Henry S. Cabin

Risk for systemic embolization of atrial fibrillation without mitral stenosis

The risk for systemic embolization was studied in 272 patients without mitral stenosis or prosthetic valves who were referred to the echocardiography laboratory with atrial fibrillation (AF). During a mean follow-up period of 33 months (range less than 1 to 83), 27 (10%) patients had a systemic embolic event, which was cerebral in 23 patients (85%) and peripheral in 4 (15%). In the analysis of individual variables, the risk of embolization was increased by female sex, underlying heart disease and left atrial size greater than or equal to 4.0 cm, but not by age, hypertension or type of AF (paroxysmal vs chronic). In multivariable analysis, left atrial size greater than or equal to 4.0 cm was the single strongest predictor of increased risk for embolization (p less than 0.001), but female sex (p = 0.014) and underlying heart disease (p = 0.027) also contributed. When each of these 3 factors was assigned 1 point in a risk score, embolic events were found to occur in none (0%) of 24 patients with a risk score of 0, in 2 (3%) of 83 patients with a risk score of 1, in 13 (11%) of 118 patients with a risk score of 2 and in 12 (26%) of 47 patients with a risk score of 3. The score allows patients with AF and without mitral stenosis to be stratified into high-, medium- and low-risk groups for systemic embolization. Such information could be useful in decision making for anticoagulation in patients with AF.

Modulation of circulating cellular adhesion molecules in postmenopausal women with coronary artery disease

OBJECTIVESnThe present study examined the association of estrogen (E2) and the inflammatory response of endothelium in coronary artery disease (CAD) by measuring circulating cellular adhesion molecules (cCAMs) in subjects with atherosclerosis.nnnBACKGROUNDnAtherosclerotic plaque demonstrates features similar to inflammation. Endothelial cell activation by inflammatory cytokines induces expression of cellular adhesion molecules (CAMs), thereby perhaps augmenting leukocyte adhesion and recruitment and subsequent development of atherosclerosis. The incidence of CAD is lower in women; this may be due to the cardioprotective effects of E2.nnnMETHODSnConsecutive eligible subjects with CAD admitted for cardiac catheterization were studied. The groups evaluated were men, postmenopausal women receiving E2 replacement therapy (ERT), postmenopausal women not receiving ERT and premenopausal women. Control groups included men and women without CAD. Preprocedural blood samples were drawn from all groups. Measurements of cCAMs, E-selectin, vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 were performed by enzyme-linked immunoabsorbant assay. E2 levels were assessed by radioimmunoassay.nnnRESULTSnWe observed a statistically significant increase in all cCAMs in men with CAD and postmenopausal women with CAD not receiving ERT compared with postmenopausal women with CAD receiving ERT. Premenopausal women with CAD and postmenopausal women with CAD receiving ERT had a significant increase in VCAM-1 alone compared with the female control group.nnnCONCLUSIONSnA possible mechanism by which E2 exerts one of its cardioprotective effects is by limiting the inflammatory response to injury by modulating the expression of CAMs from the endothelium.

Right ventricular myocardial infarction with anterior wall left ventricular infarction: An autopsy study

Right ventricular myocardial infarction has been reported to occur exclusively in association with inferior left ventricular infarction. To determine the frequency of right ventricular myocardial infarction in association with anterior left ventricular myocardial infarction, all hearts with anterior myocardial infarction studied over a 3-year period were examined for evidence of right ventricular necrosis or scar. Of 97 hearts with anterior myocardial infarction, 13 (13%) had anterior right ventricular myocardial infarction. The right ventricular infarcts involved from 10% to 50% (mean 28%) of the circumference of the right ventricular free wall from base to apex. The associated left ventricular infarcts were all anteroseptal and large and involved from 36% to 67% (mean 50%) of the total area of the left ventricular free wall and septum. Nine of the 13 patients underwent equilibrium radionuclide angiography and six had demonstrable right ventricular regional and global dysfunction. Thus, right ventricular myocardial infarction does occur with anterior wall left ventricular infarction, and right ventricular dysfunction may be demonstrable by radionuclide angiography. Further investigation is needed to define the hemodynamic characteristics, clinical importance, and therapeutic implications of anterior right ventricular myocardial infarction.

Silent ischemia during coronary occlusion produced by balloon inflation: Relation to regional myocardial dysfunction

Thirty patients with stable exertional angina undergoing percutaneous transluminal coronary angioplasty of an isolated obstructive lesion of the proximal left anterior descending artery were prospectively evaluated to investigate the relation between angina induced by balloon inflation and the quantity and severity of myocardial ischemia as determined by electrocardiographic (ECG) monitoring and by echocardiographic assessment of regional and global left ventricular wall motion. Anginal pain interviews, continuous two-dimensional echocardiographic recordings and 12 lead ECG recordings at 10 second intervals were obtained for the first two inflation sequences. Seventeen patients had angina with both inflations (symptomatic group), seven patients had no angina or related symptoms during either inflation (asymptomatic group) and six patients had both painful and painless inflations (mixed response group). Comparison of the three groups revealed that they did not differ in mean age, sex distribution, prior history of angina or the incidence of comorbid conditions. Echocardiographic measurements of global and regional left ventricular dysfunction during balloon inflation were comparable in the symptomatic and asymptomatic groups. Similarly, there were no significant differences in the time to onset or magnitude of ST segment changes. The results of the wall motion and ECG studies in the mixed response group paralleled the results in the symptomatic and asymptomatic groups, with no significant differences in any of the variables measured between the painful and painless inflations. These data demonstrate that silent myocardial ischemia occurs in an appreciable proportion of patients during coronary angioplasty and the absence of angina does not imply that a lesser amount of myocardium is jeopardized than with painful inflations.

Length of Hospital Stay and Complications After Percutaneous Transluminal Coronary Angioplasty Clinical and Procedural Predictors

BACKGROUNDnAlthough several studies have established that the complications of percutaneous transluminal coronary angioplasty (PTCA) are related to clinical and angiographic variables such as advanced age and lesion complexity, it is uncertain whether the use of hospital resources after PTCA also depends on the same baseline variables. The purpose of this study was to identify the factors responsible for prolonged hospital stay after PTCA.nnnMETHODS AND RESULTSnThe study cohort included 591 consecutive patients undergoing conventional balloon angioplasty at nine medical centers in North America. Major or minor complications occurred in 91 patients (15.4%) and were observed to be related to several baseline characteristics, including unstable angina, multivessel coronary artery disease, patient age, and lesion complexity. Compared with a median length of hospital stay of 2.0 days after PTCA (25th, 75th percentiles: 2.0, 4.0) for the entire cohort of patients, the length of stay was increased in patients with unstable angina (3.0 days [2.0, 5.0]; P = .002), multivessel coronary artery disease (3.0 [2.0, 5.5]; P = .001), age > 65 years (3.0 [2.0, 5.5]; P = .02), complex lesions (3.0 [2.0, 6.0]; P = .001), and filling defects (6.0 [2.0, 11.0]; P < .001). The length of stay was more strikingly increased, however, in patients who experienced major or minor PTCA complications, such as emergency bypass surgery (9.0 days [8.0, 18.0]; P < .001), Q-wave or non-Q-wave myocardial infarction (8.0 [6.0, 15.5]; P < .001), transfusion unrelated to bypass surgery (8.0 [4.0, 12.0]; P < .001), or abrupt vessel closure (6.0 [3.0, 10.5]; P < .001). On stepwise multiple linear regression, PTCA complications appeared to be the strongest predictors of length of hospital stay (all P < .001) and overwhelmed the weaker relation between length of stay and several individual baseline variables. Inclusion of a composite clinical risk score (reflecting the presence of unstable angina, multivessel disease, advanced age, complex lesions, or filling defects) in the regression model confirmed that patients with several high-risk baseline variables had a significant increase in length of stay after PTCA (P = .003), but PTCA complications remained the strongest predictors of length of stay.nnnCONCLUSIONSnAlthough PTCA complications were correlated with baseline variables such as unstable angina, multivessel disease, advanced age, complex lesions, and filling defects, excess length of stay after PTCA was most strongly influenced by the development of minor and major PTCA complications. Because patients with several baseline risk factors experienced significantly prolonged hospitalizations, improved selection of patients may contribute to reductions in length of stay after PTCA. A greater reduction in resource use after PTCA, however, would be expected from developing new treatments to decrease PTCA complications rather than limiting the access of patients with unstable angina, advanced age, or complex lesions to PTCA.

Regional dysfunction by equilibrium radionuclide angiocardiography: a clinicopathologic study evaluating the relation of degree of dysfunction to the presence and extent of myocardial infarction.

The relation of degree of regional wall motion abnormality by equilibrium radionuclide angiocardiography to the presence and mural extent of regional necrosis or scar at autopsy was evaluated in 23 autopsy patients who had a history of myocardial infarction and had equilibrium radionuclide angiocardiography within 40 days of death. Of the 228 regions evaluated by equilibrium radionuclide angiocardiography, 135 had abnormal regional wall motion and 102 (76%) of these 135 regions had evidence of myocardial infarction at autopsy. The overall sensitivity, specificity and predictive values of regional wall motion abnormality for regional necrosis or scar were 69, 59 and 76%, respectively. Of the 33 false positive regions, 20 (61%) had severe narrowing of the coronary artery supplying that region, 13 (39%) were adjacent to a region with a myocardial infarction and almost half (16 [48%]) were in the lateral wall. Eighty-three (36%) of the 228 regions were akinetic or dyskinetic, 52 (23%) were hypokinetic and 93 (41%) were normal. Sixty-three (76%) of the 83 akinetic/dyskinetic segments had transmural myocardial infarction at autopsy, 14 (17%) had nontransmural myocardial infarction and only 6 (7%) contained no necrosis or scar. In contrast, 14 (27%) of 52 hypokinetic segments had transmural myocardial infarction, 11 (21%) had nontransmural myocardial infarction and 27 (52%) were normal. Thus, the most severe regional wall motion abnormality (akinesia/dyskinesia) almost always indicates regional myocardial infarction which is usually transmural whereas less severe dysfunction (hypokinesia) is not necessarily associated with regional necrosis or scar. The severity of regional dysfunction must be considered if equilibrium radionuclide angiocardiography is used to evaluate the presence and mural extent of myocardial infarction within a region.

Preservation of left ventricular ejection fraction during percutaneous transluminal coronary angioplasty by distal transcatheter coronary perfusion of oxygenated fluosol DA 20

The cardioprotective efficacy of coronary perfusion during angioplasty was evaluated. Forty-two patients underwent transcatheter infusion of oxygenated Fluosol DA, 20% emulsion (FDA-20), a perfluorocarbon oxygen transport fluid, into the distal coronary artery during balloon inflations. Left ventricular function was continuously monitored by two-dimensional echocardiography, and left ventricular ejection fraction was quantitatively analyzed from the video record by an area-length method with a validated computer algorithm. Each patient had multiple nonperfused and perfused balloon inflations lasting more than 45 seconds. Nineteen of the 42 patients also received control solutions of oxygenated Ringers lactate and nonoxygenated FDA-20. The ejection fraction of nonperfused sequences fell from a baseline value of 57 +/- 15% to 36 +/- 14% at 45 seconds of inflation time (p less than 0.0005). Falls of similar magnitude were seen in the lactated Ringers and nonoxygenated FDA-20 perfused balloon inflations. The ejection fraction fall was associated with a 54% rise in end-systolic volume (p less than 0.0005) and a 4% rise in end-diastolic volume (p = ns) compared to baseline. Inflations perfused with oxygenated FDA-20 showed a 45-second, left ventricular ejection fraction of 53 +/- 13% (p = ns compared to baseline), which was significantly greater (p less than 0.0001) than the 45-second ejection fraction of the nonperfused, or control solution perfused sequences. Results indicate that the profound fall in ejection fraction occurring during percutaneous transluminal coronary angioplasty can be ameliorated by distal coronary perfusion with an oxygenated perfluorocarbon emulsion.

Validation of continuous radionuclide left ventricular functioning monitoring in detecting silent myocardial ischemia during balloon angioplasty of the left anterior descending coronary artery.

Silent myocardial ischemia has been inferred from transient ST-segment depression during continuous electrocardiographic monitoring. Recently, continuous ambulatory monitoring of left ventricular (LV) function using a radionuclide technique (VEST) has demonstrated episodes of significant silent LV dysfunction in the absence of electrocardiographic changes. To validate the demonstration of silent LV dysfunction with this technique, 12 men were studied during percutaneous transluminal coronary angioplasty. A total of 18 left anterior descending coronary artery balloon inflations were performed. Balloon inflations at 8 +/- 2 atm (4 to 10 atm) lasted 70 +/- 16 seconds. Seventeen of 18 inflations were associated with a decrease in LV ejection fraction greater than 0.10. Mean LV ejection fraction decreased from 0.53 +/- 0.08 to 0.28 +/- 0.11 (p less than 0.0001). In contrast, there was pain in only 10 inflations and ST-segment changes in 7. LV dysfunction was associated with a minimal increase in end-diastolic volume (4 +/- 3%, p less than 0.003), and a major increase in relative end-systolic volume (69 +/- 43%, p less than 0.001). These data suggest that continuous monitoring of LV function with the VEST can sensitively detect silent ischemic decreases in LV function occurring during angioplasty, and provide further validation of the use of this technique for detecting silent myocardial ischemia.

Dynamics of early and late left ventricular filling determined by Doppler two-dimensional echocardiography during percutaneous transluminal coronary angioplasty

To study the influence of ischemia on both early and late left ventricular filling, Doppler 2-dimensional echocardiography was used to measure filling parameters during percutaneous transluminal coronary angioplasty (PTCA) in 26 patients. Doppler recordings were taken immediately before balloon inflation and continuously during balloon inflation and deflation until 60 seconds into the recovery period. During PTCA of the left anterior descending artery (16 patients) there was a 35% decrease in early peak filling rate from 269 +/- 88 to 169 +/- 55 ml/s (p less than 0.0005) by 60 seconds of balloon inflation. In patients undergoing PTCA of the left circumflex (4 patients) or dominant right coronary artery (6 patients), the early peak filling rate decreased 15% from 325 +/- 126 to 284 +/- 137 ml/s (p less than 0.005). The decrease in early peak filling rate became evident at approximately 15 seconds after balloon inflation and fully recovered 20 seconds after balloon deflation. Rather than an expected increase in atrial stroke volume and a decrease in early to late filling ratio during coronary occlusion, there was a 28% decrease in atrial stroke volume during left anterior descending coronary artery PTCA and a 6% decrease during right coronary and circumflex PTCA. Because of the simultaneous decrease in both early and late ventricular filling, peak early to late filling ratio was only slightly altered during PTCA. There was an 83% increase in mean pulmonary artery wedge pressure during balloon inflation from 12 +/- 5 to 20 +/- 4 mm Hg. In 11 of these patients global systolic function was measured on subsequent inflations during PTCA using 2-dimensional echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Health after coronary stenting or balloon angioplasty : Results from the Stent Restenosis Study

This study was designed to compare health-related quality of life (HRQOL) in patients undergoing coronary stenting or balloon angioplasty in the randomized Stent Restenosis Study. The study sample was drawn from patients at nine U.S. clinical sites of the Stent Restenosis Study, a randomized trial comparing Palmaz-Schatz coronary stent implantation with conventional balloon angioplasty. One hundred ninety-nine consecutive patients were sent surveys 6 to 18 months after enrollment and 160 (80%) were returned. The survey sent to the patients included the Medical Outcomes Study 36-Item Short-Form Health Survey, the Canadian Cardiovascular Society Classification, and the Duke Activity Status Index. Although patients who underwent stenting had less angiographic restenosis and a tendency for fewer ischemic events, there were few differences in HRQOL after a mean of 456 days after randomization. The group that underwent stenting reported significantly less bodily pain than the group that underwent angioplasty (p = 0.02). Otherwise, there were no significant differences in generic or disease-specific measures. In a rating of their overall health, 47% of the group that underwent stenting and 45% of the group that underwent percutaneous transluminal coronary angioplasty reported very good or excellent health. In each group, 60% of the patients reported being symptom free from a cardiovascular perspective. This survey revealed no marked differences in long-term HRQOL between patients who underwent Palmaz-Schatz coronary stenting compared with those who underwent conventional angioplasty.