Joan García

Resultados inmediatos y a largo plazo de la angioplastia con stent del tronco común

Introduccion y objetivos La cirugia de derivacion aortocoronaria ha sido considerada el tratamiento de eleccion de la estenosis del tronco comun. Diversos estudios multicentricos sugieren la posibilidad de la angioplastia con stent. El objetivo del presente estudio fue analizar los resultados inmediatos y a largo plazo de la angioplastia con stent en el tronco comun, asi como identificar los factores predictores de mortalidad. Pacientes y metodo Se incluyo a 38 pacientes no consecutivos de 69 ± 8 anos de edad con una lesion severa del tronco comun a los que se implanto un stent entre noviembre de 1997 y marzo del 2003. La indicacion de la angioplastia fue «electiva» en 27 pacientes y «urgente » en los 11 restantes. El tronco comun no estaba protegido en 23 pacientes (60,5%). En todos los pacientes se realizo el seguimiento clinico a los 25 ± 20 meses. Resultados En todos los pacientes, el procedimiento angiografico se realizo con exito. Un paciente presento una oclusion aguda 1 h despues. En 4 pacientes (10%) se produjo un infarto de miocardio no transmural. La mortalidad hospitalaria fue del 15,8%. En el grupo con indicacion urgente, 5 de 11 pacientes (45,4%) fallecieron por fallo cardiaco severo (clase Killip III-IV) en el contexto de un infarto agudo de miorcadio. En cambio, solo fallecio 1 de los 27 pacientes (3,7%) del grupo electivo (p = 0,007). Durante el seguimiento se produjeron eventos clinicos mayores en 5 pacientes (13%): 3 fallecieron y los 2 restantes presentaron recurrencia de la angina. Todos los pacientes que fallecieron tenian el tronco comun desprotegido. La probabilidad acumulada de supervivencia para el grupo electivo fue del 92 ± 0,5, 88 ± 0,6 y 86 ± 0,7% a los 6 meses, 1 y 3 anos, respectivamente. En cambio, para el grupo urgente fue del 54 ± 0,2% a partir del sexto mes (p Conclusiones La angioplastia con stent del tronco comun en pacientes seleccionados se asocia con una elevada tasa de exito inmediato. En la angioplastia electiva, la incidencia de eventos cardiacos durante el seguimiento es relativamente baja. La angioplastia urgente y la presencia de signos de disfuncion ventricular izquierda son los principales predictores de mortalidad.

Coronary endothelial dysfunction and myocardial cell damage in chronic stable idiopathic dilated cardiomyopathy

UNLABELLED Impairment of endothelium-dependent vasodilatation in response to acetylcholine reflects an abnormal endothelial function. Labelled indium-111 monoclonal antimyosin antibodies enable detection of myocardial cell damage. We analysed whether endothelial dysfunction correlates with myocardial antimyosin uptake in a selected group of patients with idiopathic dilated cardiomyopathy. METHODS Twenty-two consecutive patients with chronic stable idiopathic dilated cardiomyopathy (18 males and four females) were included. The duration of heart failure symptoms was 46+/-34 months. At inclusion, the functional class of New York Heart Association was 2.1+/-0.7. Endothelial function was evaluated using intracoronary graded concentrations of acetylcholine. Vasomotor responses of the left anterior descending coronary artery were measured by quantitative coronary analysis. Myocardial uptake of antimyosin antibodies was quantified by means of a heart-to-lung ratio (HLR). RESULTS Eighteen patients showed endothelial dysfunction (82%) and the remaining four patients showed a normal endothelial function. There were no statistically significant differences between patients with and without endothelial dysfunction in relation to clinical, echocardiographic and hemodynamic parameters. In addition, these variables did not correlate with the magnitude of the vasomotor response to acetylcholine. Eighteen patients (82%) showed abnormal antimyosin uptake; 15 of them (83%) showed endothelial dysfunction. The global mean HLR of antimyosin uptake was 1.73+/-0.24. The coronary vasomotor response to acetylcholine correlated with the intensity of uptake of antimyosin antibodies (r=-0.45, P<0.04). CONCLUSIONS Coronary endothelial dysfunction and myocardial antimyosin uptake was found in a high percentage of patients with chronic stable idiopathic dilated cardiomyopathy. The abnormal vasomotor response seems to be related to the degree of myocardial damage.

The EXTREME registry: Titanium-nitride-oxide coated stents in small coronary arteries†

Objectives: We sought to explore the immediate results of Titan2® stent implantation in small coronary arteries, as well as the incidence of major adverse cardiac events (MACE) at six months follow‐up. Background: The safety of Titan2® stent has been confirmed in several studies in real‐life unselected populations. Methods: We enrolled 311 consecutive patients admitted for percutaneous intervention for at least one significant (50%) de novo lesion in a native small coronary artery (2.0–2.75 mm). All lesions were treated with Titan2® stent implantation. Patients were prospectively followed up for at least six months. The primary endpoint was MACE at six months follow‐up [death, myocardial infarction (MI), or target vessel revascularization (TVR)]. Secondary endpoints included angiographic and clinical procedural success, in‐hospital MACE, target lesion revascularization (TLR) during follow‐up, and stent thrombosis. Results: The mean age was 67.3 ± 10.9 years (65.9% males). A total of 356 Titan2® stents were implanted in 353 lesions. Angiographic and clinical procedural success was achieved in 344 (97.5%) patients. No case of in‐hospital MACE or acute stent thrombosis was reported. Clinical follow‐up was completed for an average of 8 ± 2 months. Two patients (0.7%) died, and 6 (2.1%) developed MI. TLR was performed in 12 (4.2%) and TVR in 16 (5.5%) patients, all were clinically driven. Cumulative MACE occurred in 20 (6.9%) patients. One patient suffered subacute stent thrombosis, but no late stent thrombosis. Conclusions: Titan2® stent implantation in small coronary arteries achieves excellent immediate outcome, with a low incidence of MACE at mid‐term follow‐up.

Influence of residual stenosis in determining restenosis after cutting balloon angioplasty.

The cutting balloon is a new device for coronary angioplasty, which, by the combination of incision and dilatation of the plaque, is believed to minimize arterial wall trauma, the neoproliferative response, and subsequent restenosis. In this study, we sought to determine predictors of the restenosis using this technique. Seventy‐seven patients underwent successful coronary angioplasty with cutting balloon alone. In 67 of these patients (87%), we performed a control angiogram at 6‐month follow‐up. Pre‐, post‐, and late angiographic results were evaluated by quantitative coronary analysis. Clinical and angiographic variables were correlated with restenosis as a binary variable and a continuous variable (late loss and late minimum luminal diameter). Univariate analysis showed that the immediate postprocedure minimum luminal diameter (MLD) was smaller in the restenotic group (defined as MLD > 50% by quantitative coronary angiography) than in the nonrestenotic group (1.90 ± 0.47 mm vs. 2.19 ± 0.56 mm, P < 0.05). In addition, the immediate percentage of stenosis was higher in the restenotic group than in the nonrestenotic group (37% ± 10% vs. 27% ± 11%, P < 0.003). Multivariate analysis identified the immediate postcutting balloon percentage of stenosis as an independent determinant of binary restenosis (P < 0.008). When restenosis was defined as a continuous variable, the immediate postprocedure MLD was an independent predictor of late loss (P < 0.02) and of late MLD (P < 0.0002). No clinical, preprocedure angiographic, or technical variables tested were associated with restenosis. The degree of postprocedural residual stenosis after cutting balloon angioplasty is predictive of late restenosis. Cathet. Cardiovasc. Intervent. 49:410–414, 2000.

Arthroscopically assisted knee contracture release secondary to melorheostosis: a case report

Melorheostosis is a rare non-hereditary bone disease characterized by a radiographic pattern of flowing hyperostosis along the cortex with sclerotomal distribution. We report a case of a patient with severe knee contracture and a restricted range of motion caused by intraarticular bone fragment and hyperostotic bone lesions secondary to melorheostosis. An arthroscopically assisted approach was used successfully in order to remove free bone fragments and to release the hyperostotic lesions in the bone cortex of the distal femur.

Combined therapeutic strategy for multiple coronary thromboemboli.

A female with mitral valvular disease presented an acute myocardial infarction. She suddenly complained of recurrent chest pain with symptoms of pulmonary edema. The angiogram evidenced multiple coronary thromboemboli. A combined strategy using intracoronary thrombolysis, a platelet glycoprotein IIb/IIIa antagonist (abciximab) and percutaneous transluminal coronary angioplasty to help disrupt the thrombus was performed. Clinical and angiographic signs of coronary reperfusion were rapidly achieved. No bleeding complications appeared. Cathet. Cardiovasc. Intervent. 50:343–345, 2000.

Twelve-month outcome after coronary stent implantation without predilatation.

S tent implantation has traditionally been performed after predilatation of the stenotic lesion with a conventional catheter balloon, thus allowing the lesion to be crossed easily. As a result of the improved design of the stent delivery systems with lower crossing profiles and greater flexibility and better stent stability on the balloon, predilatation may not be necessary in some cases. The clinical feasibility, efficacy, and procedural safety of direct stenting in selected groups of patients have been shown in recent reports. This technique reduces the procedure time and radiation exposure times and costs. In addition, it may cause less myocardial ischemia due to a decrease in balloon inflations. However, there are few reports about midand long-term outcome after direct stenting. The purpose of the present study was first, to know the clinical and angiographic restenosis rate in patients in whom direct stenting was successfully implanted and also to identify clinical, lesional, and procedural variables predictive of angiographic restenosis after direct stent implantation. • • • From September 1998 to October 1999, 107 patients with significant coronary stenosis were eligible for primary direct coronary stenting. The study population represented 20% of patients undergoing percutaneous transluminal coronary angioplasty in our center during this period. Direct stenting was not attempted in patients with (1) severe calcified lesions, (2) long lesions ( 20 mm), (3) total occlusions, (4) severe tortuosity of the vessel proximal to the stenosis, (5) severe angulation within the lesion, and (6) contraindication to acetylsalicylic acid or ticlopidine. Patients in whom a direct stent was deployed in a vein graft were also excluded. The presence of intraluminal thrombus and the type of symptomatology at onset (stable angina, unstable angina, and acute myocardial infarction) were not considered exclusion criteria. Before angioplasty, oral acetylsalicylic acid and an intravenous bolus of sodium heparin were administered in all patients. After placing a soft guiding catheter into the coronary ostium, intracoronary nitroglycerin, 0.2 to 0.8 mg, was administrated. Another bolus of intracoronary nitroglycerin, 0.2 to 0.4 mg, was given after crossing the lesion with the guidewire to revert a potential associated vasoconstriction and to reach the maximum vasodilatation of the vessel for correct calculation of the stent size. A ratio stent/ reference diameter of 1.1-to-1.0/1.0 was chosen. The stent was then positioned in the target lesion with moderate pushing or proximal intubation of the guiding catheter when necessary. The balloon was slightly inflated over nominal pressures to assess an adequate stent deployment. When the expansion was incomplete, higher pressures with the same balloon or another balloon were performed. At least 2 orthogonal projections were performed for analysis. Quantitative analysis was performed by computer using a coronary detection border analysis system (Integris HM 3000, Phillips Medical System, Leiden, The Netherlands). Angiographic measurements were obtained during diastole after intracoronary nitroglycerin administration using the guiding catheter for calibration. The percentage of stenosis and minimum luminal diameter (MLD) were measured at the basal stage, immediately after stent implantation, and at follow-up. We calculated the following variables: (1) acute gain, defined as an increase in MLD of the stented artery immediately after the procedure; (2) late loss, defined as subsequent reduction in luminal diameter of the treated artery at follow-up angiography; and (3) loss index, as the average ratio of the late loss to acute gain. Coronary angiography was performed no earlier than 6 months after angioplasty, except in cases of recurrent angina. If angiography was performed within 4 months of angioplasty and the lesion was not redilatated, it was repeated 6 months after the procedure. Clinical, procedural, and angiographic data were evaluated as potential determinants of restenosis as a binary variable (defined as 50% diameter stenosis at follow-up in the stented segment) and as a continuous variable (as absolute late MLD and late loss). The unpaired Student’s t test was used to detect differences in continuous variables and chi-square test for categorical variables between the restenotic and nonrestenotic groups. Logistic regression multivariate analysis using the stepwise procedure was performed to identify significant independent risk variables of binary restenosis. Multiple regression analysis was performed to evaluate the potential determinants of restenosis considered as continuous variables (late loss and late MLD). Data are expressed as mean SD. A p value 0.05 was considered statistically significant. Of the 107 patients for whom a primary direct stent was electively indicated, the lesion could not be crossed in 7 (6.5%), and they were excluded from the study. In these patients, predilatation of the lesion with From the Interventional Cardiology Unit, Department of Cardiology and Cardiac Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Dr. Marti’s address is: Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain. E-mail: 18461vmc@comb.es. Manuscript received March 14, 2001; revised manuscript received and accepted May 18, 2001.

Immediate and Long-Term Outcome After Angioplasty With Stenting of the Left Main Coronary Artery

INTRODUCTION AND OBJECTIVES Coronary artery bypass graft surgery is the treatment of choice for severe left main coronary artery stenosis. The results of a number of multicenter trials have suggested angioplasty with stenting as a possible alternative treatment. The aim of the present study was to analyze the immediate and long-term results of angioplasty with stenting of the left main coronary artery, and to identify factors predictive of death. PATIENTS AND METHOD A total of 38 nonconsecutive patients (mean age 69 [8] years) with a severe lesion in the left main coronary artery were treated with angioplasty and stenting between November 1997 and March 2003. The procedure was elective in 27 patients and urgent in the remaining 11. In 23 patients (60.5%) the left main coronary artery was not protected by aortocoronary bypass. All patients underwent clinical follow-up examination at 25 (20) months. RESULTS Angiographically documented success was obtained in all patients. However, one patient died from acute occlusion one hour after the operation. Four patients (10%) had a non-Q-wave myocardial infarction. In-hospital mortality was 15.8% (6/38 patients). Five of the 11 patients (45.4%) who underwent emergency angioplasty and stenting died in the hospital from acute myocardial infarction complicated by severe (Killip grade III-IV) heart failure. However, only one of 27 patients (3.7%) in the elective surgery group died (P=.007). Major clinical cardiac events during follow-up occurred in 5 patients (13%); 3 died and the other 2 had recurrent angina. All patients who died had an unprotected left main coronary artery. Cumulative survival rates for the elective group were 92 (0.5)% at 6 months, 88 (0.6)% at 1 year and 86 (0.7)% at 3 years, respectively. For the emergency surgery group cumulative survival rate was 54 (0.2)% at 6 months (P<.05). CONCLUSIONS Elective angioplasty and stenting of the left main coronary artery in selected patients was associated with a high immediate success rate. In patients who underwent elective angioplasty and stenting, the incidence of major cardiac events during follow-up was relatively low. Emergency angioplasty and signs of left ventricular dysfunction were the main predictors of in-hospital mortality.

Expanding subintimal coronary dissection under a stent-covered arterial segment: serial intravascular ultrasound observations.

A patient with an angiographically unrecognized minor coronary dissection in a stent‐covered coronary segment in which a type D spiral dissection extended submedially to the distal artery is described. This complication occurred 6 months after stent implantation and was ascribed to injury of the stented vessel wall during an intravascular ultrasound study. Cathet. Cardiovasc. Intervent. 48:308–311, 1999.