Ahmad A. Elesber

Incidence, retrieval methods, and outcomes of stent loss during percutaneous coronary intervention: A large single‐center experience

Our goal was to examine the incidence and consequences of stent loss during percutaneous coronary intervention (PCI) and the retrieval techniques used. We retrospectively reviewed 11,773 consecutive PCI cases involving stents performed at our institution between January 1994 and March 2004 to identify cases of stent loss. Stent loss occurred in 38 of 11,773 PCI procedures involving stents (0.32%; 95% CI = 0.23–0.44%). Mean age of the patients was 67 ± 11 years and 82% were men. Stent loss occurred more frequently in lesions with calcification and/or significant proximal angulation. In three patients, the stent was crushed and covered with another stent without attempting retrieval. Stent retrieval was attempted in 35 of 38 cases and was successful in 30 (86%). The following retrieval methods were used (more than one method was used in some cases): advancing a balloon through the stent, inflating the balloon, and withdrawing the stent (45%); twirling two wires around the stent (5%); loop snare (26%); biliary forceps (12%); Cook retained fragment retriever (10%); and basket retrieval device (2%). Patients in whom stent loss occurred had a higher incidence of bleeding requiring transfusion (24% vs. 7%; P < 0.001) and more often required emergency coronary artery bypass surgery (5% vs. 0.4%; P < 0.001). No patients in whom the stent was crushed or deployed in the coronary artery had any major cardiac complication. Stent loss during PCI occurs infrequently. Lost stents can be successfully retrieved in the majority of cases using a variety of retrieval techniques, yet stent loss is associated with an increased risk of complications. Stent deployment or crushing may be a good alternative to retrieval.

Preeclampsia as a risk factor for cardiovascular disease later in life: validation of a preeclampsia questionnaire

OBJECTIVE This study was undertaken to validate a self-administered questionnaire in verifying the diagnosis of preeclampsia, eclampsia, or toxemia in a group of women with a greater than 20-year history of preeclampsia. STUDY DESIGN Questionnaires were mailed to a random sample of 144 women who received a diagnosis of any of these 3 conditions and 158 women who had normotensive pregnancies at Mayo Clinic, Rochester, Minnesota, from 1960-1979. RESULTS A previous diagnosis of preeclampsia, eclampsia, or toxemia was verified with 80% sensitivity and 96% specificity. CONCLUSION Our validated questionnaire may be a useful research tool in identifying women with a previous history of preeclampsia. Women with a history of preeclampsia had a higher prevalence of future hypertension than those with a history of normotensive pregnancy.

Utility of isoproterenol to provoke outflow tract gradients in patients with hypertrophic cardiomyopathy.

It is important to identify patients with hypertrophic cardiomyopathy (HC) who have labile left ventricular outflow tract (LVOT) obstruction for consideration of ventricular septal reduction therapy. Although Doppler echocardiography has become the diagnostic modality to assess LVOT obstruction, it may not identify all patients with labile obstruction. This study assessed the diagnostic value of cardiac catheterization using isoproterenol challenge in 25 patients with HC in whom an LVOT obstruction (gradient >or=50 mm Hg) was clinically suspected, but not diagnosed using Doppler echocardiography. These patients underwent cardiac catheterization using a transseptal approach with isoproterenol challenge. During isoproterenol infusion, the gradient increased to >or=50 mm Hg in 14 patients and remained <50 mm Hg in 11 patients. Ten patients subsequently underwent surgical myectomy, 6 patients underwent alcohol septal ablation, and 9 patients were managed medically. Median follow-up was 26 months. Of patients who had a provoked gradient >50 mm Hg during isoproterenol infusion, 8 patients who underwent septal myectomy and 5 of 6 patients who underwent alcohol septal ablation had sustained alleviation of symptoms at follow-up. In conclusion, cardiac catheterization with isoproterenol challenge may identify patients with HC who may benefit from septal reduction therapy for whom the initial noninvasive evaluation does not show severe obstruction.

Plasma 8-iso-prostaglandin F2α, a marker of oxidative stress, is increased in patients with acute myocardial infarction

Background: Oxidative stress has been implicated in the pathogenesis of atherogenesis. The aim of our study is to examine whether the plasma 8-iso-prostaglandin F2α level, a marker of oxidative stress, is elevated in patients with acute myocardial infarction. Methods: Three groups of patients were enrolled: (1) patients with no or minimal coronary artery disease (CAD) (n = 15); (2) patients with stable CAD (n = 31); (3) patients with acute myocardial infarction (n = 13). Results: Plasma 8-iso-prostaglandin F2α levels were significantly elevated (p < 0.001) in patients with acute myocardial infarction (290.7 ± 73.9 pg/ml) as compared to patients with stable CAD (182.0+75.7 pg/ml) and patients with no significant CAD (118.9 ± 85.5 pg/ml). This remained significant after correcting for coronary atherosclerosis risk factors, age, extent of atherosclerosis, and C-reactive protein (CRP) level. Conclusion: Plasma 8-iso-prostaglandin F2α levels are elevated in patients with acute myocardial infarction. Endogenous oxidative stress may contribute to the pathogenesis of atherosclerosis and its complications, namely myocardial infarction.

Bosentan preserves endothelial function in mice overexpressing APP

This study was designed to test the hypothesis that Alzheimers disease (AD) is associated with endothelial dysfunction and that chronic endothelin-1 antagonism preserves endothelial function in mice overexpressing the AD amyloid precursor protein (APP). Three groups of mice were studied: C57BL/6 (normal control, n = 6), transgenic mice overexpressing APP (Tg2576, n = 5), and Tg2576 mice fed Bosentan (100 mg/(kg day)(-1)), a combined endothelin A and B receptor antagonist, for 4 months (Tg2576+Bosentan, n = 5). Mice were sacrificed at the age of 7 months. In vitro, the endothelium-dependent aortic vasorelaxation was significantly attenuated in Tg2576 mice as compared to C57BL/6 and Tg2576+Bosentan mice. In contrast, Tg2576+Bosentan and C57BL/6 mice showed similar endothelium-dependent aortic vasorelaxation. Similarly, endothelium-dependent carotid vasorelaxation was significantly attenuated in Tg2576 mice compared to C57BL/6 and Tg2576+Bosentan mice. There was no difference between the three groups in the response to nitroprusside. The current study demonstrates the presence of endothelial dysfunction in both carotid and aortic arteries in mice overexpressing APP and suggests a pathophysiological role for the endogenous endothelin system in AD.

The effect of drug eluting stents on cardiovascular events in patients with intermediate lesions and borderline fractional flow reserve.

To assess the role of fractional flow reserve (FFR) in guiding therapy in the drug eluting stent (DES) era.

Approach to patients with heart failure and normal ejection fraction.

Approximately 50% of patients with a firm clinical diagnosis of heart failure (HF) have a normal ejection fraction. Some patients have valvular disease, but most have underlying diastolic dysfunction that leads to pulmonary and systemic congestion and signs and symptoms of HF. Although diastolic HF is clinically and radiographically indistinguishable from HF with depressed left systolic ventricular function, knowledge of which patients are at risk of diastolic HF, the common clinical profiles, and the common echocardiographic findings enhances the clinicians ability to diagnose diastolic HF with confidence. The prognostic implications of a diagnosis of diastolic HF and the therapeutic approach to such patients are reviewed.

Immediate improvement in coronary flow reserve after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy

Objectives: To examine whether percutaneous alcohol septal ablation affects coronary flow reserve (CFR) in patients with hypertrophic cardiomyopathy (HCM). Methods: CFR was measured immediately before and after septal ablation in patients with symptomatic obstructive HCM. CFR was also obtained in normal subjects (NL) for comparison. Results: Patients with HCM (n = 11), compared with NL (n = 22), had a lower mean (SD) baseline CFR (1.96 (0.5) vs 3.0 (0.7), p<0.001), a lower coronary resistance (1.04 (0.45) vs 3.0 (2.6), p = 0.002), a higher coronary diastolic/systolic velocity ratio (DSVR; 5.1 (3.0) vs 1.8 (0.5), p = 0.04) and a lower hyperaemic coronary flow per left ventricular (LV) mass (0.73 (0.4) vs 1.1 (0.6) ml/min/g, p = 0.007). Septal ablation in the HCM group (n = 7) reduced the outflow tract gradient but not the left atrial or LV diastolic pressures. Ablation resulted in immediate normalisation of CFR (to 3.1 (1), p = 0.01) and DSVR (to 1.9 (0.8), p = 0.09) and an increase in coronary resistance (to 1.91 (0.6), p = 0.02). This was probably related to an improvement in the systolic coronary flow. Conclusions: This study demonstrates that successful septal ablation in patients with symptomatic HCM results in immediate improvement in CFR, which is reduced in HCM partly because of the increased systolic contraction load.

Noninvasive Assessment of Acute Changes in Atrial Electrophysiology After Cardioversion by Signal‐Averaged P‐Wave Electrocardiography

Background: Atrial remodeling secondary to atrial fibrillation (AF) may be important in the arrhythmogenic process. Unfortunately, the study of electrophysiologic remodeling in humans has been limited by the invasive nature of most tests of electrophysiologic characteristics. We sought to determine whether changes in atrial electrophysiology occur acutely (within the first hour) after cardioversion and whether these changes could be detected noninvasively by measuring the signal‐averaged P‐wave.