high (?7) risk group. There were significant differences between the risk groups in the probability of significant CAD (12.6% vs 29.4% vs 57.7%, P for all?0.001) and 5-year cardiac event-free survival rate (96.6%?±?1.5% vs 88.9%?±?1.8% vs 73.8%?±?4.1%, log-rank P for trend?0.001). This model predicts significant CAD on CCTA and has the potential to identify asymptomatic type 2 diabetes with high risk. PMID:25634204
Clinical Presentation, Management and Outcome of Acute Coronary Syndrome in Yemen: Data from GULF RACE - 2 Registry
Ahmed, Al-Motarreb; Abdulwahab, Al-Matry; Hesham, Al-Fakih; Nawar, Wather
Background: Acute Coronary Syndrome (ACS) is increasing in Yemen in recent years and there are no data available on its short and long-term outcome. We evaluated the clinical pictures, management, in-hospital, and long-term outcomes of the ACS patients in Yemen. Design and Setting: A 9-month prospective, multi-center study conducted in 26 hospitals from 9 governorates. The study included 30-day and 1-year mortality follow-up. Patients and Methods: One thousand seven hundred and sixty one patients with ACS were collected prospectively during the 9-month period. Patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTEACS), including non-ST-elevation myocardial infarction and unstable angina were included. Conclusions: ACS patients in Yemen present at a relatively young age with high prevalence of Smoking, khat chewing and hypertension. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates are high, but coronary revascularization procedures were very low. In-hospital mortality was high and long-term mortality rates increased two folds compared with the in-hospital mortality. PMID:24695681
A Multicentre Randomized Clinical Trial on Efficacy and Safety of Huxin Formula in Patients Undergoing Percutaneous Coronary Intervention
Wu, Huan-Lin; Wang, Yun-Fei; Li, Jun-Zhe; Zhang, Min-Zhou; Sheng, Xiao-Gang; Wang, Xia; Li, Song; Chen, Qiu-Xiong; Li, Xiao-Qing; Ou, Ai-hua; Ruan, Xin-Min
Percutaneous coronary intervention (PCI) is widely used in clinical treatment of coronary artery disease. However, the effects of PCI on preventing restenosis after revascularization and improving the quality of life were not satisfying. Huxin Formula is formulated by modifying an experienced Chinese medicine formula and has been widely used in clinical practice due to its marked effects on coronary heart disease. A multicentre double-blind randomized controlled clinical trial was designed to evaluate the effects and safety of Huxin Formula in patients undergoing PCI. Our results showed that there was no significant difference between the two groups in main outcomes. For patients with ejection fraction (EF) >50%, score of the quality of life scale was higher in treatment group compared with control group. For patients with unstable angina, score of the quality of life scale in 360 days was significantly higher in treatment group compared with control group (P < 0.05). No obvious adverse reaction was found in the use of Huxin Formula. In conclusion, Huxin Formula, believed to be a safe treatment for patients after PCI, has benefits in improving the quality of life in patients with unstable angina though it failed to show superiority in primary and secondary outcomes. PMID:24971144
Comparison of coronary angiographic features and oral dipyridamole thallium 201 tomography
Jain, A.; Myers, G.H.; Rowe, M.W.; Dehmer, G.J.; Robinson, D.S. (Univ. of North Carolina Hospitals, Chapel Hill (USA))
Coronary angiography and left ventriculography is commonly used to identify those patients with incomplete infarctions and therefore, a need for revascularization. The authors compared coronary angiography and left ventriculography with thallium 201 tomography using oral dipyridamole to identify patients with potential ischemia in the infarct zone indicating viable tissue. Forty-five patients (37 men, 8 women) with acute myocardial infarctions (29 anterior, 16 inferior) who received intravenous thrombolytic therapy were studied. On the basis of the left ventriculograms, only 16 patients were judged to have residual function in the infarct zone. Six of these patients had no thallium redistribution in the infarct zone, indicating lack of residual ischemia. Of the 29 patients with no residual function in the infarct zone, 18 had redistribution in the infarct zone, suggesting residual ischemic myocardium and thus viable tissue. Among the 32 patients with open infarct vessels, 15 had no redistribution in the infarct zone, but of the remaining 13 patients with occluded infarct vessels, 9 had redistribution in the infarct zone indicating residual ischemia and thus viable tissue. The authors' data suggest that neither wall motion analysis by left ventriculography nor the angiographic status of the infarct vessel identifies those patients with residual ischemia as evidenced by thallium tomography using oral dipyridamole.
Coronary Artery Disease Risk Factors, Coronary Artery Calcification and Coronary Bypass Surgery
Ulusoy, Fatih Rifat; Ipek, Emrah; Korkmaz, Ali Fuat; Gurler, Mehmet Yavuz; Gulbaran, Murat
Introduction Atherosclerosis is an intimal disease which affects large and medium size arteries including aorta and carotid, coronary, cerebral and radial arteries. Calcium accumulated in the coronary arterial plaques have substantial contribution to the plaque volume. The aim of our study is to investigate the relationship between coronary artery disease (CAD) risk factors and coronary arterial calcification, and to delineate the importance of CACS in coronary artery bypass surgery. Materials and Methods The current study is retrospective and 410 patients admitted to our clinic with atypical chest pain and without known CAD were included. These individuals were evaluated by 16 slice electron beam computed tomography with suspicion of CAD and their calcium scores were calculated. Detailed demographic and medical history were obtained from all of the patients. Results In our study, we employed five different analyses using different coronary arterial calcification score (CACS) thresold levels reported in previous studies. All of the analyses, performed according to the previously defined thresold levels, showed that risk factors had strong positive relationship with CACS as mentioned in previous studies. Conclusion Coronary arterial calcification is part of the athero-sclerotic process and although it can be detected in atherosclerotic vessel, it is absent in a normal vessel. It can be concluded that the clinical scores, even they are helpful, have some limitations in a significant part of the population for cardiovascular risk determination. It is important for an anastomosis region to be noncalcified in coronary bypass surgery. In a coronary artery, it will be helpness for showing of calcific field and anostomosis spot.
Validation of the Appropriate Use Criteria for Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease (from the COURAGE Trial).
Bradley, Steven M; Chan, Paul S; Hartigan, Pamela M; Nallamothu, Brahmajee K; Weintraub, William S; Sedlis, Steven P; Dada, Marcin; Maron, David J; Kostuk, William J; Berman, Daniel S; Teo, Koon K; Mancini, G B John; Boden, William E; Spertus, John A
Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI. PMID:25960375
What Are the Signs and Symptoms of Coronary Heart Disease?
... What Are the Signs and Symptoms of Coronary Heart Disease? A common symptom of coronary heart disease ( ... narrow the coronary arteries. Signs and Symptoms of Heart Problems Related to Coronary Heart Disease Some people ...
Coronary tortuosity: a long and winding road
Zegers, E.S.; Meursing, B.T.J.; Zegers, E.B.; Oude Ophuis, A.J.M.
Coronary tortuosity is a phenomenon often encountered by cardiologists performing coronary angiography. The aetiology and clinical importance of coronary tortuosity are still unclear. Coronary tortuosity without fixed atherosclerotic stenosis in patients with angina pectoris and an abnormal exercise stress test has never been described in the literature. This article describes three cases of patients with anginal complaints, an abnormal exercise stress test and coronary angiography without the presence of a fixed atherosclerotic lesion. It is hypothesised that coronary tortuosity leads to flow alteration resulting in a reduction in coronary pressure distal to the tortuous segment of the coronary artery, subsequently leading to ischaemia. Future studies will be necessary to elucidate the actual mechanism of coronary tortuosity and its clinical significance. (Neth Heart J 2007;15:191-5.17612682) PMID:17612682
[A case of chronic ischemic erosive gastropathy healed after surgical revascularization].
Bouché, O; Clément, C; Le Louargant, M; Carteret, E; Zeitoun, P
A case of chronic ischemic erosive gastropathy secondary to chronic abdominal vascular insufficiency is reported. This gastropathy healed after revascularization procedure but then recurred after stenosis of the aortomesenteric graft. The clinical picture was characterized by post-prandial abdominal pain, weight loss and an abdominal bruit. The upper gastrointestinal endoscopy showed multiple non hemorrhagic antral erosions with irregular outlines and a pseudomembranous floor. Reduction of the resistance of the gastric mucosal barrier by a chronic decrease of mucosal blood flow probably accounted for the gastric erosions. Although the prevalence is unknown, ischemic injury to the stomach is unexpected, because of the rich collateral circulation of this organ. Increased awareness of the disease and its prognostic implications should lead to suggest abdominal vascular insufficiency based on their clinical and gastroscopic aspects, thus leading to operation before acute mesenteric infarction occurs. PMID:2925046
A novel route of revascularization in basilar artery occlusion and review of the literature.
Morales, Alejandro; Parry, Phillip Vaughan; Jadhav, Ashutosh; Jovin, Tudor
Ischemia of the basilar artery is one of the most devastating types of arterial occlusive disease. Despite treatment of basilar artery occlusions (BAO) with intravenous tissue plasminogen activator, antiplatelet agents, intra-arterial therapy or a combination, fatality rates remain high. Aggressive recanalization with mechanical thrombectomy is therefore often necessary to preserve life. When direct access to the basilar trunk is not possible, exploration of chronically occluded vessels through collaterals with angioplasty and stenting creates access for manual aspiration. We describe the first report of retrograde vertebral artery (VA) revascularization using thyrocervical collaterals for anterograde mechanical aspiration of a BAO followed by stenting of the chronically occluded VA origin. Our novel retrograde-anterograde approach resulted in resolution of the patient's clinical stroke syndrome. PMID:26055597
Revascularization of Immature, Nonvital Permanent Tooth Using Platelet-rich Fibrin in Children.
Nagaveni, N B; Poornima, P; Joshi, Jooie S; Pathak, Sidhant; Nandini, D B
The purpose of this paper was to present a new approach wherein revascularization of the immature, nonvital permanent tooth was performed using platelet-rich fibrin (PRF) as a novel scaffold material. This was performed after disinfection of the root canal space using triple antibiotic paste followed by placing a PRF membrane in the root canal. The patient was followed up regularly at three-, six-, nine-, and 12-month intervals for review. After 12 months, clinical examination showed negative response to percussion and palpation tests but positive response to cold and electric pulp tests. Radiographic examination revealed continued thickening of the root dentinal walls, narrowing of root canal space, root lengthening, and closure of the root apex with normal periradicular architecture. However, more clinical research using large samples is necessary to prove it advantageous for regenerative endodontic therapy in children. PMID:25685966
Diffusion-cooled high-power single-mode waveguide CO2 laser for transmyocardial revascularization
NASA Astrophysics Data System (ADS)
Berishvili, I. I.; Bockeria, L. A.; Egorov, E. N.; Golubev, Vladimir S.; Galushkin, Michail G.; Kheliminsky, A. A.; Panchenko, Vladislav Y.; Roshin, A. P.; Sigaev, I. Y.; Vachromeeva, M. N.; Vasiltsov, Victor V.; Yoshina, V. I.; Zabelin, Alexandre M.; Zelenov, Evgenii V.
The paper presents the results on investigations and development of multichannel waveguide CO2 laser with diffusion cooling of active medium excited by discharge of audio-frequency alternating current. The description of high-power single-mode CO2 laser with average beam power up to 1 kW is presented. The result of measurement of the laser basic parameters are offered, as well as the outcomes of performances of the laser head with long active zone, operating in waveguide mode. As an example of application of these laser, various capabilities a description of the developed medical system 'Genom' used in the transmyocardial laser revascularization (TMLR) procedure and clinical results of the possibilities of the TMLR in the surgical treatment are presented.
Human nerve xenografting in nude mouse: Experimental study of graft revascularization
Duprez, K.; Bour, C.; Merle, M.; Duprez, A. (Hopital Jeanne d'Arc, Dommartin-les-Toul (France))
In the nude mouse, the congenital absence of T lymphocytes makes it possible to implant human nerve grafts without rejection or iatrogenic modifications (by immunosuppression) of human and murine tissues. Medial antebrachial cutaneous nerves were harvested from human cadavers 1-18 hours after death. These nerve grafts were implanted using different techniques in nude mice. All the grafts were macroscopically and microscopically revascularized 3 days after implantation. The modifications in time of this vascularization could be studied with precision through the use of repeated biopsies. The absence of human blood group antigens on the neovessel endothelium suggested a murine origin for angiogenesis. In situ DNA hybridizations with human and mouse DNA confirmed this origin. The topography of the revascularization (maximal in the perineurium and endoneurium) and the almost complete absence of human cells other than Schwann cells in the grafts at the peak of angiogenesis (26 days after grafting) suggested that Schwann cells had a determining role in graft vascularization. The irradiation of the nerve grafts with a dose of 30 grays before implantation did not modify significantly their histologic appearance compared to the control group, whereas an irradiation of 60 grays led to massive lesions. The neurotization of murine axons led to chimerical structures of normal histologic appearance, with vascularization similar to that observed in nonneurotized nerves. Through chimerism (human Schwann cells, murine vessels and axons) this model makes it possible to dissociate the respective role of the host and of the nerve graft in angiogenesis and suggests the existence of growth factors produced by the human Schwann cells.
Aneurysmal coronary cameral fistula.
Jamil, Gohar; Khan, Asad; Malik, Azhar; Qureshi, Anwer
A 26-year-old asymptomatic man, being medically managed for ventricular septal defect since childhood, presented to the outpatient clinic for a second opinion. Clinically, he was well built with normal vital signs. Cardiac auscultation was significant for a diastolic murmur over the praecordium. An ECG showed non-specific ST changes, and a subsequent transthoracic echocardiography performed revealed diastolic flow from the left ventricular (LV) anteroseptal wall into the LV cavity. A diagnosis of coronary-cameral fistula was confirmed by a multidetector CT which showed a 2.5×2 cm aneurysmal left anterior descending artery fistula to the LV. In addition to starting aspirin, transcatheter closure with occlusion device was considered knowing the potential risk of thrombus formation in the aneurysm and subsequent systemic embolisation. The patient however refused any percutaneous or surgical intervention. He remains asymptomatic 1 year after returning to his home country. PMID:23737570
Aneurysmal coronary cameral fistula
Jamil, Gohar; Khan, Asad; Malik, Azhar; Qureshi, Anwer
A 26-year-old asymptomatic man, being medically managed for ventricular septal defect since childhood, presented to the outpatient clinic for a second opinion. Clinically, he was well built with normal vital signs. Cardiac auscultation was significant for a diastolic murmur over the praecordium. An ECG showed non-specific ST changes, and a subsequent transthoracic echocardiography performed revealed diastolic flow from the left ventricular (LV) anteroseptal wall into the LV cavity. A diagnosis of coronary–cameral fistula was confirmed by a multidetector CT which showed a 2.5×2?cm aneurysmal left anterior descending artery fistula to the LV. In addition to starting aspirin, transcatheter closure with occlusion device was considered knowing the potential risk of thrombus formation in the aneurysm and subsequent systemic embolisation. The patient however refused any percutaneous or surgical intervention. He remains asymptomatic 1?year after returning to his home country. PMID:23737570
Coronary Angiography and Angioplasty
NSDL National Science Digital Library
Patient Education Institute
This patient education program explains the benefits and risks of coronary angiography and angioplasty. It also reviews the anatomy of the cardiovascular system, the causes and symptoms of blocked arteries, and what the procedure involves. This is a MedlinePlus Interactive Health Tutorial from the National Library of Medicine, designed and developed by the Patient Education Institute. NOTE: The tutorial requires a special Flash plug-in, version 4 or above. If you do not have Flash, you will be prompted to obtain a free download of the software before you start the tutorial. You will also need an Acrobat Reader, available as a free download, in order to view the Reference Summary.
Anatomic and electrophysiologic relation between the coronary sinus and mitral annulus: implications for ablation of left-sided accessory pathways.
Shinbane, J S; Lesh, M D; Stevenson, W G; Klitzner, T S; Natterson, P D; Wiener, I; Ursell, P C; Saxon, L A
To determine whether precise left-sided accessory pathway localization is possible from the coronary sinus, electrocardiogram (ECG) characteristics from the coronary sinus pair demonstrating earliest activation via the accessory pathway were compared to simultaneous mitral annular ablation catheter ECGs at successful ablation sites in 48 patients. To define the coronary sinus-mitral annular relation, the coronary sinus to mitral annulus distance (D) was measured at sequential distances from the coronary sinus os in 10 cadaver hearts. Mitral annular ECGs demonstrated earliest activation via the accessory pathway more frequently than the earliest coronary sinus pair (p < 0.001), more frequent continuous electrical activity (p < 0.001), and more frequent accessory pathway potentials (p < 0.01). D was >10 mm at 20, 40, and 60 mm, respectively, from the coronary sinus os. Coronary sinus ECGs do not precisely localize left-sided accessory pathways, which may be due in part to an average anatomic separation of more than 10 mm between the coronary sinus and accessory pathways bridging the mitral annulus. PMID:9453527
Comparison of outcomes in patients with ST-segment elevation myocardial infarction discharged on versus not on statin therapy (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial).
Larsen, Alf I; Tomey, Matthew I; Mehran, Roxana; Nilsen, Dennis W T; Kirtane, Ajay J; Witzenbichler, Bernhard; Guagliumi, Giulio; Brener, Sorin J; Généreux, Philippe; Kornowski, Ran; Dudek, Dariusz; Gersh, Bernard J; Stone, Gregg W
Statin therapy is indicated after ST-segment elevation myocardial infarction (STEMI) to reduce recurrent ischemic events, but approximately 6% of patients with STEMI do not receive a statin prescription at discharge. This substudy aimed to define the clinical outcomes and patient characteristics associated with statin nonprescription after STEMI. We compared clinical, angiographic, and procedural characteristics and in-hospital, 30-day, 1-year, 2-year, and 3-year outcomes in 3,512 patients discharged after STEMI with and without (6%) statin prescriptions in the harmonizing outcomes with revascularization and stents in acute myocardial infarction trial (www.clinicaltrials.gov, NCT00433966). Statin nonprescription was associated with female sex, nonwhite race, previous bypass surgery, heart failure, renal impairment, anemia, thrombocytopenia, care in the United States, lower prescription rates of antiplatelets and neurohormonal antagonists, less percutaneous coronary intervention and stents, and, in 26% of cases, angiographically normal or nonobstructed coronary arteries. At every time point of follow-up after discharge, patients with no discharge statin prescription had significantly higher rates of net adverse clinical events, major adverse cardiac events, major bleeding unrelated to bypass surgery, and death. After multivariable adjustment, absence of a discharge statin prescription independently predicted 3-year major adverse cardiac event (hazard ratio 1.54, 95% confidence interval 1.15 to 2.07, p=0.0037) and death (hazard ratio 2.30, 95% confidence interval 1.41 to 3.77, p=0.0009). In conclusion, within the framework of this randomized trial of patients presenting with STEMI, approximately 6% of patients were discharged without statin therapy. Absence of a discharge statin prescription after STEMI was an independent predictor of ischemic events including death. PMID:24576541
A comparison of off-pump and on-pump coronary bypass surgery in patients with low EuroSCORE
Background The aim of the present study was to evaluate and compare postoperative short-term, mid-term and long-term outcomes of coronary artery bypass surgery performed with or without cardiopulmonary bypass in patients with a low European System for Cardiac Operative Risk Evaluation score. Methods A retrospective analysis of 478 consecutive low risk patients undergoing coronary bypass surgery between January 2002 and December 2007 was performed. Of these patients, 83 cases had undergone on-pump and 395 cases had undergone off-pump coronary bypass surgery. The patients were assessed in terms peri-operative complications, survival, mortality due to cardiac events, need for rehospitalization and repeated coronary revascularization. Results There was no significant difference between the two groups in terms of preoperative characteristics, except for chronic obstructive pulmonary disease. The number of distal anastomosis per patient was significantly lower in the off-pump group than in the on-pump group (2.66?±?0.74 vs. 3.21?±?0.85, p?0.001). Early mortality rates were similar in both groups (1.01% for the off-pump group and 1.2% for the on-pump group, p?=?0.687). Neurological complications were significantly lower in the off-pump group than in the on-pump group (1.1% vs. 6%, p?=?0.01). The mean follow-up period was 80?±?19.1 months (range, 3–112 months). The need for revascularization during long-term follow-up was 10.1% in the off-pump group and 7.2% in the on-pump group (p?=?0.416). The 5-year survival was 95.2?±?1.1% and 95.5?±?2.7% in the off-pump and on-pump groups, respectively (p?=?0.8), whereas the 7-year survival was 91.9?±?1.6% and 84.7?±?6.8% in the off-pump and on-pump groups, respectively (p?=?0.274). The 5-year revascularization-free period was 89.5?±?1.6% and 89.7?±?3.5% in the off-pump and on-pump groups, respectively (p?=?0.785). The 7-year revascularization-free period was 71.1?±?3.1% and 73.5?±?7.3% in the off-pump and on-pump groups, respectively (p?=?0.075). The 7-year event-free survival was 80.1?±?2.2% and 73.4?±?7.3% in the off-pump and on-pump groups, respectively (p?=?0.377). Conclusions The present study demonstrated that off-pump cardiac surgery had advantages over on-pump cardiac surgery in the short term; however, both interventions had similar mid-term and long-term outcomes, when performed in low-risk patient. PMID:24942178
Fatal coronary artery disease in an infant with severe mucopolysaccharidosis type I.
van den Broek, Leonie; Backx, Ad P C M; Coolen, Hans; Wijburg, Frits A; Wevers, Ron; Morava, Eva; Neeleman, Chris
A previously healthy 10-month-old boy was referred to our hospital because of coarse facial features that were suggestive of lysosomal storage disease. Apart from noisy respiration, there was no medical history. Elevated levels of urinary glycosaminoglycans and complete deficiency of leukocyte ?-l-iduronidase indicated severe mucopolysaccharidosis type I. A chest radiograph revealed a markedly enlarged heart, and echocardiography revealed hypertrophic cardiomyopathy. While hematopoietic stem cell transplantation was being planned, progressive cardiac failure developed with a striking hypokinesia of the left-ventricle free wall. In combination with ischemic changes on the electrocardiogram, this was suggestive of coronary artery disease. Results of coronary echo Doppler interrogation were inconclusive, and intravascular ultrasound in this little infant was not feasible. Despite the patient's small size, a successful selective coronary angiography was performed and revealed diffuse narrowing of the left coronary artery with collateral flow from the right coronary artery. Enzyme-replacement therapy was started immediately in an attempt to improve myocardial performance. Evaluation after 3 months, however, revealed complete obliteration of the left coronary main stem with diffuse hypokinesia/akinesia of the left ventricle. At the age of 13 months the boy died of terminal cardiac failure. This case report illustrates the importance of considering early development of coronary artery disease in children with severe mucopolysaccharidosis type I and cardiomyopathy. PMID:21464194
A critical review of clinical trials for low-molecular-weight heparin therapy in unstable coronary artery disease.
Husted, S; Becker, R; Kher, A
Unstable angina and non-ST-segment elevation myocardial infarction (MI) are collectively referred to as unstable coronary artery disease (UCAD). They are conditions that share a common pathophysiology and represent frequently encountered, potentially life-threatening clinical manifestations of advanced atherosclerosis. Therefore, treatment of UCAD is a major focus for practicing clinicians, and although pharmacologic agents have been developed that impact on patient outcome, recent data suggest that a further reduction in ischemic complications is possible. Acute-phase treatment with aspirin is associated with a significant reduction in death and nonfatal MI in patients with UCAD. This benefit is enhanced by the addition of unfractionated heparin (UFH) to the treatment strategy; however, UFH requires careful monitoring and titration. In contrast, low-molecular-weight heparins (LMWHs), produced by chemical or enzymatic depolymerization of UFH, yield a predictable and consistent pharmacokinetic profile and anticoagulant response, making them an attractive treatment alternative to UFH in patients with UCAD. The optimal duration of treatment with LMWH is an important question influenced by the observation that reactivation of coagulation occurs following the early and abrupt discontinuation of heparin treatment. Early trials, such as FRISC and FRIC, demonstrated the benefit of acute therapy with dalteparin sodium; however, the results of extended treatment with dalteparin were inconclusive. The extended phase of these studies included relatively low-risk patients, and a once-daily, relatively low-dose strategy was employed. The findings derived from the FRISC II trial, which used a twice-daily dose of dalteparin, suggest a benefit for at least 60 days with extended treatment in high-risk patients with UCAD. Although an early-invasive treatment strategy is particularly beneficial, patients in whom early revascularization is not possible should be considered for extended treatment with dalteparin for up to 45 days, especially those awaiting percutaneous coronary intervention. Extended treatment with dalteparin therefore provides a protective "bridge" to enhance the outcome of patients with UCAD awaiting revascularization. PMID:11444639
Desirability of immediate surgical standby for coronary angioplasty.
Levy, R D; Bennett, D H; Brooks, N H
OBJECTIVE--To assess the value of emergency surgical standby for percutaneous transluminal coronary angioplasty. DESIGN--Retrospective review of the major complications of coronary angioplasty in a regional cardiac centre. SETTING--All angioplasties were performed in the cardiac catheterisation laboratory of Wythenshawe Hospital with surgical standby in an adjoining operating theatre. PATIENTS--1262 vessels were dilated in 1032 patients (mean age 53 years) between 1984 and 1989. MAIN OUTCOME MEASURES--In-hospital mortality from emergency surgical revascularisation after angioplasty; the rate of myocardial infarction and overall morbidity. RESULTS--Coronary angioplasty achieved primary success in 90% of cases. Thirty eight (3.7%) patients (five women (mean age 55.8) and 33 men (mean age 53.0] were referred for urgent surgical revascularisation--36 direct to operation and two within 24 hours. All patients survived surgery. Five of the 38 had had a previous angioplasty to the same vessel and one had had previous coronary artery grafts. Four of the 38 had an angioplasty for unstable angina. Eighteen had single, 13 double, and seven triple vessel coronary artery disease. The target vessel was the left anterior descending in 25, right coronary artery in nine, circumflex in three, and the left anterior descending and circumflex coronary arteries in one. Five required external cardiac massage on the way to the operating theatre; two of them had a left main stem occlusion. Four internal mammary artery and 60 reversed saphenous vein grafts were implanted (1.6 per patient). Complete revascularisation was achieved in 36 (94.7%) patients. Q wave myocardial infarction occurred in six (15.8%). The final outcome was: none dead, three patients with angina, one late death, one cerebrovascular accident, one late operation for a new left anterior descending lesion, two patients on diuretics with or without an angiotensin converting enzyme inhibitor. One orthotopic transplant was performed in a patient in whom cardiogenic shock developed after the left anterior descending coronary artery became occluded 72 hours after angioplasty. CONCLUSION--There was no surgical mortality and low morbidity among patients for whom immediate surgical cover was requested. PMID:1867949
Postpartum multivessel spontaneous coronary artery dissection confirmed by coronary CT angiography
Schroder, Catherine; Stoler, Robert C.; Branning, George B.
Spontaneous coronary artery dissection is a rare but potentially life-threatening event associated with the peripartum period. We present a case of postpartum multivessel spontaneous coronary artery dissection diagnosed by conventional angiography and monitored with computed tomographic coronary angiography. The patient was initially managed medically and later received a coronary stent. PMID:17106495
Nager, F
Age: an annoying burden or a priceless gain? The ancient physicians differentiated between senium and senectus to describe old age. In modern-day terminology, the former corresponds to the deficit model, the latter to the competence model of old age. Its success or failure is dependent on biological, psychological, social and mental determinants. In the first part, these four determinants will be compared from the perspectives of competence and deficit, success and failure. The second part will outline selected meaningful aspects of the art of living that are relevant for successful ageing, namely, an awareness for the transient nature of life, attention to life, conciliation with oneself, F. Nietzsche's higher state of health, attention to god and humor. PMID:14640023
Effect of Gender on Patients With ST-Elevation and Non-ST-Elevation Myocardial Infarction Without Obstructive Coronary Artery Disease.
Johnston, Nina; Jönelid, Birgitta; Christersson, Christina; Kero, Tanja; Renlund, Henrik; Schenck-Gustafsson, Karin; Lagerqvist, Bo
The aim of this study was to compare the prognoses of patients with ST-segment elevation myocardial infarction (STEMI) and those with non-ST-segment elevation myocardial infarction (NSTEMI) without obstructive coronary artery disease (CAD) and the risk associated with gender for future cardiovascular events. The study population was selected from 95,849 patients who underwent coronary angiography for myocardial infarction from 2005 to 2010 and registered in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Outcome analyses, including all-cause death, myocardial infarction, congestive heart failure, stroke, and revascularization, were performed in 2,268 patients with STEMI and 10,904 with NSTEMI without obstructive CAD (<50% stenosis). Hazard ratios and 95% confidence intervals comparing women with men were calculated for events, adjusting for cardiovascular risk factors and age. Nonobstructive CAD was found in 7% of patients with STEMI (6% men, 10% women) and in 17% of those with NSTEMI (11% men, 28% women). During a median follow-up of 2.6 years, 8% of patients with STEMI and 5% of those with NSTEMI died. Gender-associated differences in risk were observed in patients with NSTEMI, with adjusted hazard ratios lower in women than men for mortality (hazard ratio 0.90, 95% confidence interval 0.50 to 0.73) and congestive heart failure (hazard ratio 0.61, 95% confidence interval 0.52 to 0.72). In the 2 groups, women underwent less revascularization. In conclusion, nonobstructive CAD was more common in patients with NSTEMI than those with STEMI, as well as in women compared with men. Long-term mortality in patients with nonobstructive CAD was higher after STEMI than NSTEMI. The gender differences in outcomes suggest gender differences in the underlying pathogenesis of myocardial infarction without obstructive CAD. PMID:25900352
Effects of a comprehensive rehabilitation programme in patients with three-vessel coronary disease.
Monpere, C; Francois, G; Brochier, M
The aim of the study was to assess the effects of rehabilitation in 46 consecutive three-vessel coronary disease patients who were considered to have no possibility of revascularization; there were 45 males and one female (mean age 58) sent in the third week after acute myocardial infarction (N = 31) or after unstable angina (N = 15). Left ventricular ejection fraction (EF) was normal in 50% of the patients, but 15% had an EF less than or equal to 0.30. Three patients could not begin their rehabilitation because of unstable angina (N = 2) or severe pulmonary oedema (N = 1). After a 4-week rehabilitation programme, the comparison of stress tests revealed an increase in functional capacities (maximal work-load = 103.6 +/- 27 W before rehabilitation, 126.4 +/- 31 W after rehabilitation, P less than 0.001), and an improvement of the ischaemic threshold [82 +/- 32 W before rehabilitation, 91 +/- 31 W after rehabilitation, P less than 0.05]. During long-term follow up [20.8 months], four patients died of cardiac events [8.7%]; all of them had an EF less than 0.45. Among the 42 living patients 61.9% were asymptomatic, 28.7% had exertional angina, and 9.4% had cardiac complications, and coronary surgery was performed in two cases with good results. The level of return to work was 85% with the mean delay of 1.7 months after rehabilitation. So, rehabilitation in three-vessel coronary disease patients is safe under medical control; improvements in exertional capacities are obvious and give the patients a better self confidence as assessed by the good score of return to work after rehabilitation. PMID:3246238
TLR4 Expression Is Associated with Left Ventricular Dysfunction in Patients Undergoing Coronary Artery Bypass Surgery
Avlas, Orna; Bragg, Arieh; Fuks, Avi; Nicholson, James D.; Farkash, Ariel; Porat, Eyal; Aravot, Dan; Levy-Drummer, Rachel S.; Cohen, Cyrille; Shainberg, Asher; Arad, Michael; Hochhauser, Edith
Introduction Toll-like receptor 4 (TLR4) is an innate immune receptor expressed in immune cells and the heart. Activation of the immune system following myocardial ischemia causes the release of proinflammatory mediators that may negatively influence heart function. Aim The aim of this study is to determine whether TLR4 is activated in peripheral monocytes and heart tissue taken from patients with varying degrees of myocardial dysfunction caused by coronary artery diseases and scheduled for coronary artery bypass graft (CABG) surgery before 12 months following operation. Methods and Results Patients (n = 44) undergoing CABG surgery having left ventricular ejection fraction ? 45% ('reduced EF', n = 20) were compared to patients with preserved EF >45% ('preserved EF' group, n = 24). 'Reduced EF' patients exhibited increased TLR4 expression in monocytes (2.78±0.49 vs. 1.76±0.07 rMFI, p = 0.03). Plasma levels of C-reactive protein, microRNA miR-320a, brain natriuretic peptide (pro BNP) and NADPH oxidase (NOX4) were also significantly different between the 'preserved EF' and 'reduced EF'groups. Elevated TLR4 gene expression levels in the right auricle correlated with those of EF (p<0.008), NOX4 (p<0.008) and miR320, (p<0.04). In contrast, no differences were observed in peripheral monocyte TLR2 expression. After CABG surgery, monocyte TLR4 expression decreased in all patients, reaching statistical significance in the 'reduced EF' group. Conclusion TLR4 is activated in peripheral monocytes and heart tissue obtained from patients with ischemic heart disease and reduced left ventricular function. Coronary revascularization decreases TLR4 expression. We therefore propose that TLR4 plays a pathogenic role and may serve as an additional marker of ischemic myocardial dysfunction. PMID:26030867
Relative effectiveness of moderate versus more aggressive lipid lowering, and of low dose anticoagulation versus placebo, in delaying saphenous vein coronary bypass graft atherosclerosis and preventing occlusion of saphenous grafts of patients with saphenous vein coronary bypass ...
Who Needs Coronary Artery Bypass Grafting?
... from the NHLBI on Twitter. Who Needs Coronary Artery Bypass Grafting? Coronary artery bypass grafting (CABG) is used to treat people ... or after a heart attack to treat blocked arteries. Your doctor may recommend CABG if other treatments, ...
Composite versus conventional coronary artery bypass grafting strategy for the anterolateral territory: study protocol for a randomized controlled trial
Background In severe coronary artery disease, coronary artery bypass grafting (CABG) surgery is indicated to re-establish an adequate blood supply to the ischemic myocardium. Effectiveness of CABG surgery for symptom relief and mortality decrease should therefore depend on bypass graft patency. As bypass using a left internal mammary artery (LIMA)-to-left anterior descending coronary artery (LAD) anastomosis allows the best results in terms of graft patency, we designed a new surgical technique using a saphenous vein graft as a venous bridge to distribute the LIMA flow to the cardiac anterolateral territory. This novel strategy could extend the patency benefits associated to the LIMA. Other potential benefits of this technique include easier surgical technique, possibility to use saphenous vein grafts as vein patch angioplasty, shorter saphenous vein grafts requirement and reduced or eliminated manipulations of the ascendant aorta (and associated stroke risk). Methods/Design Between July 2012 and 2016, 200 patients undergoing a primary isolated CABG surgery using cardiopulmonary bypass with a LAD bypass graft and at least another target on the anterolateral territory will be randomized (1:1) according to 1) the new composite strategy and 2) the conventional strategy with a LIMA-to-LAD anastomosis and revascularization of the other anterolateral target(s) with a separated aorto-coronary saphenous vein graft. The primary objective of the trial is to assess whether the composite strategy allows non-inferior anterolateral graft patency index (proportion of non-occluded CABGs out of the total number of CABGs) compared to the conventional technique. The primary outcome is the anterolateral graft patency index, evaluated at one year by 256-slice computed tomography angiography. Ten years of clinical follow-up is planned to assess clinical outcomes including death, myocardial infarction and need for revascularization. Discussion This non-inferiority trial has the potential to advance the adult cardiac surgery field, given the potential benefits associated with the composite grafting strategy. Trial registration ClinicalTrials.gov: NCT01585285. PMID:23971858
An unusual case of chronic coronary artery dissection: Did cisplatin play a role?
Ghosh, Nina; Chow, Chi-Ming; Korley, Victoria; Chisholm, Robert
Spontaneous coronary artery dissection is an unusual cause of acute myocardial ischemia. The natural history of spontaneous coronary artery dissection that persists on angiography after the acute event has not been well characterized. A case of a 36-year-old man who presented with monomorphic ventricular tachycardia 12 years following a myocardial infarction that occurred during his last course of bleomycin-etoposidecisplatin therapy for testicular cancer is reported. On further investigation, coronary angiography revealed a long chronic dissection of the right coronary artery. The patient was successfully treated with medical management and insertion of an implantable cardioverter defibrillator. The case also highlights the increased cardiovascular morbidity in testicular cancer survivors and evokes the possibility of mechanisms of myocardial ischemia other than atherosclerotic disease in these young patients. PMID:18841261
Complex coronary artery anatomy in a patient with prolapsing left atrial myxoma.
Andreou, A Y; Iakovou, I; Dimopoulos, A K; Karatasakis, G; Anastasiou, P; Vasiliadis, I; Pavlides, G
The case of an asymptomatic patient with prolapsing left atrial myxoma, in whom preoperative coronary angiography revealed a rare coronary artery anatomy in the absence of atherosclerotic obstructive disease, is presented. There was a type IV dual left anterior descending (LAD) artery with intraseptal course of the right aortic sinus-connected (long) LAD artery and an ectopic left circumflex artery originating from the right aortic sinus and having a retroaortic course. The patient underwent successful surgical excision of the mass which was confirmed by histology to be cardiac myxoma. This particular coronary artery anatomy has only been described once, and this is the first reported case of its combination with cardiac myxoma. This report highlights the importance of differentiating between the possible courses of such ectopic coronary arteries. The angiographic signs which enabled differentiation of the intraseptal course of the long LAD artery from the malignant interarterial course with which it is frequently confused are presented. PMID:21947023
The ASSURE ROT Registry: Bioresorbable Vascular Scaffold Following Rotablation for Complex Coronary Lesions
Cardiovascular Diseases; Coronary Artery Disease; Myocardial Ischemia; Coronary Disease; Coronary Restenosis; Heart Diseases; Coronary Stenosis; Arteriosclerosis; Arterial Occlusive Diseases; Vascular Diseases
[Single coronary artery and right aortic arch].
Martínez-Quintana, Efrén; Rodríguez-González, Fayna
Coronary anomalies are mostly asymptomatic and diagnosed incidentally during coronary angiography or echocardiography. However, they must be taken into account in the differential diagnosis of angina, dyspnea, syncope, acute myocardial infarction or sudden death in young patients. The case is presented of two rare anomalies, single coronary artery originating from right sinus of Valsalva and right aortic arch, in a 65 year-old patient with atherosclerotic coronary artery disease treated percutaneously. PMID:25304052
[Anatomical and coronary angiography data on coronary anastomosis].
Lo, E A; Dia, A; Ba, S A; Faivre, R; Bernard, Y; Bassand, J P; Sow, M L
Beyond two series of heart studies (anatomical with 150 hearts treated by injection-corosion method, and angiographic with 211 coronarography 3 days after a heart attack) the authors have noticed 92 coronary anastomosis with: 28 right homolateral 22 left homolateral 42 contralateral The existence of these anastomosis has been confirmed by coronarography of 30 out of 173 patients having a significant lesion of the artery responsible for the heart attack. The authors noticed also that these anastomosis are effective when the coronary system is deficient and the supplies are ensured by the other artery. The study permits to distinguish two groups of functional collateral: the functional collateral spontaneously observed during coronarography recruitable collaterals which are ready to be functional in case of main coronary artery obstruction. PMID:1842772
[Transluminal coronary angioplasty. Experience apropos of 155 procedures].
Schmitt, R; Sabatier, M; Ratovo, R; Isetta, C; Elbčze, J P; Jourdan, J; Kreitmann, P; Dor, V
The authors report their experience of transluminal coronary angioplasty (TCA) from February 1980 to November 1983. 140 patients underwent TCA and 155 procedures were performed. The mean age was 55 years (range 33 to 74 years). Clinically, the patients presented with Stage I angina in 26 cases (18 p. 100), Stage II in 18 cases (13 p. 100), Stage III in 24 cases (17 p. 100) and Stage IV in 72 cases (52 p. 100), according to the NYHA Classification. 23 patients (16.5 p. 100) underwent combined thrombolysis - TCA. The coronary artery disease was limited to a single vessel in 135 cases (96 p. 100) and involved 2 vessels in 5 cases (4 p. 100). The overall results showed a 71 p. 100 primary success rate. There were no fatalities. The incidence of myocardial infarction was 3 p. 100 (5 patients) and emergency coronary bypass surgery was necessary in 16 patients (10 p. 100). The results in two groups of patients were compared: Group A: 69 patients treated with a conventional balloon catheter. Group B: 86 patients treated with a balloon catheter with a guide wire. The coronary stenosis was catheterised in 73 p. 100 of patients in Group A, and 90 p. 100 of patients in Group B (p less than 0.01). The primary success rate was 56 p. 100 in Group A and 83 p. 100 in Group B. The use of this new material improves the primary success rate and also makes more distal, anatomically atypical lesions, accessible. PMID:3157357
Cerebral Arterial Calcification Is an Imaging Prognostic Marker for Revascularization Treatment of Acute Middle Cerebral Arterial Occlusion
Lee, Seong-Joon; Hong, Ji Man; Lee, Manyong; Huh, Kyoon; Choi, Jin Wook
Background and Purpose To study the significance of intracranial artery calcification as a prognostic marker for acute ischemic stroke patients undergoing revascularization treatment after middle cerebral artery (MCA) trunk occlusion. Methods Patients with acute MCA trunk occlusion, who underwent intravenous and/or intra-arterial revascularization treatment, were enrolled. Intracranial artery calcification scores were calculated by counting calcified intracranial arteries among major seven arteries on computed tomographic angiography. Patients were divided into high (HCB; score ?3) or low calcification burden (LCB; score <3) groups. Demographic, imaging, and outcome data were compared, and whether HCB is a prognostic factor was evaluated. Grave prognosis was defined as modified Rankin Scale 5-6 for this study. Results Of 80 enrolled patients, the HCB group comprised 15 patients, who were older, and more commonly had diabetes than patients in the LCB group. Initial National Institutes of Health Stroke Scale (NIHSS) scores did not differ (HCB 13.3±2.7 vs. LCB 14.6±3.8) between groups. The final good reperfusion after revascularization treatment (thrombolysis in cerebral infarction score 2b-3, HCB 66.7% vs. LCB 69.2%) was similarly achieved in both groups. However, the HCB group had significantly higher NIHSS scores at discharge (16.0±12.3 vs. 7.9±8.3), and more frequent grave outcome at 3 months (57.1% vs. 22.0%) than the LCB group. HCB was proven as an independent predictor for grave outcome at 3 months when several confounding factors were adjusted (odds ratio 4.135, 95% confidence interval, 1.045-16.359, P=0.043). Conclusions Intracranial HCB was associated with grave prognosis in patients who have undergone revascularization for acute MCA trunk occlusion. PMID:25692109
Changes in Coronary Perfusion after Occlusion of Coronary Arteries in Kawasaki Disease
Kwak, Ji Hee; Kang, I-Seok; Huh, June; Lee, Heung-Jae
Purpose Myocardial infarction in children with total occlusion of a coronary artery after Kawasaki disease is rare due to multiple collateral vessels. We aimed to investigate the changes in coronary perfusion associated with coronary artery occlusion after Kawasaki disease. Materials and Methods Eleven patients with coronary artery occlusion after Kawasaki disease were investigated. Serial coronary angiographies after total occlusion of a coronary artery were reviewed and the changes were described in all patients with additive information collected. Results The median age at the occlusion was 5.9 years old. The interval to occlusion was 6.2±6.9 years. Four left anterior descending coronary artery total occlusions and 10 right coronary artery total occlusions were detected. Immediate coronary artery bypass graft for left anterior descending coronary artery total occlusion made right coronary total occlusion occurred in all except one patient and the intervals thereof were 1 year, 1.8 years, and 4 years. Collaterals to the left coronary artery regressed after recanalization, while new collaterals to the right coronary artery developed. In three, collaterals to the right coronary artery decreased without recanalization without clinical signs. Conclusion The right coronary artery should be followed up carefully because of possible occlusion of new onset or changes in collaterals. PMID:24532503
Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes.
Cannon, Christopher P; Blazing, Michael A; Giugliano, Robert P; McCagg, Amy; White, Jennifer A; Theroux, Pierre; Darius, Harald; Lewis, Basil S; Ophuis, Ton Oude; Jukema, J Wouter; De Ferrari, Gaetano M; Ruzyllo, Witold; De Lucca, Paul; Im, KyungAh; Bohula, Erin A; Reist, Craig; Wiviott, Stephen D; Tershakovec, Andrew M; Musliner, Thomas A; Braunwald, Eugene; Califf, Robert M
Background Statin therapy reduces low-density lipoprotein (LDL) cholesterol levels and the risk of cardiovascular events, but whether the addition of ezetimibe, a nonstatin drug that reduces intestinal cholesterol absorption, can reduce the rate of cardiovascular events further is not known. Methods We conducted a double-blind, randomized trial involving 18,144 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and had LDL cholesterol levels of 50 to 100 mg per deciliter (1.3 to 2.6 mmol per liter) if they were receiving lipid-lowering therapy or 50 to 125 mg per deciliter (1.3 to 3.2 mmol per liter) if they were not receiving lipid-lowering therapy. The combination of simvastatin (40 mg) and ezetimibe (10 mg) (simvastatin-ezetimibe) was compared with simvastatin (40 mg) and placebo (simvastatin monotherapy). The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization (?30 days after randomization), or nonfatal stroke. The median follow-up was 6 years. Results The median time-weighted average LDL cholesterol level during the study was 53.7 mg per deciliter (1.4 mmol per liter) in the simvastatin-ezetimibe group, as compared with 69.5 mg per deciliter (1.8 mmol per liter) in the simvastatin-monotherapy group (P<0.001). The Kaplan-Meier event rate for the primary end point at 7 years was 32.7% in the simvastatin-ezetimibe group, as compared with 34.7% in the simvastatin-monotherapy group (absolute risk difference, 2.0 percentage points; hazard ratio, 0.936; 95% confidence interval, 0.89 to 0.99; P=0.016). Rates of prespecified muscle, gallbladder, and hepatic adverse effects and cancer were similar in the two groups. Conclusions When added to statin therapy, ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. Moreover, lowering LDL cholesterol to levels below previous targets provided additional benefit. (Funded by Merck; IMPROVE-IT ClinicalTrials.gov number, NCT00202878 .). PMID:26039521
Autologus Platelet Rich Fibrin aided Revascularization of an immature, non-vital permanent tooth with apical periodontitis: A case report
Jadhav, Ganesh Ranganath; Shah, Dipali; Raghvendra, Srinidhi Surya
Caries or trauma induced non-vital immature permanent tooth with blunderbuss, thin root which are very common among childrens are corrected using regenerative endodontic (revascularization) procedures. In the presented case, a 16-year-old boy reported with chief complaint of pain in maxillary left central incisor (Tooth #21). Tooth #21 showed grade III mobility, draining labial sinus, and short blunderbuss root with diffuse periapical radiolucency. Patient was explained the treatment plan and written informed consent was taken. Platelet rich fibrin (PRF) was prepared according to standard protocol. Autologous PRF was carried to the apical portion of the root canal after inducing revascularization. Access opening was double sealed with MTA and resin modified glass ionomer cement (RMGI). Baseline, 12 month and 18 month follow-up intraoral radiographs were taken. Clinically case was asymptomatic with complete resolution of intraoral sinus. Periapical healing, apical closure, root lengthening and dentinal wall thickening were uneventful. Thus PRF supplementation hastens the predictability and rate of revascularization in non-vital immature permanent teeth. PMID:25810668
Endovascular Repair of Acute Symptomatic Pararenal Aortic Aneurysm With Three Chimney and One Periscope Graft for Complete Visceral Artery Revascularization
Brechtel, Klaus, E-mail: email@example.com; Ketelsen, Dominik [Eberhard-Karls-University, Department of Diagnostic and Interventional Radiology (Germany); Endisch, Andrea [Eberhard-Karls-University, Department of Thoracic and Cardiovascular Surgery (Germany); Heller, Stephan; Heuschmid, Martin [Eberhard-Karls-University, Department of Diagnostic and Interventional Radiology (Germany); Stock, Ulrich A.; Kalender, Guenay [Eberhard-Karls-University, Department of Thoracic and Cardiovascular Surgery (Germany)
PurposeTo describe a modified endovascular technique for complete revascularization of visceral and renal arteries in symptomatic pararenal aortic aneurysm (PRAA).TechniqueArterial access was surgically established in both common femoral arteries (CFAs) and the left subclavian artery (LSA). Revascularization of the left renal artery, the celiac trunk, and the superior mesenteric artery was performed through one single sheath via the LSA. Suitable covered stents were put in the aortic branches but not deployed. The right renal artery was accessed over the left CFA. Due to the longitudinal extension of the presented aneurysm two stent-grafts were introduced via the right CFA. After deploying the aortic stent-grafts, all covered stents in the side branches were deployed consecutively with a minimum overlap of 5 mm over the cranial and caudal stent-graft edges. Simultaneous ballooning was performed to fully expand all stent-grafts and warranty patency. Conclusion: This is the first report in the literature of chimney grafting in PRAA for complete revascularization of visceral and renal branches by using more than two covered stents introduced from one side through one single sheath. However this technique is modified, it should be used only in bailout situations when branched stent-grafts are not available and/or surgery is not suitable.
Improving long term outcome for diabetic patients undergoing surgical revascularization by use of the radial artery conduit: a propensity matched study
Background Diabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA. Methods A propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010. Results We compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/? SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122]. Conclusion For diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined. PMID:23421972
Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis
Stortecky, Stefan; Stefanini, Giulio G; daCosta, Bruno R; Rutjes, Anne Wilhelmina; Di Nisio, Marcello; Siletta, Maria G; Maione, Ausilia; Alfonso, Fernando; Clemmensen, Peter M; Collet, Jean-Philippe; Cremer, Jochen; Falk, Volkmar; Filippatos, Gerasimos; Hamm, Christian; Head, Stuart; Kappetein, Arie Pieter; Kastrati, Adnan; Knuuti, Juhani; Landmesser, Ulf; Laufer, Günther; Neumann, Franz-Joseph; Richter, Dimitri; Schauerte, Patrick; Sousa Uva, Miguel; Taggart, David P; Torracca, Lucia; Valgimigli, Marco; Wijns, William; Witkowski, Adam; Kolh, Philippe; Juni, Peter
Objective To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease. Design Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation. Eligibility criteria for selecting studies A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease. Data sources Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation. Main outcome measure All cause mortality. Results 100 trials in 93?553 patients with 262?090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment. Conclusion Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment. PMID:24958153
[Percutaneous transluminal coronary angioplasty for postinfarction residual ischemia: mid- and long-term results].
Orzan, F; Bonamini, R; Garachemani Asl, A R; Carini, G; Conte, M R; Defilippi, G; Fontana, V; Massobrio, N; Presbitero, P; Brusca, A
Aim of this study was to assess the long-term results of PTCA in patients with a recent myocardial infarction. The study population consisted of 244 consecutive patients who underwent a PTCA < or = 30 days after myocardial infarction either because of angina (116 patients), or because of provoked ischemia (62 patients), or in the absence of both (66 patients). "Simple" balloon angioplasty, without adjunctive devices, was performed. Most of the patients were seen at 1 year intervals at the outpatient clinic; otherwise information was gathered either from the family physician or by telephone. The following events were noted during a follow-up of 6-102 months (median 39 months): death, myocardial infarction, need for re-PTCA or surgical revascularization, recurrence of angina. Survival and event-free curves were calculated according to the method of Kaplan and Meier; statistical comparisons between the curves were obtained by the log-rank test. Periprocedural deaths, infarctions and surgical revascularizations are included in the actuarial curves. Differences were examined between patients with Q and non-Q wave infarctions, single vessel versus multivessel disease, left ventricular ejection fraction > or 50% versus < 50%. A clinical success was achieved in 85% of the procedures. Sixteen patients were lost at follow-up. Overall, within the first 30 days and during follow-up, 12 (4.9%) patients died, 19 (7.7%) suffered from myocardial infarction, 34 (13.9%) required re-PTCA or surgical revascularization, and 63 (25.8%) experienced angina again.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7634310
Acute and prolonged treatment with low-molecular-weight heparin therapy in patients with unstable coronary artery disease.
Husted, S; Kher, A
Unstable angina and non-ST-segment elevation myocardial infarction (MI) are known as unstable coronary artery disease (UCAD). They are syndromes that share a common pathobiology and represent a frequently encountered and potentially life-threatening medical condition. Acute-phase treatment with aspirin is associated with a significant reduction in death and non-fatal MI in patients with UCAD. This benefit is enhanced by the addition of unfractionated heparin (UFH) to the treatment strategy; however, UFH requires careful monitoring and titration. In contrast, low-molecular-weight heparins (LMWHs), produced by chemical or enzymatic depolymerization of UFH, yield a predictable and consistent pharmacokinetic profile and anticoagulant response making them an attractive alternative treatment to UFH in patients with UCAD. In several studies, acute-phase treatment with LMWH has been shown to be at least as effective and safe as UFH. The optimal duration of treatment with LMWH is an important question that has been influenced by the observation that reactivation of coagulation occurs following the early and abrupt discontinuation of heparin treatment. In early trials, such as FRISC (Fragmin during instability in coronary artery disease) and FRIC (Fragmin in unstable coronary artery disease), the results of extended treatment were inconclusive; however, the trial populations included patients of relatively low risk and used a once-daily dosing regimen. In the TIMI 11B (Thrombolysis in myocardial infarction) extended treatment beyond the few days of acute treatment with enoxaparin did not add to the beneficial LMWH effect, but in this study 40% of the high-risk patients did not continue on extended treatment. The findings derived from the FRISC II trial, which used a twice-daily dose of dalteparin sodium, suggest a benefit for up to 45 days with extended treatment in high-risk UCAD patients. Although an early invasive treatment strategy is particularly beneficial, patients in whom early revascularization is not possible should be considered for extended treatment with dalteparin sodium awaiting percutaneous coronary intervention. PMID:11209983
Elevated survivin expression in peripheral blood mononuclear cells is central to collateral formation in coronary chronic total occlusion.
Xu, Yiguan; Tan, Xuerui; Wang, Dongming; Wang, Wei; Li, Yuguang; Wu, Min; Chen, Songming; Wu, Yinge; Tan, Chunjiang
Survivin is essential to angiogenesis and revascularization, but its role in coronary collateral formation remains unclear. The role of survivin in peripheral blood mononuclear cells (PBMCs) of coronary chronic total occlusion (CTO) patients was investigated. Coronary CTO patients (n=46; mean age 60.1±8.5, male 54.3%) (CTO group) and normal control patients (n=18; mean age 58.0±10.0, male 55.6%) underwent angiographic collateral vessel grading by Rentrop classification (C0 - C3) and provided peripheral blood between June 2006 and February 2007. Rat hind limb ischemia models were constructed using four equal groups of Sprague-Dawley rats (n=36): normal control, sham operation, operation and granulocyte macrophage colony-stimulating factor (GM-CSF). PBMC numbers and characteristics, collateral vessels, survivin, CD4, CD8, CD44, vascular endothelial growth factor (VEGF) and intercellular adhesion molecule-1 (ICAM-1) expression were determined using RT-PCR, flow cytometry, immunocytochemistry and western blot analysis. PBMC survivin mRNA and protein expression levels were higher in patients with good collateral circulation (C2 + C3) than in patients with no collateral flow (C0) (all P<0.05). Survivin single-positive and survivin and CD8, VEGF and ICAM-1 double-positive percentages were elevated in patients with good collateral circulation compared to those with normal and no collateral flow (all P<0.05), consistent with the rat model results, wherein higher survivin levels produced significantly larger and more visible collateral vessels. In conclusion, elevated survivin expression in PBMCs, particularly survivin and CD8, VEGF, and ICAM-1 double-positive PBMCs, may be crucial for good collateral formation in patients with coronary CTO, as confirmed by assessment of a rat model. PMID:25816072
Elevated survivin expression in peripheral blood mononuclear cells is central to collateral formation in coronary chronic total occlusion
Survivin is essential to angiogenesis and revascularization, but its role in coronary collateral formation remains unclear. The role of survivin in peripheral blood mononuclear cells (PBMCs) of coronary chronic total occlusion (CTO) patients was investigated. Coronary CTO patients (n=46; mean age 60.1±8.5, male 54.3%) (CTO group) and normal control patients (n=18; mean age 58.0±10.0, male 55.6%) underwent angiographic collateral vessel grading by Rentrop classification (C0 – C3) and provided peripheral blood between June 2006 and February 2007. Rat hind limb ischemia models were constructed using four equal groups of Sprague-Dawley rats (n=36): normal control, sham operation, operation and granulocyte macrophage colony-stimulating factor (GM-CSF). PBMC numbers and characteristics, collateral vessels, survivin, CD4, CD8, CD44, vascular endothelial growth factor (VEGF) and intercellular adhesion molecule-1 (ICAM-1) expression were determined using RT-PCR, flow cytometry, immunocytochemistry and western blot analysis. PBMC survivin mRNA and protein expression levels were higher in patients with good collateral circulation (C2 + C3) than in patients with no collateral flow (C0) (all P<0.05). Survivin single-positive and survivin and CD8, VEGF and ICAM-1 double-positive percentages were elevated in patients with good collateral circulation compared to those with normal and no collateral flow (all P<0.05), consistent with the rat model results, wherein higher survivin levels produced significantly larger and more visible collateral vessels. In conclusion, elevated survivin expression in PBMCs, particularly survivin and CD8, VEGF, and ICAM-1 double-positive PBMCs, may be crucial for good collateral formation in patients with coronary CTO, as confirmed by assessment of a rat model. PMID:25816072
Evaluation of Clinical Outcomes in Patients Undergoing Dual Vessel Percutaneous Coronary Intervention Using Sirolimus-Eluting Coronary Stent System in India
Prajapati, Jayesh; Porwal, Sanjay; Khambhati, Bhavesh; Thakkar, Ashok
Introduction: Coronary artery disease is the most common catastrophic disease in India. The safety and effectiveness of dual vessel sirolimus-eluting stent (SES) implantation (used as an intervention in CAD) is currently unknown in Indian population. The purpose of this study was to investigate one year clinical outcomes of patients with dual vessel coronary artery disease after implantation of the Supralimus-Core SES, in a "real-world" setting. Materials and Methods: We evaluated 60 patients between April-2011 and August-2012, who underwent dual vessel percutaneous coronary intervention (PCI) with the Supralimus-Core SES implantation at the same index procedure. Dual vessels were defined as involvement of two major epicardial vessels (right, left anterior descending, circumflex, or left main coronary arteries) or one major epicardial vessel and a branch (?2.5 mm in diameter) originating from another major epicardial vessel. The primary endpoint was target lesion failure (TLF) defined as the composite of cardiac death, myocardial infarction (MI), and clinically-driven target lesion revascularization (TLR) at one year. Secondary endpoint included combined (definite, probable and possible) stent thrombosis (ST). Results: A total of 120 lesions were treated in 60 enrolled patients (mean age 56.0±9.2 y; 80.0% male) with average stent length of 23.1±8.5 mm. Among 60 patients, diabetes, hypertension and hypercholesterolemia were present in 15 (25.0%), 22 (36.7%) and 25 (41.7%) patients respectively. Indications for PCI were unstable angina in 30 (50.0%) patients and stable angina in 11 (18.3%) patients. Overall, 40 (33.3%) lesions were classified as complex (American College of Cardiology/American Heart Association type B2/C). The cumulative TLF rate was 5.0% (n=3) at one year. Cardiac death, MI and clinically-driven TLR occurred in 1 (1.7%), 0 (0%) and 2 (3.3%) patients, respectively at one year follow-up. The Kaplan-Meier curve of the freedom from overall events at one year was 95.0%. According to the Academic Research Consortium definition, there were no events of stent thrombosis during one year. Conclusion: Our study shows that, dual vessel Supralimus-Core SES implantation allows safe and effective treatment with low rates of TLF at one year follow-up in Indian population. PMID:25859478
[Drug-eluting coronary stents].
Fontos, Géza
The first method of percutaneously treating a diseased vessel was developed by Dotter and Judkins in 1964. Andreas Grüntzig performed the first coronary angioplasty in 1977. In 1985 Palmaz et al. implanted the first balloon-mounted stent in a peripheral artery. Puel and Sigwart implanted the first human coronary stent in March 1986; it was a self-expanding mesh-like device. Schatz et al. applied some small modifications to the original Palmaz stent, which resulted in the first coronary stent available on the market, called Palmaz-Schatz stent. In 1987 Sigwart was the first to suggest the use of coronary stents in acute vessel occlusions during unsuccessful PTCA. Using the device it became possible to cover the intimal flap and to prevent elastic recoil. Because of the high incidence of subacute stent thromboses and the bleeding complications (aggressive anticoagulation regimens) these times the coronary stents were implanted only in order to avoid emergency CABG surgery. In 1993 BENESTENT and STRESS trials have proved that elective stent implantation can significantly reduce the incidence of restenosis. The dual antiplatelet therapy and the high pressure stent implantation technique dramatically reduced the incidence of subacute stent thrombosis. The treatment of coronary artery disease has undergone revolutionary changes in the past decade but remained the leading cause of mortality in the developed world. The most important limitation of PCI has been in-stent restenosis, which occurs in 20-40% of stent implantations. Clinically it results in recurrent ischemic episodes most often requiring repeat revascularisation (rePCI or CABG). With the use of drug-eluting stents the incidence of in-stent restenosis can be reduced dramatically, based on the currently available clinical trials it remains below 10%. PMID:17297752