Pierre Vogt

Angiographic follow-up after placement of a self-expanding coronary artery stent

BACKGROUND The placement of stents in coronary arteries after coronary angioplasty has been investigated as a way of treating abrupt coronary-artery occlusion related to the angioplasty and of reducing the late intimal hyperplasia responsible for gradual restenosis of the dilated lesion. METHODS From March 1986 to January 1988, we implanted 117 self-expanding, stainless-steel endovascular stents (Wallstent) in the native coronary arteries (94 stents) or saphenous-vein bypass grafts (23 stents) of 105 patients. Angiograms were obtained immediately before and after placement of the stent and at follow-up at least one month later (unless symptoms required angiography sooner). The mortality after one year was 7.6 percent (8 patients). Follow-up angiograms (after a mean [+/- SD] of 5.7 +/- 4.4 months) were obtained in 95 patients with 105 stents and were analyzed quantitatively by a computer-assisted system of cardiovascular angiographic analysis. The 10 patients without follow-up angiograms included 4 who died. RESULTS Complete occlusion occurred in 27 stents in 25 patients (24 percent); 21 occlusions were documented within the first 14 days after implantation. Overall, immediately after placement of the stent there was a significant increase in the minimal luminal diameter and a significant decrease in the percentage of the diameter with stenosis (changing from a mean [+/- SD] of 1.88 +/- 0.43 to 2.48 +/- 0.51 mm and from 37 +/- 12 to 21 +/- 10 percent, respectively; P less than 0.0001). Later, however, there was a significant decrease in the minimal luminal diameter and a significant increase in the stenosis of the segment with the stent (1.68 +/- 1.78 mm and 48 +/- 34 percent at follow-up). Significant restenosis, as indicated by a reduction of 0.72 mm in the minimal luminal diameter or by an increase in the percentage of stenosis to greater than or equal to 50 percent, occurred in 32 percent and 14 percent of patent stents, respectively. CONCLUSIONS Early occlusion remains an important limitation of this coronary-artery stent. Even when the early effects are beneficial, there are frequently late occlusions or restenosis. The place of this form of treatment for coronary artery disease remains to be determined.

Five-Year Outcome in Patients With Isolated Proximal Left Anterior Descending Coronary Artery Stenosis Treated by Angioplasty or Left Internal Mammary Artery Grafting A Prospective Trial

BACKGROUND Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) improve the clinical status of patients with isolated proximal left anterior descending coronary artery stenosis. At 2 years, only additional revascularization was more frequently required after PTCA. METHODS AND RESULTS We monitored 134 patients randomized to PTCA (n=68) or CABG (n=66) for </=5 years. End points were death, myocardial infarction, need for additional revascularization, clinical status, and medical treatment. At 5 years, 6 patients (9%) had died in the PTCA group versus 2 (3%) in the CABG group (P=0.12). One patient in each group died of a cardiac cause. Myocardial infarction was more frequent after PTCA (15% versus 4%; P=0.0001), but Q-wave infarction was not (6% in the PTCA group versus 3% in the CABG group; P=0.8). Additional revascularization was required in 38% of patients in the PTCA group versus 9% in the CABG group (P=0.0001). Functional status was comparable, with 6% of patients after PTCA and 3% after CABG in functional class III or IV. Finally, after PTCA or CABG, 62% and 91% of patients, respectively, were free of events (P=0.0001). CONCLUSIONS The 5-year prognosis of patients with isolated proximal left anterior descending coronary artery stenosis is good. Both PTCA and CABG improve clinical status, but revascularization was needed more frequently after PTCA. There is an excess incidence of non-Q-wave myocardial infarction in the PTCA group that does not affect the vital or symptomatic outcome.

Cardiac arrest: prognostic factors and outcome at one year.

This study was designed to determine by multivariate statistical methods the influence of 38 variables on outcome after cardiopulmonary resuscitation (CPR) and to assess neuropsychological status in long-term survivors. The charts of 181 consecutive patients resuscitated in a 1,100-bed University Hospital over a 2-year period were analyzed retrospectively. Of the 181 resuscitated patients, 23 (13%) could be discharged. Outcome was significantly affected by the following variables: presence of shock or renal failure before cardiac arrest (CA) (odds ratio = 10.6; 95% confidence interval = 1.3-85.8 and odds ratio = 13.8; 95% confidence interval = 1.7-109.2, respectively), administration of epinephrine (odds ratio = 11.2; 95% confidence interval = 3.2-39.2) or prolonged CPR (> 15 min) (odds ratio = 4.9; 95% confidence interval = 1.7-13.7). By contrast, when CA occurred in uncomplicated acute myocardial infarction a significantly better prognosis could be demonstrated (odds ratio = 0.2; 95% confidence interval = 0.0-0.6). The 10 long-term survivors investigated lead an independent life and all returned to former occupation. The most common complaint was moderate memory disturbance (five patients). The conclusion is that this study confirms the critical influence of cellular anoxia on prognosis and allows the improved delineation of the situations in which cardiopulmonary resuscitation appears to be hopeless or likely to be successful. The follow up in a small number of survivors has shown a good quality of life and minor neuropsychological sequellae.

Ten-Years Follow-Up of 20 Patients with Idiopathic Ventricular Tachycardia

The follow‐up and characteristics of 20 patients with ventricular tachycardia (VT) and no detectable heart disease is reported. These were 16 men and four women with a mean age of 44 years. Symptoms were present in 18 patients (eight had syncope and ten palpitations or dizziness), VT was sustained in 11 patients and a left bundle branch block morphology with inferior axis was found in 17 patients. In three patients, VT had a right bundle branch block morphology and left‐axis deviation. The VT was inducible in 13 patients during the electrophysiological testing (EP) and was sustained in five patients. Medical treatment was introduced in 19 patients. During a mean follow‐up of 10 years from the onset of the symptoms and 6 years from the EP testing, one patient died suddenly. He had stopped taking amiodarone 5 months before. In seven patients symptoms recurred and were due to discontinuation of therapy in two cases and inefftcacy of previous effective treatment in five patients. After modification of the treatment (three cases), implantation of a pacemaker (one case) and catheter ablation (one case), all patients became asymptomatic. Eleven patients became asymptomatic with the first administered antiarrhythmic therapy. One patient continues to be asymptomatic in spite of discontinuation of his medical therapy. We conclude that patients with VT and no detectable heart disease have a good long‐term prognosis and that appropriate therapy can be found in almost all patients.

Prevalence and management of familial hypercholesterolaemia in patients with acute coronary syndromes.

AIMS We aimed to assess the prevalence and management of clinical familial hypercholesterolaemia (FH) among patients with acute coronary syndrome (ACS). METHODS AND RESULTS We studied 4778 patients with ACS from a multi-centre cohort study in Switzerland. Based on personal and familial history of premature cardiovascular disease and LDL-cholesterol levels, two validated algorithms for diagnosis of clinical FH were used: the Dutch Lipid Clinic Network algorithm to assess possible (score 3-5 points) or probable/definite FH (>5 points), and the Simon Broome Register algorithm to assess possible FH. At the time of hospitalization for ACS, 1.6% had probable/definite FH [95% confidence interval (CI) 1.3-2.0%, n = 78] and 17.8% possible FH (95% CI 16.8-18.9%, n = 852), respectively, according to the Dutch Lipid Clinic algorithm. The Simon Broome algorithm identified 5.4% (95% CI 4.8-6.1%, n = 259) patients with possible FH. Among 1451 young patients with premature ACS, the Dutch Lipid Clinic algorithm identified 70 (4.8%, 95% CI 3.8-6.1%) patients with probable/definite FH, and 684 (47.1%, 95% CI 44.6-49.7%) patients had possible FH. Excluding patients with secondary causes of dyslipidaemia such as alcohol consumption, acute renal failure, or hyperglycaemia did not change prevalence. One year after ACS, among 69 survivors with probable/definite FH and available follow-up information, 64.7% were using high-dose statins, 69.0% had decreased LDL-cholesterol from at least 50, and 4.6% had LDL-cholesterol ≤1.8 mmol/L. CONCLUSION A phenotypic diagnosis of possible FH is common in patients hospitalized with ACS, particularly among those with premature ACS. Optimizing long-term lipid treatment of patients with FH after ACS is required.

Emergency surgery for acute infective aortic valve endocarditis : performance of cryopreserved homografts and mode of failure

OBJECTIVE To describe our experience in the surgical treatment of infective, native and prosthetic aortic valve endocarditis, using cryopreserved homograft valves. METHODS Between January 1988 and September 1995, cryopreserved homografts were implanted in 49 patients (mean age 47 +/- 15 years; range 19-79) with acute infective endocarditis of the native (21/49; 43%) or the prosthetic (28/49; 57%) aortic valve. Aortic root abscesses were found in 39/49 (80%) patients, ventriculo-aortic disconnection in 27/49 (55%). An intracardiac fistula, originating from the left ventricular outflow tract was found in 25/49 (51%) patients. Indications for emergency surgery were congestive heart failure due to severe aortic valve regurgitation in 44/49 (90%) and systemic emboli in 5/49 (10%) patients. Preoperatively, 23/49 (47%) patients were in New York Heart Association (NYHA) class IV, and 5/49 (10%) were in acute circulatory failure. Mean left ventricular ejection fraction was 53 +/- 10% (25-65). Streptococci (27%) and staphylococci (27%) were the most important microorganisms found. The homograft was implanted as a scalloped freehand valve (34/49; 70%), as an intra-aortic inclusion cylinder (4/49; 6%) or as a free-standing root replacement (12/49; 24%). Combined procedures were necessary in 11/49 (22.5%) patients. RESULTS Hospital mortality was 8.2% (4/49): 2/49 (4.1%) patients died from endocarditis-related sepsis, one (2%) from low cardiac output and one (2%) from a cerebrovascular accident. After a mean interval of 21 +/- 15 months (2-48), 9/45 (20%) patients had to be reoperated, all reoperations except one being homograft related. After a mean follow-up of 35 +/- 22 months (2-90), 4/44 (9%) patients had their homograft replaced by a mechanical prosthesis. After 5 years, actuarial freedom from late death was 97 +/- 3%; from late reoperation 69 +/- 9%; from late endocarditis 85 +/- 8%; and from late homograft degeneration 87 +/- 6%. Explanted homografts were acellular and non-vital, containing bacteria and/or leucocytes. B-lymphocytes were found in all and in one, T-cell lymphocytes were present. CONCLUSION Emergency aortic valve replacement with cryopreserved homografts for acute native or prosthetic aortic valve endocarditis has a low operative mortality. The late incidence of recurrent endocarditis or homograft failure up to 7 years is acceptable. Cryopreserved homografts are non-viable. The presence of T-cell lymphocytes in explanted homografts indicates that rejection may be possible.

Circadian variations of ischemic burden among patients with myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND Several parameters of cardiovascular physiology and pathophysiology exhibit circadian rhythms. Recently, a relation between infarct size and the time of day at which it occurs has been suggested in experimental models of myocardial infarction. The aim of this study is to investigate whether circadian rhythms could cause differences in ischemic burden in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS In 353 consecutive patients with STEMI treated by PPCI, time of symptom onset, peak creatine kinase (CK), and follow-up at 30 days were obtained. We divided 24 hours into 4 time groups based on time of symptom onset (00:00-05:59, 06:00-11:59, 12:00-17:59, and 18:00-23:59). RESULTS There was no difference between the groups regarding baseline patients and managements characteristics. At multivariable analysis, there was a statistically significant difference between peak CK levels among patients with symptom onset between 00:00 and 05:59 when compared with peak CK levels of patients with symptom onset in any other time group (mean increase 38.4%, P < .05). Thirty-day mortality for STEMI patients with symptom onset occurring between 00:00 and 05:59 was significantly higher than any other time group (P < .05). CONCLUSION This study demonstrates an independent correlation between the infarct size of STEMI patients treated by PPCI and the time of the day at which symptoms occurred. These results suggest that time of the day should be a critical issue to look at when assessing prognosis of patients with myocardial infarction.

Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms

OBJECTIVE Assess outcome of patients with descending thoracic aortic aneurysms complicated by aortobronchial and aortoesophageal fistulae in comparison to patients undergoing repair of aortic aneurysms without fistulae. METHODS In a consecutive series of 145 patients (age 60 +/- 12 years) with repair of descending thoracic and thoracoabdominal aortic aneurysms, 11 patients (8%; age 63 +/- 9; NS) primarily presented for hematemesis and/or hemoptysis. In 8/11 patients (73%) an aortobronchial fistula was identified, and 3/11 patients (27%) suffered from an aortoesophageal fistula. Five of 11 patients (45%) had undergone previous aortic surgery in the same region. RESULTS Extent of aortic segments (range 1-8) replaced was 3.1 +/- 1.4 for all versus 2.6 +/- 0.9 for fistulae (NS). Aortic cross clamp time was 38 +/- 22 min for all versus 45 +/- 15 min for fistulae (NS). Mortality at 30 days was 18/145 (12%) for all versus 16/134 (12%) without fistulae versus 2/11 (18%) with fistulae (NS). Paraparesis and or paraplegia was observed in 11/145 (8%) for all versus 10/134 (7%) without fistulae versus 1/11 (9%) for cases with fistulae (NS). Nine additional patients died after hospital discharge, seven without fistulae and two with fistulae (days 80, and 120) bringing the 1-year mortality up to 23/134 (17%) without fistulae versus 4/11 (36%) with fistulae (NS). Further analysis shows that the 1-year mortality accounts for 1/8 patients (13%) with aorto-bronchial fistulae versus to 3/3 patients (100%) with aorto-esophageal fistulae (esophageal versus bronchial fistula: P = 0.018; esophageal versus no fistula: P = 0.006). CONCLUSIONS Outcome of patients suffering from descending thoracic aortic aneurysms complicated by aorto-bronchial fistulae can be similar to that without fistulae, whereas for cases complicated by aorto-esophageal fistulae the prognosis seems to remain poor even after successful hospital discharge.

Complications and follow-up after intracoronary stenting: Critical analysis of a 6-year single-center experience

From April 1986 through April 1992, 123 patients received 153 intracoronary stents (131 Medinvent, 13 Palmaz-Schatz, 9 Wiktor) during 131 procedures. The indication was bail-out treatment in 39, restenosis in 59 native coronary arteries, and stenosis or restenosis in 33 vein grafts. Stent-related events were studied during the in-hospital stay and on follow-up and included closure, stent restenosis, myocardial infarction, death, and the need for coronary bypass surgery. A Kaplan-Meier estimate extended to 6 years showed different short- and long-term outcomes for the distinct treatment groups (p < 0.05): right coronary artery stenting (more particularly, stenting for restenosis after angioplasty) had the lowest and vein graft stenting had the highest stent-related complication rate. The complication rate was similar (p > 0.25) (1) in the case of multiple nontandem stent implantation during the same procedure; (2) for the different endoprosthesis sizes; and (3) during the different procedural years. In native coronary arteries, restenosis after angioplasty of the right coronary artery could be a preferential indication for coronary artery stenting. Despite a favorable short-term outcome, vein graft stenting has a high incidence of events on long-term follow-up, mainly because of late restenosis. Multiple nontandem stenting during the same procedure is not associated with a higher incidence of complications, in particular, the restenosis rate is not appreciably higher. Finally, only a minor benefit for the learning curve is apparent from this single-center experience with continual unchanged postprocedural management.

Effectiveness of percutaneous transluminal coronary angioplasty in cardiogenic shock during acute myocardial infarction

Abstract The prognosis of cardiogenic shock during acute myocardial infarction (AMI) is poor; the mortality rate varies from 80 to 100%.1,2 Recently, interventional therapy including intracoronary thrombolysis and mechanical recanalization have been proposed and seem to improve prognosis.3–5