Renato Gianrossi

Coronary angioplasty of chronic occlusions: Factors predictive of procedural success

In a retrospective study of 365 chronic total occlusions that were submitted for angioplasty, we studied the influence of 27 clinical, morphologic, and procedural variables as possible predictors of successful outcomes. Success rate was shown to be significantly influenced by the following variables: operator experience (41% in early patients, first 6 months; 73% in late patients, last 6 months of entire series; p less than 0.001), duration of occlusion (less than or equal to 1 month, 89%; 1 to 3 months 87%; greater than or equal to 3 months 45%; unknown 60%; p less than 0.001), morphology of occlusion (tapered, 83%; abrupt, 51%), length of occlusion (less than or equal to 15 mm, 71%; greater than 15 mm, 60%; p less than 0.001), and bridging collaterals (present, 29%; absent, 67%; p less than 0.001). None of the other clinical, angiographic, or procedural variables correlated with the success rate of coronary angioplasty. The calculated probability for an experienced operator (greater than 100 occlusions attempted) to successfully open an occlusion with favorable morphology (less than or equal to 1 month old, short, tapered, without bridging collaterals) is 99%. An attempt by the same operator to open an occlusion with unfavorable structure (greater than or equal to 3 months old, long, untapered) has only 47% probability of success. The probability increases to 84% when the occlusion is tapered. We concluded that in addition to the duration and the length of occlusion, tapered morphology, bridging collaterals, and operator experience can predict successful angioplasty in chronic total coronary occlusion.

Coronary stenting for treatment of acute or threatened closure following dissection after coronary balloon angioplasty

We studied 32 patients (age 58 +/- 9 years) who had been treated with a Palmaz-Schatz stent after significant dissection complicating percutaneous transluminal coronary angioplasty (PTCA). We attempted to cover the entire site of dissection with prosthesis. The presence of dissection after PTCA was associated with Thrombolysis in Myocardial Infarction grade 0 to 1 flow in 19 patients and grade 2 flow in 13. The stented arteries were: left anterior descending artery in 19 patients, right coronary artery in seven, and left circumflex artery in five. A single stent was implanted in 11 and multiple stents in 21 patients. Angiographic success was achieved in 30 patients (94%). Two patients (6%) had urgent coronary artery bypass graft surgery, two (6%) had a myocardial infarction, and one (3%) patient died. Subacute occlusion occurred in one patient (3%). Angiographic restenosis was found in three of nine patients (33%) with a single stent and 11 of 17 (65%) with multiple stents. Clinical follow-up at 11 +/- 3 months showed the necessity of coronary artery bypass graft surgery in two patients and repeat PTCA in nine (31%). We conclude that coronary stenting is an effective treatment for significant coronary dissection after PTCA with an acceptable incidence of major cardiac events at follow-up.

Cardiac fluoroscopy for the diagnosis of coronary artery disease: a meta analytic review.

To evaluate variability in the reported accuracy of fluoroscopically detected coronary calcific deposits for predicting angiographic coronary disease, we applied meta analysis to 13 consecutively published reports comparing the results of cardiac fluoroscopy with coronary angiography. Population characteristics and technical and methodologic factors were analyzed. Sensitivity and specificity for predicting serious coronary disease compare quite well with those from the literature on the exercise ECG and the exercise thallium scintigram. Sensitivity increases and specificity decreases more significantly with patient age, and sensitivity is paradoxically lower in laboratories testing patients with more severe disease, as well as when 70% rather than 50% diameter narrowing is used to define angiographic disease. Work-up and test review bias were also significantly related to reported accuracy.

Percutaneous transluminal coronary angioplasty in patients aged 70 years and older: immediate and long-term results

We analyzed all coronary angioplasty procedures performed in patients aged greater than 70 yr since 1987. There were a total of 92 patients with a mean age of 74 +/- 4 yr (range 70-82). The clinical diagnosis was unstable angina in 79%. Single-vessel disease was present in 41%, double-vessel in 29% and triple-vessel in 30% of patients. A left ventricular ejection fraction of less than 40% was present in 18 patients. Angioplasty was attempted on one vessel in 52 patients (56%), on two vessels in 29 patients (32%) and in three vessels in 10 patients (11%). Angiographic success was achieved in 96% of stenoses and in 53% of chronic total occlusions attempted. Complete revascularization was achieved in 56% of patients. Complications included three patients (3.2%) who underwent emergency coronary artery bypass grafting, 1 patient (1.1%) who sustained a myocardial infarction and 5 patients (5.4%) who died. During hospitalization, which averaged 3 +/- 2 days, 1 patients sustained reversible renal failure and 5 patients required blood transfusion for a large groin hematoma. Clinical success at discharge was 83%. At a mean follow-up of 13 months (range 3-45 months), symptomatic improvement was observed in 59 of the 76 patients who had achieved clinical success, with 42 of these patients (55%) being asymptomatic. The following clinical events occurred: myocardial infarction in 1 patient, new percutaneous transluminal coronary angioplasty in 9 and 3 patients died of cardiac reasons.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of Beta-Blockade on Postexercise Oxygen Uptake Kinetics in Patients with Chronic Heart Failure

Background: Beta-blocking agents have recently been demonstrated to improve survival in chronic heart failure (CHF), but a debate exists regarding the influence of beta-blockade on exercise capacity in these patients. The time delay for oxygen uptake to return to baseline after exercise (VO2 recovery kinetics) has been shown to be related to the severity of CHF, skeletal muscle metabolic abnormalities and prognosis. We performed the present study to determine the effect of beta-blockade on VO2 recovery kinetics in patients with CHF. Methods: Twenty-five patients with CHF were randomized to 6 months of bisoprolol (n = 10, ejection fraction = 27 ± 6%) or placebo (n = 15, ejection fraction = 25 ± 5%) therapy. Bisoprolol dosage was titrated in accordance with the Cardiac Insufficiency Bisoprolol Study protocol. Before and after the study period, oxygen uptake kinetics in recovery from maximal exercise were calculated and expressed as the slope of a single exponential relation between oxygen uptake and time during the first 3 min of recovery. Results: Resting and maximal heart rates were reduced after bisoprolol therapy, by 17 (p < 0.05) and 14 (p = 0.08) beats/min, respectively. Maximal oxygen uptake was unchanged in the bisoprolol (19.0 ± 4.9 vs. 19.9 ± 4.3 ml/kg/min) and placebo (18.9 ± 3.6 vs. 19.4 ± 3.6 ml/kg/min) groups. The time constants in recovery were reduced by modest and insignificant amounts in both groups (127.2 ± 41 vs. 112.6 ± 27 s for bisoprolol and 119.5 ± 55 vs. 97.3 ± 31 s for placebo). The time constant in recovery was poorly related to peak VO2 (r = –0.10). Conclusion: In patients with CHF, beta-blockade does not influence exercise capacity or oxygen uptake recovery kinetics. While this study confirms the suppression of sympathetic drive which has been shown to have beneficial effects in CHF, these results suggest that beta-blockade has minimal effects on indices of exercise tolerance, including VO2 recovery time.