Ebo D. de Muinck

Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction

OBJECTIVES The study assessed the value of the electrocardiogram (ECG) as predictor of the left anterior descending coronary artery (LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1) in patients with acute anterior myocardial infarction (AMI). BACKGROUND In anterior AMI, determination of the exact site of LAD occlusion is important because the more proximal the occlusion the less favorable the prognosis. METHODS One hundred patients with a first anterior AMI were included. The ECG showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site as determined by coronary angiography. RESULTS ST-elevation in lead aVR (ST elevation(aVR)), complete right bundle branch block, ST-depression in lead V5 (ST depression(V5)) and ST elevation(V1) > 2.5 mm strongly predicted LAD occlusion proximal to S1, whereas abnormal Q-waves in V4-6 were associated with occlusion distal to S1 (p = 0.000, p = 0.004, p = 0.009, p = 0.011 and p = 0.031 to 0.005, respectively). Abnormal Q-wave in lead aVL was associated with occlusion proximal to D1, whereas ST depression(aVL) was suggestive of occlusion distal to D1 (p = 0.002 and p = 0.022, respectively). For both the S1 and D1, inferior ST depression > or = 1.0 mm strongly predicted proximal LAD occlusion, whereas absence of inferior ST depression predicted distal occlusion (p < or = 0.002 and p < or = 0.020, respectively). CONCLUSIONS In anterior AMI, the ECG is useful to predict the LAD occlusion site in relation to its major side branches.

AUTOPERFUSION BALLOON VERSUS STENT FOR ACUTE OR THREATENED CLOSURE DURING PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

Efficacy and major clinical end points were compared in 61 patients treated with a Stack autoperfusion balloon versus 36 patients who received a Palmaz-Schatz stent for acute or threatened closure during coronary angioplasty. The groups were comparable regarding baseline clinical characteristics. Procedural success was achieved in 43 patients (70%) treated with an autoperfusion balloon versus 34 patients (94%) who received a stent (p < 0.02). Emergency bypass surgery was performed in 13 patients (21%) with the autoperfusion balloon versus none of the patients with a stent (p < 0.001). In the stent group, 3 patients (8%) died (p < 0.05); 2 deaths were caused by thrombotic reclosure, and 1 patient died after unsuccessful stent delivery. Subacute reclosure during hospitalization occurred in none of the patients with autoperfusion versus 8 patients with the stent (22%) (p < 0.0002). Therefore, the number of patients with successful stent implantation at discharge decreased to 26 (72%). At 3-month follow-up in all patients with a successful intervention, reclosure or angiographic restenosis (> 50%) occurred in 13 patients with autoperfusion (30%) versus 3 patients with stents (12%) (p = NS). There was no difference in event-free survival during follow-up. Thus, both interventions were equally successful in the treatment of acute and threatened closure. More emergency surgery was performed in the autoperfusion balloon group, whereas a higher subacute reclosure rate was seen in the stent group. At 3-month follow-up, there were no significant differences regarding reclosure, restenosis, and event-free survival.

Ten-Year Experience With Early Angioplasty in 759 Patients With Acute Myocardial Infarction

OBJECTIVES How effective and safe is rescue percutaneous transluminal coronary angioplasty [PTCA] compared with primary PTCA, and is it cost effective? BACKGROUND In acute myocardial infarction (AMI), primary PTCA has been shown to be beneficial in terms of clinical outcome. In contrast, the value of rescue PTCA has not been established. METHODS In a retrospective analysis, we compared the angiographic and clinical outcomes of 317 consecutive patients who had rescue PTCA approximately 90 min after failed thrombolysis and 442 patients treated with primary PTCA. An estimation of interventional costs was compared with the strategies of primary and rescue PTCA or with the strategy of thrombolysis with rescue PTCA, when indicated. RESULTS Baseline characteristics between primary and rescue PTCA were comparable for most variables. Treatment delay was longer for patients who had rescue PTCA: 240 min. versus 195 min. Coronary patency after PTCA was comparable: 90.2% for rescue PTCA and 91.4% for primary PTCA (p = 0.67, power 71.9%). In-hospital mortality rates were 4.7% and 6.6%, respectively (p = 0.37). Also, the other complications were fairly similar during the in-hospital phase and during one-year follow-up. Predictors of death were age, infarct size, localization of AMI, failed PTCA and left main stem occlusion. The estimated interventional costs during one-year follow-up were

LATE ONSET ATRIOVENTRICULAR NODAL TACHYCARDIA

7,377 for primary PTCA and

Autoperfusion balloon catheter for complicated coronary angioplasty: a prospective study with retrospective controls

8,246 for rescue PTCA: difference

Electrophysiologic and antiarrhythmic effects of intravenous bisoprolol in atrioventricular nodal reentry tachycardia

869 (11.7%). CONCLUSIONS In this retrospective analysis of 759 patients with AMI, rescue angioplasty early after failed thrombolysis seems to be as effective and safe as primary PTCA. In the present evaluation, interventional costs of primary PTCA are less than those of rescue PTCA (p = 0.0001).

IN-VITRO EVALUATION OF THE INFLUENCE OF PULSATILE INTRAVENTRICULAR PUMPING ON VENTRICULAR PRESSURE PATTERNS

AV nodal tachycardia may present at any age, but onset in late adulthood is considered uncommon. To evaluate whether onset of AV nodal tachycardias at older age is related to organic heart disease (possibly setting the stage for re-entry due to degenerative structural changes) 32 consecutive patients with symptomatic AV nodal tachycardia were studied. The age at onset of attacks showed a bimodal pattern, with 2 peaks: one between 15 and 35 years (22 patients) and one around 55 years (10 patients). Significantly more older patients had an underlying heart disease (60% versus 14%, P < 0.01), with coronary artery disease in 4 and hypertensive heart disease in 3. Frequent supraventricular ectopic activity was seen during baseline 24-h ambulatory monitoring in all the older patients, versus in only half of the younger patients (P = 0.005). These results indicate that late onset AV nodal tachycardia (i.e. > age 45 years) is not infrequent (33%). The frequent supraventricular arrhythmias on one hand and age-related structural AV nodal changes, potentially enhanced by underlying heart disease on the other, both may contribute to the development of late onset re-entrant AV nodal tachycardia.

720-5 Perfusion Balloon versus Stent for Acute or Threatened Closure: Equal Efficacy but Higher Mortality and Costs After Stenting

Prolonged angioplasty balloon inflation with an autoperfusion balloon for failed conventional coronary angioplasty, was compared with emergency surgery for this condition. Restenosis was assessed 6 weeks after successful intervention with the autoperfusion balloon. Forty consecutive patients with persistent acute occlusion and/or severe intimal dissection during conventional angioplasty, were treated with the autoperfusion balloon. They were candidates for emergency surgery if it failed. Total inflation time was significantly longer (p < 0.001) with the autoperfusion balloon (27.5; 10-180 min) than with the standard balloon (10; 1-20 min) (median; range). The number of inflations was significantly lower (p < 0.001) with the autoperfusion balloon (2; 1-5 times) than with the standard balloon (5; 2-14 times) (median; range). Two patients died, one before surgery could be performed. The autoperfusion balloon was successful in 26 patients (65%). After 6 weeks, 16 (62%) were asymptomatic without anti-anginal medication, 24 underwent repeat angiography, 10 (42%) had restenosis, 7 (27%) underwent elective bypass surgery. Emergency surgery remained necessary in 13 patients (33%), 9 received arterial grafts. In 31 retrospective controls, who had undergone immediate surgery for the same indication, only venous grafts could be used. Thus, prolonged autoperfusion balloon inflation was successful in 65% of the cases of failed, conventional angioplasty. The angiographic restenosis rate after 6 weeks was 42%. If emergency surgery remained necessary, the autoperfusion balloon facilitated the use of arterial bypass grafts.

infarction Ten-year experience with early angioplasty in 759 patients with acute myocardial

Abstract Beta-blockade may be useful in the termination and prevention of atrioventricular nodal reentry tachycardia (AVNRT). An electrophysiologic study was performed in 9 patients (4 men and 5 women; mean ± SD age, 56 ± 16 years) with documented AVNRT before and after the intravenous administration of 5 mg of bisoprolol. In 5 of the 9 patients, AVRNT was terminated by bisoprolol, and AVNRT could no longer be induced in 6 of the 9 patients. Bisoprolol significantly prolonged the Wenckebach cycle length but did not affect fast pathway refractoriness or atrioventricular (AV) nodal conduction time during sinus rhythm or various paced cycle lengths up to 430 milliseconds. Conversely, it significantly prolonged the mean atrium-His bundle (AH) interval during AVNRT from 244 ± 65 milliseconds to 320 ± 64 milliseconds. These observations suggest that the effects of bisoprolol on the AV node, primarily at short cycle lengths, are rate dependent. Due to AH prolongation, mean tachycardia cycle length significantly increased from 313 ± 58 milliseconds to 378 ± 50 milliseconds, but there was no difference in the relative amount of prolongation between responders (60.8 ± 26 ms) and nonresponders (64.6 ± 37 ms). Bisoprolol appears to be useful in the termination and prevention of AVNRT during programmed electrical stimulation studies. Its effects on the AV node are use dependent.