Conrad Simpfendorfer

Frequency, management and follow-up of patients with acute coronary occlusions after percutaneous transluminal coronary angioplasty

Angiograms from 1,500 consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) at the Cleveland Clinic were reviewed to determine the frequency of acute coronary occlusion after successful PTCA. Thirty-two patients (2%) had acute coronary occlusions. Of these, 27 (84%) presented within 6 hours. Compared with control group, only the presence of eccentric lesions (72% vs 24%) and intimal tears (78% vs 34%) was more predominant in the group with acute occlusion. Redilation was attempted in 31 patients and was successful in 27 (87%). Nine of these patients eventually required coronary bypass surgery and 18 were discharged and followed for 11 to 34 months (mean 18). Thus, redilation is a safe and effective approach to manage patients in whom coronary occlusion develops after PTCA.

Laparoscopic Lysis of Adhesions

BackgroundIntra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen.MethodsThe purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique.ResultsThe most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%–93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%–2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4–6 days in most series.ConclusionsLaparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.

Efficacy and Safety of a Hemostatic Puncture Closure Device With Early Ambulation After Coronary Angiography fn1

Abstract A collagen hemostatic puncture closure device has been developed as an alternative to traditional manual pressure techniques for achieving effective femoral arterial hemostasis after coronary angiography. The purpose of the current study was to determine if patients receiving this device can ambulate safely at 1 hour compared with patients receiving traditional manual pressure and bed rest after sheath removal for diagnostic cardiac catheterization. Patients (n = 304) were randomized to either the device group (n = 202) with ambulation at 1 hour after sheath removal or to the manual pressure control group (n = 102) with ambulation at 4 to 6 hours after sheath removal. The device group achieved earlier time to hemostasis (0.9 ± 3 vs 17.0 ± 8 minutes, p = 0.0001) and faster time to outpatient discharge (5.0 ± 4 vs 7.7 ± 4 hours, p = 0.0001) compared with the control group. There were bleeding or vascular complications in 19 patients (9%) in the device group and in 6 patients (6%) in the manual pressure group (p = 0.397). In patients undergoing diagnostic coronary angiography, this device, compared with traditional techniques for achieving hemostasis after sheath removal, allows for faster time to effective hemostasis with resultant earlier discharge from the hospital.

First chronic platelet glycoprotein IIb/IIIa integrin blockade. A randomized, placebo-controlled pilot study of xemilofiban in unstable angina with percutaneous coronary interventions.

BACKGROUND Clinical studies have demonstrated the efficacy of intravenous administration of agents that block platelet glycoprotein IIb/IIIa receptors in the setting of percutaneous coronary revascularization. Although the optimal duration of treatment has not been determined, more prolonged receptor blockade has been associated with increased efficacy. Orally active glycoprotein IIb/IIIa receptor antagonists may be advantageous and required for chronic therapy. METHODS AND RESULTS Thirty patients with unstable angina who were undergoing percutaneous coronary interventions were randomized to placebo or Xemilofiban 35 mg orally before and 20 to 25 mg TID for 30 days after angioplasty. Bleeding events, platelet aggregation, and pharmacokinetic and hematologic parameters were assessed during hospitalization and at 2 and 4 weeks after drug initiation. Xemilofiban produced a rapid, sustained, marked inhibition of platelet aggregation. ADP-induced platelet aggregation at 2 hours after the initial dose at 2 and 4 weeks was 15%, 8%, and 11% in the Xemilofiban group compared with 80%, 68%, and 69% in the placebo group. Among 20 patients randomized to Xemilofiban there was 1 death after emergency coronary bypass surgery complicated by severe bleeding diathesis, and 3 patients had major bleeding events. Patients on Xemilofiban for 30 days reported episodes of mild mucocutaneous bleeding. CONCLUSIONS Xemilofiban, an orally active glycoprotein IIb/ IIIa receptor inhibitor, produced rapid, sustained, extensive inhibition of platelet aggregation for a period of up to 30 days. At the dose initially tested, however, acute major bleeding and mucocutaneous bleeding during chronic administration were encountered.

An 11 year evolution of coronary arterial surgery (1967-1978)

All patients who underwent isolated myocardial revascularization procedures from 1967–70 (n = 741) were compared with the first 1,000 patients who received similar elective operations each year from 1971 through 1978. Data from these eight years were processed through a computerized cardiovascular information registry. Median age increased from 50 to 56 years, multiple-vessel disease increased from 44 to 89%, and left ventricular asynergy from 41 to 54%. The number of grafts per patient increased from 1.5 to 2.5 and yet morbidity declined in every category except neurologic deficit. Operative mortality was 1.1% from 1967 through 1978 and 0.9% from 1971 through 1978. Graft patency was determined for 475 patients from 1967–70, 553 patients from 1971, 519 from 1972, and 540 from 1973. Patency rates after a mean catheterization interval of 21 months were 77, 77, 84, and 87% respectively. Higher graft patency coincides with introduction of the internal mammary artery graft. Five year follow-up was completed for the 1967–1970 series and 1971, 1972, and 1973 cohorts. Actuarial five year survival was 89.6, 91.6, 93.2, and 91.7%. Five year survival comparisons between 1967–1970 patients and 1971–1973 patients in single-, double-, and triple-vessel disease categories show significant extended longevity in the later experience. Abnormal ventricular function and incomplete revascularization adversely influenced longevity (p < 0.05) in all years surveyed. In those series the percentage of asymptomatic patients at five years was 66, 65, 69, and 67%. Lower risk and higher five year survival are attributed to greater technical experience, changing technology, and improved management rather than to selection of lower risk cases.

Safety of femoral closure devices after percutaneous coronary interventions in the era of glycoprotein IIb/IIIa platelet blockade.

We compared in-hospital femoral complications of Angio-Seal, Perclose, and manual compression in consecutive patients who underwent percutaneous coronary interventions in the era of glycoprotein IIb/IIIa platelet inhibition. Femoral closure devices have a similar overall risk profile as manual compression, even in patients treated with glycoprotein IIb/IIIa platelet inhibition, although certain rare complications such as retroperitoneal hemorrhage and severe access-site infection may be more common with the use of these devices.

Percutaneous transluminal coronary angioplasty after previous coronary artery bypass surgery

To improve symptomatic status and avoid repeat coronary artery bypass graft surgery (CABG), 115 lesions were approached for transluminal coronary angioplasty (PTCA) in 94 patients (82 men, 12 women) with angina pectoris and prior CABG at a mean of 60 months (range 4 to 192) after CABG. Fifteen patients were in Canadian Cardiovascular Society functional class I, 32 were in class II, 31 were in class III, and 16 were in class IV. Patients were 37 to 76 years old (mean 57). PTCA was successful (at least a 40% reduction in stenosis diameter and improvement in symptomatic status) in 83 patients (88%) and 103 (90%) lesions. Mean stenosis was reduced from 80 +/- 14% to 20 +/- 16% (mean +/- standard deviation) and mean pressure gradient from 41 +/- 7 mm Hg to 14 +/- 6 mm Hg. Seven patients had lesions that could not be crossed for technical reasons and these patients underwent non-emergency CABG. Four patients required emergency CABG after PTCA; 1 patient subsequently died and 2 survived acute myocardial infarction. One patient had a femoral artery laceration, which required surgical repair. At a mean follow-up of 8 +/- 4 months, 63 patients (76%) with initially successful results were free of angina or in improved condition. Of the remaining 20 patients, 18 consented to repeat coronary angiography. Four patients did not have restenosis. Of the 14 patients with documented restenosis, 5 underwent successful repeat PTCA, 5 had repeat CABG, and 4 were treated medically. Thus, when coronary anatomy is suitable, PTCA is an effective alternative to reoperation in symptomatic patients with prior CABG.

Gender differences for coronary angioplasty

To determine if differences in early and late outcome after angioplasty were related to gender or body surface area, 5,000 consecutive patients (1,274 women and 3,726 men) were studied. Baseline variables, procedural outcome, and long-term and event-free survival were assessed. Baseline variables included age, history of hypertension, diabetes mellitus, heart failure, myocardial infarction, prior angioplasty or bypass surgery, familial coronary disease, Canadian heart classification, extent of angioplasty, left ventricular function, and body surface area. Overall and event-free survival (freedom from infarction, repeat angioplasty, bypass surgery and death) were assessed at follow-up. The results showed that, compared with men, women were older (p < 0.0001), had a higher prevalence of diabetes (p < 0.0001), familial coronary disease (p = 0.002), hypertension (p < 0.0001), prior infarction (p = 0.004), and more involvement of the anterior descending artery (p = 0.017). Whereas men had similar extents of angioplasty and worse left ventricular function (p = 0.012), women more often had unstable angina (p < 0.0001). The success rates were similar, yet women had a higher procedural mortality (1.1% women, 0.3% men, p = 0.001). When corrected for body surface area, however, women were at no greater risk than men. Follow-up was complete for 97.4% of patients (mean 4 +/- 2 years). Event-free survival was significantly better in women, even after correcting for body surface area. Men were at higher risk for late death and repeat angioplasty on follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and 1-year survival rates in acute myocardial infarction complicated by cardiogenic shock : a retrospective study comparing coronary angioplasty with medical treatment

Cardiogenic shock remains a frequently lethal complication of acute myocardial infarction. Early revascularization of the infarct-related artery by coronary angioplasty has been suggested to significantly improve patient survival. In-hospital and 1-year survival was assessed in 50 patients hospitalized for acute myocardial infarction complicated by cardiogenic shock. All patients received medical treatment and intraaortic balloon pump support. Thirty-three patients underwent coronary angioplasty (PTCA group), while 17 patients remained on conventional therapy (no PTCA group). The two groups were comparable for all baseline characteristics. Survival was significantly better in the PTCA group than in the no PTCA group: 64% versus 24% in-hospital survival (p = 0.007) and 52% versus 12% at 1 year (p = 0.006). When angioplasty was successful in achieving reperfusion, survival was further enhanced: in-hospital survival rate was 76% versus 25% in patients with unsuccessful angioplasty and 60% versus 25% at 1 year.

Digital subtraction fluoroscopy: a new method of detecting coronary calcifications with improved sensitivity for the prediction of coronary disease.

The association between calcification of the coronary arteries and coronary artery narrowing is well established. However, fluoroscopic visualization of coronary calcifications has been insufficiently sensitive to be useful as a screening test. Since digitization of radiographic images permits the subtraction of noncardiac structures from moving cardiac structures, such subtraction might increase the sensitivity of coronary fluoroscopy. To determine whether coronary calcifications were better visualized with digital subtraction fluoroscopy than with conventional fluoroscopy, we taped diseased human coronary arteries to a pulsating water balloon inside the thorax of a dog cadaver and studied this model with both fluoroscopic techniques. Calcific atherosclerotic plaques were more easily identified with digital subtraction fluoroscopy than with conventional fluoroscopy. We tested the method clinically by submitting 191 subjects without history or electrocardiographic evidence of previous myocardial infarction who were referred for coronary arteriography to both fluoroscopic studies. For at least one, at least two, and three calcified coronary arteries, digital fluoroscopy was more sensitive (92%, 66%, and 40%) than conventional fluoroscopy (63%, 21%, and 2%) (all p less than .001) for the prediction of significant coronary obstructions (greater than 50%). Although digital fluoroscopy was less specific than conventional fluoroscopy (digital: 65%, 89%, and 97%; conventional: 81%, 98%, and 100%) (all but last, p less than .01), receiver operating curve analysis revealed a significantly larger area under the curve, indicating higher accuracy for the digital technique (p = .03). Digital subtraction fluoroscopy was more accurate in younger than in older patients.(ABSTRACT TRUNCATED AT 250 WORDS)