Fabrice Leroy

Percutaneous transluminal coronary rotary ablation with rotablator (European experience)

This study reports the results from 3 European centers using rotary ablation with Rotablator, a device that is inserted into the coronary artery and removes atheroma by grinding it into millions of tiny fragments. Rotary ablation was performed in 129 patients. Primary success (reduction in percent luminal narrowing greater than 20%, residual stenosis less than 50%, without complications) was achieved by rotary angioplasty alone in 73 patients (57%). An additional 38 patients (29%) had successful adjunctive balloon angioplasty. Thus primary success was achieved in 111 patients (86%) at the end of the procedure. Acute occlusion occurred in 10 patients (7.7%). Recanalization was achieved by balloon angioplasty in 7: urgent bypass grafting was undertaken in 2. Q-wave and non-Q-wave myocardial infarction occurred in 3 and 7 patients, respectively. No deaths occurred. Follow-up angiography was performed in 74 patients (60%). Restenosis, defined as the recurrence of significant luminal narrowing (greater than 50%) occurred in 17 of 37 patients (46%) who underwent rotary ablation alone, and 11 of 37 patients (30%) who had adjunctive balloon angioplasty. The overall angiographic restenosis rate was 37.8%. In conclusion, rotary ablation is technically feasible, and relatively safe in the coronary circulation. The low primary success rate reflects the limited size of the device, which can be introduced through available guiding catheters, and limits the use of rotary ablation as a stand-alone procedure to lesions in small arteries or in distal locations. No reduction in restenosis was seen, but the role of this device combined with balloon angioplasty in larger arteries needs to be further defined.

Clinical characteristics and angiographie follow-up of patients undergoing early or late repeat dilation for a first restenosis

OBJECTIVE The aim of this study was to analyze the angiographic rate of recurrent restenosis in patients who underwent repeat coronary angioplasty for a first restenosis within 3 months or greater than 3 months after the first procedure. BACKGROUND Several studies that have examined risk factors for restenosis after coronary angioplasty have suggested that a short interval between a first angioplasty and a repeat procedure is associated with an increased risk for a second restenosis. METHODS Between January 1981 and December 1990, 423 patients underwent a repeat coronary angioplasty procedure because restenosis had occurred at the site of a successful first angioplasty procedure. The clinical characteristics, immediate outcome and angiographic rate of recurrent restenosis were compared in patients who underwent repeat dilation within 3 months (early redilation group, n = 77) or greater than 3 months (late redilation group, n = 346) after the first procedure. RESULTS The incidence of unstable angina at the time of the repeat procedure was significantly higher in the patients who underwent early redilation (42% vs. 8%, p = 0.0001). The procedural success rate (95%) and complication rate were similar in both groups. Follow-up angiography was performed in 86% of patients with an initially successful procedure. The incidence of restenosis was significantly higher in the group that underwent early redilation (56% vs. 37%, p = 0.007) and was similar in patients in this group who presented with stable (55%) or unstable (57%) angina. CONCLUSIONS Rapidly recurring coronary stenoses have an extremely high rate of restenosis when again treated by coronary angioplasty, irrespective of the clinical presentation at the time of repeat dilation. The outcome in patients with early restenosis who have stable angina might be improved by delaying the repeat procedure.

Prevention of coronary spasm by nicorandil: comparison with nifedipine.

The efficacy of nicorandil was compared with that of nifedipine in 13 patients with vasospastic angina enrolled in a randomized, placebo-controlled, crossover study. All patients had a coronary spasm during coronary arteriography, either spontaneously or ergometrine-induced. During two consecutive periods of 2 days, patients received active drugs or placebo in a randomized order. Each patient received single oral doses of 30 mg nicorandil, 10 mg nifedipine, and, on 2 days, a placebo. One hour after drug intake, patients underwent an ergometrine test with increasing doses of Methergin (ergometrine) (0.05,0.10, 0.20, and 0.40 mg every 5 min). After placebo, the tests always were positive, and the ECG changes occurred at the same ± 1 dose of ergometrine in 10 cases, showing good reproducibility. After nicorandil, the tests were negative in nine patients and positive for a higher or lower dose of ergometrine in three and one patient, respectively (p = 0.0034 vs. placebo). After nifedipine, the tests were negative in five patients and positive for a higher or the same dose of ergometrine in four and four patients, respectively (p = 0.0039 vs. placebo). Nifedipine (10 mg) and nicorandil (30 mg) were equally effective in eight patients; in the remaining five patients, nicorandil had better results (p = 0.06). Nicorandil (30 mg) prevents ergometrine-induced coronary spasm. This compound may be beneficial in patients with vasospastic angina.

Relative prognostic value of clinical, exercise, and angiographic data after a first myocardial infarction.

BackgroundStudies examining the relative value of clinical, exercise test, and angiographic data in the prediction of further clinical events after a first acute myocardial infarction (AMI) have produced conflicting results. MethodsWe examined the relative value of clinical, exercise test, and angiographic data as predictors of death, recurrent infarction, and the subsequent development of angina or dyspnea in 303 consecutive patients who underwent exercise testing and coronary angiography within 2 months of an uncomplicated first acute myocardial infarction (AMI), and who were followed for 48 (± 22) months. ResultsA combination of two clinical and two exercise variables correctly identified 79% of subsequent deaths. No variables had a predictive value for re-infarction. A combination of two exercise variables correctly identified 75% of patients who developed angina during follow up. A combination of two clinical variables and one exercise variable correctly identified 76% of patients who developed dyspnea during follow up. ConclusionsExercise testing provided useful prognostic information independent of clinical data. Combining clinical and exercise data identified a group of patients at low risk of future events. In this low-risk group of patients, the addition of angiographic data did not provide additional prognostic information.

Prognostic value of changes in R-wave amplitude during exercise testing after a first acute myocardial infarction

To investigate the prognostic value of exercise-induced changes in R-wave amplitude and their relation to other exercise and angiographic variables, 303 consecutive patients who underwent maximal exercise testing and coronary angiography within 2 months of a first acute myocardial infarction were studied. R-wave amplitude at peak exercise increased or was unchanged in 159 patients (57.4%) and decreased in 118 (42.6%). Increased R-wave amplitude was significantly related to underlying 3-vessel disease (p = 0.0001), the extent of ST-segment depression on exercise (p = 0.0001), and the time to 1 mm ST depression (p less than 0.05). Follow-up information was available in 285 patients (86.4%) at a mean of 4 +/- 1.8 years. Death from cardiac causes occurred in 25 patients (9%); 18 (6.5%) developed recurrent myocardial infarction, and 32 (11.6%) developed angina. Variables with a predictive value for cardiac death were maximal exercise heart rate (p = 0.0005), occurrence of exercise-related supraventricular arrythmia (p = 0.02), and number of diseased vessels (p = 0.02). R-wave changes had no predictive value. No variable had a predictive value for recurrent infarction. Maximal exercise heart rate (p = 0.02) and increased R-wave amplitude (p = 0.0001) were significantly related to the occurrence of angina at follow up. Exercise-related R-wave increases were associated with the presence of angina at follow-up, but had no predictive value for cardiac death or recurrent infarction; their association with subsequent angina appears to reflect an association with more severe underlying coronary disease.

Quantitative assessment of the residual stenosis after percutaneous transluminal cororonary rotary ablation: European Experience

Quantitative assessment of the residual stenosis after percutaneous transluminal coronary rotary ablation was performed in a population of 77 patients who underwent Rotary ablation in 3 European Centers.