Louis Bernstein

Prognosis after an initial non-Q-wave myocardial infarction related to coronary arterial anatomy☆

Eighty-six consecutive hospital survivors (aged less than or equal to 60 years) of a first non-Q-wave acute myocardial infarction (MI) were followed up prospectively. Coronary arteriography was performed a median of 2 weeks after MI. The size of the MI was small (as judged by a mean peak creatine kinase level of 906 IU/liter); 90% were in Killip class I, and the mean left ventricular ejection fraction was 60 +/- 11% (+/- standard deviation). Forty-nine patients had 1 vessel significantly narrowed by disease (greater than or equal to 70% luminal diameter reduction), 19 had 2-vessel, 2 had 3-vessel, 3 had left main (greater than or equal to 50% luminal diameter reduction), and 13 minimal or no coronary artery disease (CAD). Complete occlusion of the MI-related vessel was present in 33 patients. All 33 and an additional 5 patients had collateral vessels to the MI area. During a mean follow-up of 25 months, 1 cardiac death and 4 recurrent infarcts (3 with non-Q-wave MI) occurred. Angina occurred in 53 patients (62%) and responded medically in all but 7 who underwent coronary artery surgery. Angina after MI occurred frequently in patients with severe proximal left anterior descending CAD (greater than or equal to 90%), and in those with CAD (greater than or equal to 50%) in a vessel supplying collaterals to the infarct area. Because angina can be managed medically in most patients and the outcome is good, routine coronary angiography is not indicated in asymptomatic survivors less than or equal to 60 years of a first non-Q-wave MI.

Mechanism and significance of precordial ST-segment depression during inferior wall acute myocardial infarction associated with severe narrowing of the dominant right coronary artery

The mechanism and significance of precordial ST depression during inferior wall acute myocardial infarction (AMI) is debated. This study assessed the location and extent of arterial perfusion distribution responsible for this electrocardiographic finding. Intracoronary thallium-201 was injected in 11 patients with 1-vessel right coronary disease to delineate perfusion distribution that was quantitated by a new angiographic distribution score. The angiographic score correlated with posterior (r = 0.84), posterolateral (r = 0.88) and total (r = 0.73) extent of intracoronary thallium distribution. The angiographic distribution score was related to electrocardiographic changes in 16 patients showing an inferior ST-segment elevation during angioplasty (7 with and 9 without precordial ST depression), of which 6 received intracoronary thallium injection. None had thallium distribution in the anterior or septal segment, but there was a trend toward a greater angiographic distribution score and posterior segment thallium score in patients with precordial ST depression. In another 77 patients with inferior wall AMI due to right coronary occlusion (24 with concomitant left anterior descending narrowing), precordial ST depression was present in 16 with and 31 without left anterior descending narrowing (p = NS). The angiographic distribution score was higher in those with than without precordial ST depression (0.59 +/- 0.10 vs 0.44 +/- 0.11, p < 0.001) in both patients with and without left anterior descending disease. The magnitude of both inferior ST elevation and precordial ST depression correlated with the angiographic distribution score, but only precordial ST depression was independently related in multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

ST monitoring for myocardial ischemia during and after coronary angioplasty.

We performed 12-lead electrocardiographic monitoring in 97 patients during coronary angioplasty (PTCA) of a single vessel to correlate ischemic ST changes with clinical, angiographic and coronary hemodynamic variables and to determine the optimum lead or combination of leads for their detection. Ischemia (chest pain or ST change, group A) occurred in 79 patients (80%), but in only 15 of 23 patients (65%) with collaterals (p less than 0.05). Ischemia occurred more often in left anterior descending and left circumflex PTCA than right coronary PTCA, but pain was the only manifestation more often in left circumflex and right coronary PTCA. Ischemic ST change was silent in 16% and this proportion did not differ in clinical or angiographic groups except for diabetes with 3 of 5 (60%) having silent ischemia (p less than 0.05). Patients in group A (ischemia) compared to group B (no ischemia) had less severe lesions (85 +/- 9 vs 91 +/- 7%, p less than 0.01), higher transstenotic gradients (62 +/- 19 vs 53 +/- 9 mm Hg, p less than 0.05) and lower distal occluded pressures (24 +/- 11 vs 33 +/- 10 mm Hg, p less than 0.01), suggesting less collateral flow. Compared with a 12-lead electrocardiogram, the best single lead for detecting ST change during PTCA in each artery had a sensitivity of 80% and this increased to 93% using the best 2 leads. The best 3 leads (V3/III/V5 for left anterior descending and III/V2/V5 for right coronary and left circumflex) increased sensitivity to 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

ST-segment changes during transmural myocardial ischemia in chronic left bundle branch block.

Abstract The electrocardiographic diagnosis of acute myocardial infarction is difficult in the presence of left bundle branch block (BBB). The accuracy of electrocardiographic criteria derived from studies using either creatine kinase estimation,1–5 autopsy findings2–4 or thallium-201 scintigraphy1 to confirm infarction is debated, and may explain why such criteria have not been widely adopted. Percutaneous transluminal coronary angioplasty of 3 patients with chronic left BBB presented us with a unique opportunity to study the electrocardiographic changes of transmural ischemia simulating acute infarction. All 3 patients showed transient and characteristic ST changes during balloon occlusion of a coronary artery.

Lack of evidence for improvement in internal mammary graft flow by occlusion of side branch

Coronary steal due to unligated side branches of an internal mammary artery graft has been reported previously. Embolization of these side branches has been shown to result in symptomatic improvement, but objective evidence of improved flow to the coronary artery has been lacking. We studied intracoronary Doppler flow in a patient presenting with symptoms thought to be due to a large unligated side branch of mammary graft. There was no significant change in the mammary flow after balloon occlusion of the side branch. More objective data may be required to routinely prescribe side branch embolization for symptomatic patients with unligated side branches of a mammary graft.

Coronary and left ventricular angiographic anatomy and prognosis of survivors of first acute myocardial infarction

To relate coronary anatomy and left ventricular function to prognosis, 197 of 269 consecutive survivors of a first myocardial infarction (MI) less than or equal to 60 years old underwent prospective cardiac catheterization a median of 2 weeks after admission and were followed up for a median of 24 months (range 12 to 61). Seventy-two patients were excluded from angiography because of early death (9), severe noncoronary disease (44), MI complications (6), or patient refusal (13). The prevalence of multivessel disease was low (30%) and unrelated to the site of MI or presence of Q waves but was increased in patients with previous angina pectoris (p = 0.05) or those in Killip class II or III (p = 0.02). There were only 8 deaths from heart disease. The survival rate at 12 months was 97 +/- 1% and at 24 and 36 months, 95 +/- 2%. Nineteen patients underwent coronary revascularization surgery. As the number of deaths was small, the differences in survival between patients with single or multivessel disease and normal or depressed ejection fractions failed to reach significance. Survivors of a first MI less than or equal to 60 years old have a low prevalence of multivessel disease and a good prognosis.

Delayed appearance of distal coronary perforation following stent implantation

Coronary perforations are usually apparent immediately after the occurrence. We report a case of a 67-year-old woman where coronary perforation presented 16 hours after the procedure. This case illustrates the need for extra vigilance and careful evaluation of distal vasculature while using stiff coronary guidewires.

Spontaneous regression of post-percutaneous transluminal coronary angioplasty aneurysm

We report a case of a 67-year-old male with spontaneous regression of post-percutaneous transluminal coronary angioplasty (PTCA) aneurysm. This case substantiates the benign prognosis of post-PTCA aneurysms.

Rotational atherectomy of calcified ostial saphenous vein graft lesion with long term follow-up: a case report

Rotational atherectomy, though widely used for calcified and difficult lesions, has not been used in vein graft lesions. We performed rotational atherectomy on a 75-year-old male with a calcified ostial lesion in an 11-year-old vein graft. No complications were encountered and good result was obtained. Angiogram at 10 months revealed no restenosis.

Angioplasty and stenting in the presence of a thrombus using adjuvant abciximab (ReoPro)

Abstract Intracoronary thrombus has been associated with higher rates of ischaemic complications following percutaneous transluminal coronary angioplasty (PTCA). We used platelet glycoprotein IIb/IIIa integrin antagonist, abciximab (ReoPro), to treat 13 patients undergoing PTCA with angiographically detected thrombus. None of the patients developed new ischaemic complications. Two (15.4%) patients developed groin complications. Abciximab is an important new adjuvant therapy for PTCA and stenting associated with a thrombus.