Donald Rothbaum

Emergency percutaneous transluminal coronary angioplasty in acute myocardial infarction: a 3 year experience.

In 151 patients experiencing acute myocardial infarction, emergency coronary angioplasty was performed as primary therapy. Overall, angioplasty was successful in 132 patients (87%); it was successful in 91 (85%) of 107 patients with a totally occluded infarct-related artery and in 41 (93%) of 44 patients with a subtotally occluded infarct-related artery. After successful angioplasty, mean residual stenosis was 29% (range 0 to 70). Eighteen patients were in cardiogenic shock (12%) including four patients receiving cardiopulmonary resuscitation during the angioplasty procedure. Hospital mortality was 9%, with 7 of 13 deaths occurring in patients presenting with cardiogenic shock or intractable ventricular arrhythmia. Hospital mortality was 5% in patients with successful angioplasty versus 37% in those with unsuccessful angioplasty (p less than 0.001). In the immediate period after angioplasty, left ventricular ejection fraction was significantly lower for patients with lesions of the left anterior descending artery (34 +/- 10%) than for patients with lesions of the left circumflex or right coronary artery (43 +/- 11%). In patients with successful angioplasty, significant improvement in left ventricular ejection fraction averaged 13 +/- 12% (p less than 0.001) for those with lesions of the left anterior descending artery and 10 +/- 12% (p less than 0.001) for those with lesions of the left circumflex or right coronary artery. Repeat coronary angiography was performed in 85 (70%) of 121 patients who had successful angioplasty and survived hospitalization without requiring bypass surgery; restenosis was found in 26 (31%), and angioplasty was repeated in 22 patients, successfully in each.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term outcome after primary angioplasty: report from the Primary Angioplasty in Myocardial Infarction (PAMI-I) trial

OBJECTIVES This study sought to compare the two-year outcome after primary percutaneous coronary angioplasty or thrombolytic therapy for acute myocardial infarction. BACKGROUND Primary angioplasty, that is, angioplasty without antecedent thrombolytic therapy, has been shown to be an effective reperfusion modality for patients suffering an acute myocardial infarction. This report reviews the two-year clinical outcome of patients randomized in the Primary Angioplasty in Myocardial Infarction trial. METHODS At 12 clinical centers, 395 patients who presented within 12 h of the onset of myocardial infarction were randomized to undergo primary angioplasty (195 patients) or to receive tissue-type plasminogen activator (t-PA) (200 patients) followed by conservative care. Patients were followed by physician visits, phone call, letter and review of hospital records for any hospital admission at one month, six months, one year and two years. RESULTS At two years, patients undergoing primary angioplasty had less recurrent ischemia (36.4% vs. 48% for t-PA, p = 0.026), lower reintervention rates (27.2% vs. 46.5% for t-PA, p < 0.0001) and reduced hospital readmission rates (58.5% vs. 69.0% for t-PA, p = 0.035). The combined end point of death or reinfarction was 14.9% for angioplasty versus 23% for t-PA, p = 0.034. Multivariate analysis found angioplasty to be independently predictive of a reduction in death, reinfarction or target vessel revascularization (p = 0.0001). CONCLUSIONS The initial benefit of primary angioplasty performed by experienced operators is maintained over a two-year follow-up period with improved infarct-free survival and reduced rate of reintervention.

Status of the myocardium and infarct-related coronary artery in 19 necropsy patients with acute recanalization using pharmacologic (streptokinase, r-tissue plasminogen activator), mechanical (percutaneous transluminal coronary angioplasty) or combined types of reperfusion therapy.

In acute myocardial infarction, myocardial salvage is dependent on rapid restoration of blood flow. Pharmacologic (streptokinase, recombinant tissue-type plasminogen activator), mechanical (percutaneous transluminal coronary angioplasty, guide wire perforation) or combined forms of reperfusion therapy can accomplish this goal, but their effects on infarcted myocardium and vessel occlusion site have not been compared at necropsy. The heart of 19 necropsy patients who had received various forms of acute reperfusion therapy was studied: 14 had pharmacologic or combined forms of reperfusion therapy (13 streptokinase and 1 tissue-type plasminogen activator, including 4 with combined balloon angioplasty) and 5 had had purely mechanical (balloon angioplasty) reperfusion therapy. Reperfusion was initially clinically successful in all 19 patients with the average time from onset of symptoms to reperfusion being 3.7 hours. Necropsy observations separated the 19 patients into distinct subgroups based on changes in the myocardium and infarct-related coronary arteries. Of the 19 patients, 14 (74%) had hemorrhagic myocardial infarction and they all received pharmacologic or combined forms of reperfusion therapy. The remaining five patients (26%) had nonhemorrhagic (anemic) infarction and were treated with balloon angioplasty therapy alone. Increased luminal cross-sectional area was present in 8 of 9 patients with acute balloon angioplasty but severe coronary atherosclerotic plaque remained in 9 of 10 patients without acute balloon angioplasty. Severe hemorrhage surrounded angioplasty sites in all four patients who also received streptokinase or tissue-type plasminogen activator. Severe bleeding at the angioplasty site compromised the dilated coronary lumen in one patient. No patient with angioplasty alone had intraplaque bleeding. Thus, acute coronary balloon angioplasty reperfusion therapy alone appears to avoid the potentially adverse effects of myocardial and intraplaque hemorrhage while simultaneously increasing luminal cross-sectional area at the site of acute occlusion.

Percutaneous excimer laser coronary angioplasty

To determine the efficacy of percutaneous excimer laser coronary angioplasty as an adjunct or alternative to conventional balloon angioplasty, 55 patients were studied in a multicenter trial. These patients underwent the procedure using a modification of conventional balloon angioplasty technique. A first-generation, 1.6-mm diameter catheter constructed of 12 individual silica fibers concentrically arranged around a guidewire lumen was used. Catheter tip energy density varied from 35 to 50 mJ/mm2. The mean number of pulses delivered at 20 Hz was 1,272 +/- 1,345. Acute success was defined as a greater than or equal to 20% increase in stenotic diameter and a lumen of greater than or equal to 1 mm in diameter after laser treatment. Acute success was achieved in 46 of 55 (84%) patients. Adjunctive balloon angioplasty was performed on 41 patients (75%). The percent diameter stenosis as determined by quantitative angiography decreased from a baseline of 83 +/- 14 to 49 +/- 11% after laser treatment and to 38 +/- 12% in patients undergoing adjunctive balloon angioplasty. The mean minimal stenotic diameter increased from a baseline of 0.5 +/- 0.4 to 1.6 +/- 0.5 mm after laser treatment and to 2.1 +/- 0.5 mm after balloon angioplasty. There were no deaths and no vascular perforations. One patient (1.8%) required emergency coronary bypass surgery. These data suggest that excimer laser energy delivered percutaneously by specially constructed catheters can safely ablate atheroma and reduce coronary stenoses.

Benefits of a Monitored Rehabilitation Program Versus Physician Care After Emergency Percutaneous Transluminal Coronary Angioplasty: Follow-up of Risk Factors and Rate of Restenosis

To evaluate the effect 1of a monitored rehabilitation program on restenosis after successful emergency percutaneous transiuminal coronary angioplasty (PTCA), the authors compared the results of a rehabilitation group (N = 60) with a matched group (N = 68) of patients who received the usual post-PTCA care provided by their physician or cardiologist. The rehabilitation group trained for 12 weeks, 2 to 3 times/week for 45 to 60 minutes each on a variety of stationary equipment at a heart rate of 70 to 85% of the age-predicted maximum. They also underwent an 8-session educational program and 6 months follow-up of risk factors for secondary prevention of coronary artery disease (CAD). Because the majority of patients who restenose do so during the first 6 months after PTCA, the study was terminated 5 ± 1 months after the procedure. Between groups comparison after 5.5 ± 1 months showed: 1) significantly (T

901-1 A Prospective, Randomized Trial Evaluating Early Discharge (Day 3) without Non-invasive Risk Stratification in Low Risk Patients with Acute Myocardial Infarction: PAMI-2

Few data exist regarding the need for noninvasive testing after reperfusion therapy in myocardial patients at low clinical risk. Moreover, after thrombolysis, recurrent ischemia occurs frequently and unpredictably and has resulted in physician reluctance to shorten the length of hospitalization in these patients. Alternatively, emergency catheterization with primary PTCA may provide acute determination of risk status, a stable method of reperfusion and the potential for early discharge. The objective of this multicenter study was to prospectively test the hypothesis that early discharge (day 3) without noninvasive risk stratification in low risk MI patients treated with primary angioplasty is safe, feasible, and cost effective. Patients with acute myocardial infarction 0–12 hrs who had an emergency catheterization and immediate PTCA of the infarct related artery were stratified into a low risk group if age ≤70 yrs, 1 or 2 vessel disease, EF g 45%, successful infarct vessel PTCA and no malignant arrhythmias persisted after the PTCA. Low risk patients were randomized to admission to either the intensive care unit (with hospitalization a minimum of 5 days and predischarge exercise testing) or admission to a non-intensive care PTCA unit with no non-invasive testing and discharge on day 3. To date, 340 of the anticipated 400 patients have been enrolled. The mean age was 56 ± 9, estimated ejection fraction 56 ± 9 and 74% had single vessel disease. As expected, in-hospital complications occurred infrequently; death 1.1%, recurrent MI 1.7%; stroke 0.6%; heart failure 4.6%. At 1 week follow-up, no complications attributed to early discharge have occurred. Thus, acute catheterization does allow identification of low risk MI patients who can be safely admitted to an elective PTCA unit and discharged in 3 days without additional testing. Complete data on the 400 patient cohort including cost and 6 week follow-up will be available by March 1995.

Comparison of results of percutaneous balloon valvuloplasty in patients with mild and moderate mitral stenosis to those with severe mitral stenosis

Most reported studies of percutaneous balloon valvuloplasty in adults with acquired mitral stenosis have used patients with severely stenosed valves. The risks and benefits of valvuloplasty were examined in a multicenter registry of patients to determine whether balloon valvuloplasty can effectively dilate less severely obstructed valves, and to clarify the role of this procedure in symptomatic patients with mild and moderate mitral stenosis. The study groups were derived from the North American Inoue Balloon Valvuloplasty Registry. Full hemodynamic data were available in 264 patients; 45 (17%) with mild or moderate mitral stenosis (mitral valve area > or = 1.3 cm2) were compared with the remaining 219 with severe mitral stenosis (valve area < 1.3 cm2). Percutaneous balloon valvuloplasty was performed using the anterograde transseptal technique with an Inoue balloon. The mean age of patients with mild and moderate mitral stenosis was 53 +/- 13 years, and all were symptomatic with a mean New York Heart Association functional class of 2.9 +/- 0.7. Balloon valvuloplasty resulted in an increase in calculated mitral valve area from 1.4 +/- 0.1 to 2.3 +/- 0.7 cm2 (p < 0.05), and a final valve area > or = 1.9 cm2 was achieved in 37 patients (82%). There were no procedural deaths, but complications included right atrial perforation, transient ischemic attack and emergency surgery for severe mitral regurgitation. One-year follow-up evaluation revealed symptomatic improvement in most patients (mean New York Heart Association class 1.4 +/- 0.6; p < 0.0001). However, 2 patients needed repeat valvuloplasty for restenosis, and 5 had mitral valve replacements.(ABSTRACT TRUNCATED AT 250 WORDS)

Return to Work After Successful Coronary Angioplasty: Comparison Between a Comprehensive Rehabilitation Program and Patients Receiving Usual Care

The effects of a 12-week exercise training and cardiac education program on short-term and long-term employment and realted measures of quality of life were compared in a nonrandomized study. Eighty-three trained patients and 92 patients who received, usual physician care (usual care) after successful percutaneous transluminal coronary angioplasty (PTCA) were studied. Data, were collected from medical files and by a before-and-after PTCA questionnaire. At baseline, groups did not differ with respect to age, medical status, occupational status, level of income, presence of risk factors for coronary disease, and patients perception of health. Of those working full time before PTCA, 11% of the patients in the trained group and 23% of the patients in the usual care group did not resume their work status after 18 months of follow-up. At 18 months after PTCA, 37% of the trained vs 52% of the usual care patients quit working (P