Alan Feit

Primary stent implantation compared with primary balloon angioplasty for acute myocardial infarction: a meta-analysis of randomized clinical trials

The clinical efficacy of primary angioplasty for acute myocardial infarction (AMI) is limited by recurrent myocardial ischemia during the hospital stay and restenosis in the months thereafter. 1 With the application of more effective poststenting antithrombotic regimens 2 and the improvement in stent implantation techniques, 3 coronary stenting is no longer considered contraindicated in thrombus-containing lesions and has gained substantial popularity in the setting of AMI. Recently, several randomized clinical trials have been conducted that compared coronary stenting and balloon angioplasty as the primary revascularization strategy for AMI. 4 ‐14 In the present study, we performed a meta-analysis of all the reported randomized trials to assess the overall comparative efficacy of these 2 strategies on major clinical outcomes in AMI.

Fatal left main coronary artery embolism from aortic valve endocarditis following cardiac catheterization

Coronary artery embolization has been associated with sudden cardiac death. It is more commonly seen with aortic valve endocarditis. It manifests as acute myocardial ischemia or infarction, causing instability of the cardiac rhythm, which may be fatal. We report a patient with aortic valve endocarditis who had sudden cardiac death following coronary angiography. Autopsy revealed embolic occlusion of the left main coronary artery. Cathet. Cardiovasc. Intervent. 50:74–77, 2000.

Cardiac disease and nonorganic chest pain : factors leading to disability

Research has shown that many chest pain patients, without coronary artery disease, may suffer from panic disorder, hypochondriasis, depression, and/or multiple phobias. Some patients with coronary artery disease may also suffer from these disorders and are often unable to return to previous activity. In spite of good prognosis for longevity and acceptable exercise test results, a large proportion of these patients continue to be disabled by chest pain and/or chronic cardiac fears and demand constant medical attention. This study examined the psychiatric and behavioral symptomatology that differentiated four groups of patients experiencing chest pain: the able (active/working patient) with and without coronary artery disease, as determined by exercise thallium-201 studies, and the disabled (inactive/nonworking patient) with and without coronary artery disease. The results of the study indicated that the inactive patients, both with and without heart disease, suffered from a host of debilitating psychiatric conditions.

Relationship between cytokine levels and coronary artery disease in women.

Inflammation is thought to have a role in the pathogenesis of atherosclerotic coronary artery disease (CAD), and the measurement of markers of inflammation has been suggested to improve the identification of individuals at risk for this disease. The incidence of CAD in women is not accounted for by conventional risk factors, and the association of CAD and the antiinflammatory cytokine transforming growth factor beta1 (TGF-beta1) in this population is unknown. Associations among TGF-beta1, the inflammatory cytokine tumor necrosis factor alpha (TNF-alpha), and CAD severity in inner city women were examined. Fifty-three women requiring angiography (mean age, 60.7 years) were stratified as having on of the following conditions: 0 vessel disease (VD) (n = 20), 1 (VD) (n = 10), 2 VD (n = 9), or 3 VD (n = 14). Fasting serum cytokine levels were determined by enzyme-linked immunosorbent assay. Serum TGF-beta1 was lower in patients with extensive disease (2 and 3 VD versus 0 and 1 VD). The lowest TGF-beta1 levels (<30 ng/mL) were in the 2 and 3 VD groups. In contrast, in the 0 and 1 VD groups, TGF-beta1 was above 41 ng/mL. Serum TGF-beta1 correctly classified the severity of CAD in 62.3% of patients, with a predictive threshold of 58 ng/mL by discriminant function analysis. TGF-beta1 may be a determinant of clinical events and outcome in CAD in women.

ST-T alternans and myocardial ischemia.

Previous studies using intracoronary electrocardiography have demonstrated that ST-T alternans can develop during standard balloon coronary angioplasty. Total occlusion with a large amount of myocardium in jeopardy is the postulated prerequisite. In this study, the authors used perfusion balloons instead of standard balloons, so coronary perfusion was maintained and ischemia was minimized. Fourteen patients with standard balloon technique and 11 patients with perfusion balloon technique were studied. The ST segment was less elevated during perfusion angioplasty (0.15 ±0.05 mV vs 1.04 ±0.19 mV, p<0.001). There were six (43%) patients with ST-T alternans with standard balloon technique compared with none in the perfusion balloon group (p<0.001) . In this study, the authors found that there was less ischemia, less ST segment elevation, and lack of ST-T alternans on the intracoronary electrocardiogram during perfusion balloon angioplasty. These findings support the postulate that a large amount of ischemic myocardium is a prerequisite for ST-T alternans.

Takayasu's Arteritis: An Unusual Manifestation: A Case Report

Takayasus arteritis is a rare entity. The authors describe a case of a middle-aged woman with an atypical form of Takayasus arteritis. This manifestation has not been described previously.

Complete heart block complicating retrograde left heart catheterization.

Three cases of complete heart block complicating retrograde left heart catheterization are presented. In two of the three cases, electrophysiologic study documented block below the AV (atrial ventricular) node. In the third recurrent complete heart block was fatal. It appears that complete heart block complicating retrograde left sided cardiac catheterization is not simply a pericatheterization event; rather, it appears that there is high risk of recurrent complete heart block and that electrophysiologic study is mandatory.

Use of intracoronary electrocardiography for detecting ST-T, QTc, and U wave changes during coronary balloon angioplasty.

Intracoronary electrocardiography (IC-ECG) is a more sensitive method than surface ECG to detect electrical changes during percutaneous transluminal coronary angioplasty (PTCA). It also provides direct monitoring of ST-T segment, QTc intervals, and U-wave genesis during balloon inflation. These changes are reflective of myocardial ischemia. The authors studied the effect of transient myocardial ischemia on ST-T segment, QTc intervals, and U-wave appearance by comparing standard and perfusion balloon angioplasty. PTCA of left anterior descending artery was performed in 14 patients using the standard balloons and in 11 patients using the perfusion balloons. Patients with perfusion balloon angioplasty had less ST-T elevation (0.15 +/- 0.05 mV versus 1.04 +/- 0.19 mV, P < 0.001), less QTc-shortening intervals (0.01 +/- 0.02 seconds versus -0.05 +/- 0.04 seconds, P < 0.001), and less positive U waves (two versus nine). The authors concluded that balloon angioplasty with perfusion balloons is associated with less ischemia as reflected by ST-T, QTc-shortening intervals, and U-wave changes. There was more positive U-wave appearance with the standard balloon angioplasty, which implies more ischemia. In addition, QTc-shortening intervals are associated with the development of U waves during standard balloon angioplasty. These findings suggest that IC-ECG is a sensitive tool in detecting myocardial ischemia. IC-ECG may also help to clarify the nature of chest pain during PTCA in some patients. Like QT dispersion (QTd), QTc-shortening intervals and new U waves can have prognostic implications and additional studies are needed to define this role.

Multiple balloon rupture during coronary angioplasty. A case report.

The authors report a case of coronary angioplasty of the left anterior descending artery complicated by multiple balloon rupture. Various balloon types including polyethylene terephthalate and PE 600® (ACS) ruptured at low atmospheric pressure. During balloon rupture, a septal side branch was dissected with severe intimal staining. The authors postulate that a particular lesion morphology was responsible for balloon rupture. Approaches to such lesions using alternative coronary angioplasty techniques and newer technologies are discussed.

Rescue PTCA complicated by pulmonary artery rupture after tPA and abciximab.

Since the introduction of pulmonary artery catheterization for hemodynamic monitoring, several complications associated with its use have been described. Pulmonary artery rupture is an infrequent complication of flow‐directed pulmonary artery catheters. We report a case of pulmonary artery rupture complicating rescue PTCA in the presence of systemic platelet inhibition with abciximab (Reopro), anticoagulation, and thrombolytic therapy. With the increasing use of these medications in patients undergoing acute coronary interventions, particularly those patients requiring hemodynamic monitoring, this uncommon but potentially fatal complication may be seen more frequently. Cathet. Cardiovasc. Intervent. 46:89–91, 1999.