Antonio Gaglione
University of Bari
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Circulation | 1995
Antonio Colombo; Patrick Hall; Shigeru Nakamura; Yaron Almagor; Luigi Maiello; Giovanni Martini; Antonio Gaglione; Steven L. Goldberg; Jonathan Tobis
BACKGROUND The placement of stents in coronary arteries has been shown to reduce restenosis in comparison to balloon angioplasty. However, clinical use of intracoronary stents is impeded by the risk of subacute stent thrombosis and complications associated with the anticoagulant regimen. To reduce these complications, the hypothesis that systemic anticoagulation is not necessary when adequate stent expansion is achieved was prospectively evaluated on a consecutive series of patients who received intracoronary stents. METHODS AND RESULTS From March 1993 to January 1994, 359 patients underwent Palmaz-Schatz coronary stent insertion. After an initial successful angiographic result with < 20% stenosis by visual estimation had been achieved, intravascular ultrasound imaging was performed. Further balloon dilatation of the stent was guided by observation of the intravascular ultrasound images. All patients with adequate stent expansion confirmed by ultrasound were treated only with antiplatelet therapy (either ticlopidine for 1 month with short-term aspirin for 5 days or only aspirin) after the procedure. Clinical success (procedure success without early postprocedural events) at 2 months was achieved in 338 patients (94%). With an inflation pressure of 14.9 +/- 3.0 atm and a balloon-to-vessel ratio of 1.17 +/- 0.19, optimal stent expansion was achieved in 321 of the 334 patients (96%) who underwent intravascular ultrasound evaluation, with these patients receiving only antiplatelet therapy after the procedure. Despite the absence of anticoagulation, there were only two acute stent thromboses (0.6%) and one subacute stent thrombosis (0.3%) at 2-month clinical follow-up. Follow-up angiography at 3 to 6 months documented two additional occlusions (0.6%) at the stent site. At 6-month clinical follow-up, angiographically documented stent occlusion had occurred in 5 patients (1.6%). At 6-month clinical follow-up, there was a 5.7% incidence of myocardial infarction, a 6.4% rate of coronary bypass surgery, and a 1.9% incidence of death. Emergency intervention (emergency angioplasty or bailout stent) for a stent thrombosis event was performed in 3 patients (0.8%). The overall event rate was relatively high because of intraprocedural complications that occurred in 16 patients (4.5%). Intraprocedural complications, however, decreased to 1% when angiographically appropriately sized balloons were used for final stent dilations. There was one ischemic vascular complication that occurred at the time of the procedure and one ischemic vascular complication that occurred at the time of angiographic follow-up. By 6 months, repeat angioplasty for symptomatic restenosis was performed in 47 patients (13.1%). CONCLUSIONS The Palmaz-Schatz stent can be safely inserted in coronary arteries without subsequent anticoagulation provided that stent expansion is adequate and there are no other flow-limiting lesions present. The use of high-pressure final balloon dilatations and confirmation of adequate stent expansion by intravascular ultrasound provide assurance that anticoagulation therapy can be safely omitted. This technique significantly reduces hospital time and vascular complications and has a low stent thrombosis rate.
Circulation | 1994
Shigeru Nakamura; Antonio Colombo; Antonio Gaglione; Yaron Almagor; Steven L. Goldberg; Luigi Maiello; L Finci; Jonathan Tobis
Intracoronary Ultrasound Observations During Stent Implantation Shigeru Nakamura, MD; Antonio Colombo, MD; Antonio Gaglione, MD; Yaron Almagor, MD; Steven L. Goldberg, MD; Luigi Maiello, MD; Leo Finci, MD; Jonathan M. Tobis, MD T he Palmaz-Schatz stent has been used success- fully to improve primary angioplasty results, to treat large coronary dissections, or to prevent impending closure of the lumen.-1-5 The determination of successful stent implantation is based on the angio- graphic appearance. However, angiographic projection imaging may not reveal the three-dimensional geometry that is necessary to appreciate full expansion of a cylindrical meshwork device such as the intracoronary stent. Intravascular ultrasound (IVUS) imaging has the advantage of providing detailed cross-sectional images from within the vessel lumen, allowing better evaluation of stent expansion.16-21 Based on angiographic assess- ment, it has been recommended to overdilate the ste- nosis about 10% greater than the reference vessel diameter.1 There is no quantitative guideline for IVUS assessment of successful stent implantation. The pur- pose of this study was to compare the observations of IVUS with standard angiography after stent implanta- tion and to develop recommendations for guiding stent implantation by IVUS. Methods Population and Stent Type The study population consisted of 63 consecutive patients who underwent Palmaz-Schatz stent insertion for native cor- onary arteries and received IVUS imaging at two institutions from January 1, 1993, to April 16, 1993. There were 55 men and 8 women. The mean patient age was 58.6±9.6 years. All patients had coronary artery stenosis with objective evidence of ischemia. Of the 65 lesions treated, the indications for stent insertion were elective implantation in 60 (92%) and emer- gency implantation in 5 (8%). Emergency stent deployment was defined as the presence of a large dissection with threat- ened closure after coronary angioplasty, as evidenced by chest pain and ischemic ECG changes. The target lesion was in the left anterior descending coronary artery (LAD) in 40 lesions, the left circumflex artery (LCx) in 10 lesions, the right coronary artery (RCA) in 14 lesions, and the left main artery in 1 lesion. A standard-length (15 mm) Palmaz-Schatz stent (Johnson and Johnson Interventional Systems) was used in 12 lesions (18%). A short version (7 mm) of the Palmaz-Schatz stent was made by cutting the articulation site22 and was used in 48 lesions (74%). A 10-mm-long biliary Palmaz stent was Received October 8, 1993; revision accepted November 16, From Centro Cuore Columbus (A.C., Y.A., L.M., L.F.), Milan, Italy; Villa Bianca and University of Bari (A.G.), School of Medicine, Bari, Italy; and the Division of Cardiology (S.N., S.L.G., J.M.T.), University of California Irvine. Correspondence to Antonio Colombo, MD, Centro Cuore Co- lumbus, Via Buonarotti 48, 20145 Milan, Italy. inserted in 10 lesions (15%). One stenosis was treated with a 10-mm renal Palmaz stent. The biliary and renal stents were used in heavily calcified lesions because of the additional strength of these larger devices. A single stent was implanted in 18 lesions (28%), and multiple stents were used in 47 lesions (72%). Anticoagulation All patients received aspirin 325 mg and a calcium channel antagonist before stent implantation. Heparin (10 000 U) was administrated intra-arterially at the beginning of the proce- dure and was followed by intravenous infusion to maintain the activated clotting time .300 seconds. Low-molecular-weight dextran 40 (10%) was administrated (100 mLIhr for 2 hours) and continued at 50 mIlhr for a total dose of 1 L. The sheaths were pulled 1 day after the procedure. Patients were main- tained on a heparin infusion for 4 to 5 days until a therapeutic warfarin dose was achieved with a prothrombin time between 16 and 18 seconds. Patients stayed in the hospital for 7 days after the procedure. Dipyridamole and sodium warfarin were continued for 2 months. Insertion Procedure When the lesion was severe, predilatation was performed with a 2.0-mm balloon using standard percutaneous coronary angioplasty techniques. All stents were manually mounted on a balloon that matched the angiographic reference lumen diameter. The stent was then overdilated with a balloon approximately 0.5 mm larger than the reference lumen diam- eter. To avoid balloon inflation outside of the stented segment of the vessel, a 9-mm-long balloon (Short Speedy, Schneider Europe) was used for final dilatation. The final dilatation was performed at higher pressures, if necessary. The procedure end point was achieved when the operator determined that maximal stent expansion had occurred based on the angiographic evidence of a step up into the stented area and a step down into the distal unstented segment. Ordinarily, the procedure would be terminated at this point, but for the purpose of this study, IVUS imaging was then performed using a 3.9-F monorail system with a 25-MHz ultrasound transducer (Interpret Catheter, InterTherapy/CVIS). The imaging cathe- ter was positioned under fluoroscopic guidance distal to the stent, and images were recorded continuously as the catheter was withdrawn manually through the stented segment. After the stented area was interrogated with a single pullback, the catheter was repositioned to identify the tightest segments within the stented portion. If the operator and ultrasound reviewer believed that there was a possibility to improve stent expansion, further balloon dilatations were performed using a larger balloon or higher pressure. The initial concept was to obtain a lumen cross-sectional area (CSA) approximately 70% of the expected CSA of the chosen balloon. IVUS imaging and balloon dilatation were repeated until a satisfactory lumen area and uniform expansion were achieved or no further improvement could be obtained. Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on October 10, 2015
Journal of the American College of Cardiology | 1997
Shigeru Nakamura; Patrick Hall; Antonio Gaglione; Fabio Tiecco; Marinella Di Maggio; Luigi Maiello; Giovanni Martini; Antonio Colombo
OBJECTIVES The purpose of this study was to determine the efficacy of treatment with antiplatelet therapy and no anticoagulation after high pressure assisted coronary stent implantation performed without intravascular ultrasound (IVUS) guidance. BACKGROUND Previous studies have shown that during IVUS-guided Palmaz-Schatz coronary stenting, it is safe to withhold anticoagulation when stent expansion has been optimized by high pressure balloon dilation. METHODS Patients that had successful coronary stenting without IVUS guidance were treated with ticlopidine, 500 mg/day, and aspirin, 325 mg/day, for 1 month and then received only aspirin, 325 mg/day, indefinitely. Patients were not treated with warfarin (Coumadin) or heparin after successful stenting. Clinical and angiographic events were assessed at 1 month. RESULTS A total of 201 intracoronary stents were implanted in 127 patients with 137 lesions. The average number of stents per lesion was 1.4 +/- 0.8, and the average number of stents per patient was 1.6 +/- 1.1. Stent deployment was performed for elective indications in 79% of procedures and for emergency indications in 21%. There were four stent thrombosis events for a per patient event rate of 3.1% and a per lesion event rate of 2.9%. CONCLUSIONS After high pressure assisted stenting performed without IVUS guidance, there was an acceptable incidence of 3.1% of stent thrombosis with the combination of short-term ticlopidine and aspirin therapy and no anticoagulation. Although the study involved only 127 patients, the results support the relative safety of stenting without IVUS guidance and with antiplatelet therapy only in comparison to historical trials on stenting performed with postprocedure anticoagulation.
Journal of the American College of Cardiology | 1989
Alessandro Santo Bortone; Otto M. Hess; Adele Chiddo; Antonio Gaglione; Nicola Locuratolo; Gilda Caruso; Paolo Rizzon
Passive diastolic properties of the left ventricle were determined in 10 control subjects and 12 patients with dilated cardiomyopathy. Simultaneous left ventricular angiography and high fidelity pressure measurements were performed in all patients. Left ventricular chamber stiffness was calculated from left ventricular pressure-volume and myocardial stiffness from left ventricular stress-strain relations with use of a viscoelastic model. Patients with dilated cardiomyopathy were classified into two groups according to the diastolic constant of myocardial stiffness (beta). Group 1 consisted of seven patients with a normal constant of myocardial stiffness less than or equal to 9.6 (normal range 2.2 to 9.6) and group 2 of 5 patients with a beta greater than 9.6. Structural abnormalities (percent interstitial fibrosis, fibrous content) in patients with dilated cardiomyopathy were assessed by morphometry from right ventricular endomyocardial biopsies. Heart rate was similar in the three groups. Left ventricular end-diastolic pressure was significantly greater in patients with cardiomyopathy (18 mm Hg in group 1 and 22 mm Hg in group 2) than in the control patients (10 mm Hg). Left ventricular ejection fraction was significantly lower in groups 1 (37%) and 2 (36%) than in the control patients (66%). Left ventricular muscle mass index was significantly increased in both groups with cardiomyopathy. The constant of chamber stiffness (beta*) was slightly although not significantly greater in groups 1 and 2 (0.58 and 0.58, respectively) than in the control group (0.35). The constant of myocardial stiffness beta was normal in group 1 (7.0; control group 6.9, p = NS) but was significantly increased in group 2 (23.5). Interstitial fibrosis was 19% in group 1 and 43% (p less than 0.001) in group 2 (normal less than or equal to 10%). There was an exponential relation between both diastolic constant of myocardial stiffness (beta) and interstitial fibrosis (IF) (r = 0.95; p less than 0.001) and beta and fibrous content divided by end-diastolic volume index (r = 0.93; p less than 0.001). It is concluded that myocardial stiffness can be normal in patients with dilated cardiomyopathy despite severely depressed systolic function. Structural alterations of the myocardium with increased amounts of fibrous tissues are probably responsible for the observed changes in passive elastic properties of the myocardium in patients with dilated cardiomyopathy. The constant of myocardial stiffness (beta) helps to identify patients with severe structural alterations (group 2), representing possibly a more advanced stage of the disease.
American Journal of Cardiology | 2002
Konstantinos Toutouzas; Goran Stankovic; Takuro Takagi; Vassilis Spanos; Carlo DiMario; Remo Albiero; Nicola Corvaja; Antonio Gaglione; Antonio Colombo
three-dimensional coronary MR angiography. Radiology 1996;198:55–60. 16. Post JC, van Rossum AC, Hofman MB, Valk J, Visser CA. Three-dimensional respiratory-gated MR angiography of coronary arteries: comparison with conventional coronary angiography. AJR Am J Roentgenol 1996;166:1399–1404. 17. Muller MF, Fleisch M, Kroeker R, Chatterjee T, Meier B, Vock P. Proximal coronary artery stenosis: three-dimensional MRI with fat saturation and navigator echo. J Magn Reson Imaging 1997;7:644–651. 18. Huber A, Nikolaou K, Gonschior P, Knez A, Stehling M, Reiser M. Navigator echo-based respiratory gating for three-dimensional MR coronary angiography: results from healthy volunteers and patients with proximal coronary artery stenoses. AJR Am J Roentgenol 1999;173:95–101. 19. Sandstede JJ, Pabst T, Beer M, Geis N, Kenn W, Neubauer S, Hahn D. Three-dimensional MR coronary angiography using the navigator technique compared with conventional coronary angiography. AJR Am J Roentgenol 1999; 172:135–139. 20. Kim WY, Danias PG, Stuber M, Flamm SD, Plein S, Nagel E, Langerak SE, Weber OM, Pedersen EM, Schmidt M, Botnar RM, Manning WJ. Coronary magnetic resonance angiography for the detection of coronary stenoses. N Engl J Med 2001;345:1863–1869.
Cardiovascular Drugs and Therapy | 1991
Adele Chiddo; Antonio Gaglione; Sergio Musci; Giuseppe Troito; Nicola Grimaldi; Nicola Locuratolo; Paolo Rizzon
SummaryPropionyl-L-carnitine was given intravenously to ten patients with chronic ischemic heart disease who had normal left ventricular function and had not had a previous myocardial infarction. Subsequently, pulmonary and systemic circulation, left ventricular function, and the relationship between the ventricle and afterload were evaluated. This drug, at a dose of 15 mg/kg, improves ventricular function by easing the load and by enhancing cardiac efficiency. The ejection impedance is reduced with a consequent increase in stroke volume as a result of a) a decrease in systemic and pulmonary resistance and b) an increase in arterial compliance. Arterial pressure is maintained due to an increase in total external heart power. Since the tension time index shows a proportionally smaller increase in the energy requirement, it follows that cardiac efficiency has been improved and ventricle-after load matching is optimal. These results suggest but do not prove that propionyl-L-carnitine exhibits a positive inotropic property.
Basic Research in Cardiology | 1991
Otto M. Hess; L. Felder; Antonio Gaglione; Martin Buechi; F. Vassalli; Zhihua Jiang; Joerg Grimm; H P Krayenbuehl
Coronary vasomotion and coronary blood flow are important determinants of myocardial perfusion in patients with coronary artery disease. New digital angiographic techniques allow to study, not only the dimensions of a stenotic lesion (quantitative coronary arteriography), but also coronary flow reserve (parametric imaging). In a preliminary study both techniques were combined and coronary dimensions, as well as coronary flow reserve were determined in 15 patients (seven normals and eight patients with coronary artery disease) at rest, 45 s after 10 mg i.c. papaverine, during two levels of supine bicycle exercise, as well as 5 min after 1.6 mg sublingual nitroglycerin. Our results show that with modern digital subtraction techniques, not only stenosis geometry, but also coronary flow reserve can be determined at rest and during exercise conditions.
Archive | 1985
Adele Chiddo; Antonio Gaglione; Donato Quagliara; Paolo Rizzon
Left ventricular function considerably affects prognosis and choice of treatment in patients with coronary artery disease (CAD). Nevertheless, a correct assessment of left ventricular (LV) performance, irrespective of the influence of pre- and after-load, is a hard and still unresolved problem, although solving it has been the aim of a number of clinical and experimental studies.
Catheterization and Cardiovascular Diagnosis | 1993
Antonio Colombo; Antonio Gaglione; Shigeru Nakamura; Leo Finci
Journal of the American College of Cardiology | 1987
Antonio Gaglione; Otto M. Hess; William J. Corin; Manfred Ritter; Joerg Grimm; Hans P. Krayenbuehl