Sergio Cozzi

Successful dissolution of occlusive coronary thrombus with local administration of abciximab during PTCA.

Treatment of intracoronary thrombus poses difficult problems and may result in severe complications. We used a local delivery catheter (InfusaSleeve, LocalMed, Palo Alto, CA) to treat an occlusive coronary thrombus that was refractory to systemic thrombolysis and conventional angioplasty. After local administration of 10 mg of abciximab with this catheter there was successful resolution of coronary thrombus and vessel recanalization. Cathet. Cardiovasc. Intervent. 48:211–213, 1999.

Aspirin alone antiplatelet regimen after intracoronary placement of the Carbostent™: The Antares study

The effect of stent coatings in preventing early thrombotic occlusion remains to be proved. The purpose of this study was to evaluate the safety and efficacy of the Carbostent™, a new coronary stent with a nonthrombogenic coating (Carbofilm™), in 110 consecutive patients (73.6% men, mean age 61 ± 9 years) who met prespecified clinical and angiographic inclusion criteria and were treated with aspirin monotherapy after stenting. Stable angina (75.5%), unstable angina (18.2%), and silent ischemia (6.3%) were clinical indications for coronary revascularization. Patients received 10,000 U of heparin and no IIb/IIIa inhibitors or postprocedural heparin. Complex lesion characteristics (B2, C) were present in 39 out of 129 (30.2%) lesions. Mean lesion length was 15.6 ± 7.4 mm, and 32% of the lesions were >15 mm (range 16–52 mm). Small coronary vessels (<3.0 mm) were treated in 28% of the cases. A total of 165 Carbostent™ were used in 129 coronary lesions of the 110 patients. Single‐vessel stenting was performed in 97 (88%) patients and multivessel stent placement in 13 (12%) patients. The mean length of the stented segment was 21 ± 13 mm (range 9–95 mm). Procedural and clinical success was achieved in all patients. At 1‐month follow‐up, there were no stent thrombosis or other major adverse cardiac events. We observed 2 (1.8%) non‐Q‐wave myocardial infarctions and 2 (1.8%) vascular complications. This study indicates that the Carbostent™ may prevent stent thrombosis in selected patients treated with aspirin only. A randomized study comparing aspirin alone versus combined ticlopidine and aspirin after Carbostent™ implantation will be needed to confirm these results. Cathet Cardiovasc Intervent 2002;55:150–156.

Acute coronary vasomotor effects of nifedipine and therapeutic correlates in syndrome X

In 18 patients (12 women) presenting with effort-induced chest pain and normal coronary angiograms (syndrome X), 10 mg sublingual nifedipine increased the lumen of major coronary arteries (quantitative angiography) by 13 +/- 10% (p less than 0.01), coronary blood flow (thermodilution) by 23 +/- 26% (p less than 0.05), norepinephrine plasma concentration by 60 +/- 42% (p less than 0.01) and decreased the global ST-segment shift during the effort stress test from 8.8 +/- 4.1 to 7 +/- 6.8 mm (p less than 0.03) at comparable maximal workload and at unchanged double product. There was a correlation (positive) of changes in flow with changes in coronary lumen diameter (r = 0.65, p less than 0.01) with ST-segment response to exercise (r = 0.83, p less than 0.001) and with (inverse) norepinephrine plasma concentration (r = -0.70, p less than 0.01); no correlation was found between ST-segment response and changes in arterial lumen diameter. In a few cases, nifedipine did not improve or even worsened the response to exercise; coronary flow was unchanged or decreased and norepinephrine plasma levels were modestly or greatly increased, respectively. After 4 weeks of treatment with nifedipine (10 to 20 mg 4 times daily), the effort ST-segment shift was further decreased to 4.4 +/- 3.5 mm (p less than 0.03) despite a slightly increased double product. Plasma norepinephrine values, as compared to those after acute nifedipine, were decreased by 40% in patients with further improvement and were unchanged in patients whose exercise performance did not vary.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of outcomes in women and men treated with coronary stent implantation

Worse outcomes have been observed in women after PTCA. The present study was undertaken to compare clinical and angiographic results of coronary stenting among women and men. We retrospectively analyzed acute and 6‐month results in a consecutive series of 940 men and 160 women undergoing coronary stent implantation between May 1992 and January 1998. Women were older (63 vs. 57 years; P = 0.001), more often hypertensive (46.9% vs. 31.4%; P < 0.001) and diabetic (13.2% vs. 8.3%; P = 0.05), and less often smokers than men (32.5% vs. 70.5%; P < 0.001). A previous history of Q‐wave MI was less frequently present in women (28.2% vs. 40.2%; P = 0.003) who more often underwent coronary revascularization because of unstable angina (37.5% vs. 27.1%; P = 0.027). No difference was observed in coronary artery disease extension, lesion complexity, and stented vessel between the sexes. Bailout stenting was more frequently needed in women (28% vs. 17.8%; P = 0.001). No difference was observed in the number of stent implanted per vessel and per patient and average maximal inflation pressure used for stent postdilation. However, a smaller final balloon size was used in women. Procedural and clinical success was achieved in 94.4% and 92.5% of women and 96.7% and 94.5% of men (P = NS), respectively, without differences regarding in‐hospital major adverse cardiac events. Bleeding complications occurred more often in women when anticoagulation was used (OR = 2.87; 95% CI = 1.38–5.74). At 6‐month clinical follow‐up, TLR was similar between the sexes and event‐free survival was 75.5% in women and 81.5% in men (P = NS). Angiographic follow‐up, performed in 71% of the patients, showed that restenosis was 64% higher in women (OR = 1.64; 95% CI = 1.02–2.61). Despite older age, higher incidence of comorbidities, and more unstable presentation, women treated with coronary stenting showed acute and mid‐term clinical results similar to those observed in men. However, they were significantly more likely to develop angiographic restenosis. Cathet Cardiovasc Intervent 2003;58:20–28.

Mechanism of cutting balloon angioplasty for in-stent restenosis: an intravascular ultrasound study.

We investigated by intravascular ultrasound (IVUS) the mechanism of action of cutting balloon (CB) angioplasty in patients with in‐stent restenosis. Seventy‐one consecutive restenotic lesions of 66 patients were studied by quantitative coronary angiography (QCA) and IVUS before, immediately after, and, in 20 cases, at 24‐hr time interval after CB. CB was selected according to 1:1 CB‐to‐stent ratio and inflated at 8 atm for 60–90 sec. Both IVUS planar and volumetric (Simpsons rule, 25 patients) analysis were carried out. IVUS measurements included external elastic membrane area (EEMA), stent area (SA), minimal lumen area (MLA), and restenosis area (RA). Following CB, QCA analysis showed increase of minimal lumen diameter (1.17 ± 0.46 vs. 2.45 ± 0.51 mm; P < 0.0001) and decrease of diameter stenosis (64% ± 13% vs. 21% ± 9%; P < 0.0001). IVUS measurements showed a significant increase of MLA (2.18 ± 0.80 vs. 7.31 ± 1.8 mm2; P < 0.0001), SA (9.62 ± 2.6 vs. 10.7 ± 2.75 mm2; P < 0.0001), and EEMA (17.27 ± 5 vs. 18.1 ± 5 mm2; P < 0.0001) and a decrease of RA (7.43 ± 2.63 vs. 3.45 ± 1.39 mm2; P < 0.0001). No significant change was observed in the original plaque + media area (7.65 ± 3 vs. 7.38 ± 2.9 mm2; P = NS). Thus, of the total lumen enlargement (5.13 ± 1.85 mm2), 23% was the result of increase in mean SA, whereas 77% was the result of a decrease in mean RA. These changes were associated with a 5% increase in EEMA. IVUS volumetric changes paralleled planar variations. Angiographic and IVUS changes were well maintained at 24 hr. CB enlarges coronary lumen mainly by in‐stent tissue reduction associated with a moderate degree of additional stent expansion. Favorable QCA and IVUS acute results are maintained at 24 hr. Cathet Cardiovasc Intervent 2002;56:166–173.

Coronary angiographic patterns in hypertensive compared with normotensive patients

Patients in this study were assessed by coronary angiography because of classic effort angina and a positive exercise test. Of these patients, 320 had untreated primary hypertension and 320, similar in age and gender distribution, were normotensive. In all patients coronary angiography documented that at least one major epicardial branch was restricted by 50% or more. Prevalence of single- and double-vessel disease in the fourth and fifth decades of life was similar in the two populations and in both tended to decline with age. Prevalence of triple-vessel disease was also similar in the two populations in the fourth and fifth decades; in either population it rose with age and reached a peak at the seventh decade of life. The percentages of hypertensive patients in the sixth and seventh decades with triple-vessel disease was significantly (p less than 0.01) greater (40% and 50%, respectively) than the corresponding values in normotensive individuals (25% and 31%, respectively). The left main coronary artery was not significantly more involved in the high blood pressure group. Pressure was moderately and similarly raised at any age in hypertension; serum cholesterol and triglyceride levels, blood glucose, and smoking habits were comparable in the two populations. These results suggest that hypertension does not accelerate the appearance of significant coronary narrowing or multiple vessel involvement. Starting from the sixth decade, the natural age-related evolution of coronary disease seems to be aggravated in hypertensive subjects, as reflected by an augmented number of diseased vessels. This process is probably related to high blood pressure in itself; whether the severity of hypertension might also exert an influence is not deducible from this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Elective coronary stent implantation in cardiogenic shock complicating acute myocardial infarction: in-hospital and six-month clinical and angiographic results.

Effective treatment of patients with acute myocardial infarction and cardiogenic shock depends on restoring persistent patency of the infarct‐related artery. Coronary stenting, reducing abrupt or delayed closure related to dissection and suboptimal result, may improve PTCA results in cardiogenic shock. Eighteen patients (14 males and 4 females, mean age 59 ± 7 years), referred to catheterization laboratory for acute myocardial infarction and shock, had elective stent implantation during 14 primary and 4 rescue PTCA. Time delay between shock onset and PTCA was 4.1 ± 3 hr (range, 30 min to 12 hr). The IRA was LAD in seven patients (38%), LCx in two (11%), and RCA in eight (45%). One patient (5.%) had distal LMCA occlusion. Stent deployment was successful in 100% of patients and resulted in TIMI 3 flow in 13 (72%) patients. In 13 (72%) cases, cardiogenic shock gradually resolved and the patients were discharged alive. Five patients (28%) died because of irreversible hemodynamic deterioration without evidence of reinfarction. At 6‐month follow‐up, all the discharged patients were alive and no patient had reinfarction or recurrent angina. Heart transplant was required in one patient 5 months after stenting because of refractory congestive heart failure. Angiography demonstrated patency of all the coronary arteries treated, with TIMI 3 flow in all patients. Stent restenosis rate was 30%, and target lesion revascularization with CABG or re‐PTCA was not required in any case. LV function improved from 39% ± 15% to 51% ± 15% (P < 0.01). Elective coronary stenting is an effective treatment for acute myocardial infarction complicated by cardiogenic shock and may improve acute and long‐term survival. Cathet. Cardiovasc. Intervent. 50:384–389, 2000.

Use of a new diagnostic catheter for transradial internal mammary artery angiography early after minimally invasive coronary bypass

We describe a new diagnostic catheter specifically designed for selective catheterization of the left internal mammary artery via the ipsilateral radial approach. We used this catheter to assess the patency of the distal mammary‐left anterior descending coronary artery anastomosis in 30 consecutive patients early after minimally invasive direct coronary artery bypass grafting. The new catheter design allowed easy and fast engagement of the left internal mammary artery leading to optimal vessel opacification in all cases. Angiography revealed graft problems in seven (23.3%) patients, two of whom required anastomosis revision, surgical in one case and with PTCA in the other. No LIMA injury occurred as a result of selective catheterization. Patients with functionally normal anastomosis were discharged on the same day of the diagnostic procedure. Cathet. Cardiovasc. Intervent. 50:371–374, 2000.