Steven E. Hearne

Internal mammary artery graft angioplasty: Acute and long-term outcome

Secondary to the low attrition rate of internal mammary artery grafts, limited data are available on the clinical and angiographic outcome of patients who have undergone balloon angioplasty of an internal mammary artery stenosis. This study examined a consecutive series of 68 patients who underwent balloon angioplasty of an internal mammary artery graft over a 9-year period. Procedural success was achieved in 60 of 68 (88%) patients. The primary reason for procedural failure was extreme vessel tortuosity. There were no major in-hospital complications. Angiographic follow-up was obtained in 78% of the patients with an angiographic restenosis rate of 19%. The overall event-free survival in patients with an initially successful procedure was 92%. In conclusion, internal mammary artery balloon angioplasty has both an excellent initial success rate as well as a low incidence of restenosis and repeat target lesion revascularization.

Left ventricular performance improves late after aortic valve replacement in patients with aortic stenosis and reduced ejection fraction

EF in patients with aortic stenosis and reduced EF who underwent aortic valve replacement did not improve by 1 week postoperatively despite rectification of afterload mismatch. By 6 months, however, EF significantly improved without any further change in ventricular loading conditions. This implies that the benefit from aortic valve replacement (when measured by LV ejection performance) may not be evident until late postoperatively.

Effect of inadequate cardiac output reserve on exercise tolerance in patients with moderate mitral stenosis.

Twenty-nine patients with moderate mitral stenosis and 29 age-matched normal controls underwent symptom-limited upright bicycle exercise testing with simultaneous hemodynamic monitoring. Exercise tolerance in the mitral stenosis group was found to be limited by inadequate cardiac output reserve and not by resting mitral valve area or exercise pulmonary capillary wedge pressure.

Esophageal varices in association with unilateral pulmonary vein atresia

A 27-yr-old woman with recurrent episodes of hemoptysis (and hematemesis due to esophageal varices) was found to have unilateral pulmonary vein atresia. Reversed flow in the left pulmonary artery, a finding highly suggestive of this rare congenital anomaly, was demonstrated during cardiac catheterization. The definitive diagnosis was afforded by pulmonary wedge angiography, which not only demonstrated the atretic leftsided pulmonary veins, but also revealed a serpiginous system of systemic collateral veins to be the cause of her esophageal varices. Pneumonectomy of the nonfunctioning hypoplastic lung, the most successful approach to this disorder, may be complicated by severe bleeding of the numerous systemic arterial collateral vessels transected during surgical mobilization of the affected lung. Percutaneously delivered vascular occlusion coils were used in this case to occlude the large systemic to pulmonary artery collateral arteries immediately prior to pneumonectomy. Intra- and perioperative bleeding was minimal, and the patient has done well without further episodes of hemoptysis or hematemesis. Percutaneous occlusion of systemic to pulmonary collaterals may prove useful as a preoperative step for other congenital heart disease patients requiring lung or heart/lung transplantation.

Diagnosing coronary arterial stent thrombosis and arterial closure.

This single-center review of a consecutive series of patients requiring reexamination by angiography within 1 week of a coronary stent placement due to chest pain reveals that patients treated with a poststent anticoagulation regimen of warfarin and aspirin, and those with lower poststent deployment dilation pressures, have an increased risk of subacute stent thrombosis. Repeat cardiac catheterization within the first week after coronary artery stent implantation should be reserved for patients with significant electrocardiographic changes.

731-2 Angiographic and Clinical Follow-up After Internal Mammary Artery Graft Angioplasty: A 9-Year Experience

Acute and long-term efficacy of internal mammary artery (IMA) graft angioplasty has been limited to isolated ease reports and small patient series with limited angiographic follow-up. Over a 9-year period, 68 consecutive patients (74% male; median age: 61 yrs) underwent PTCA of IMA stenoses. In 59 patients, the lesion was located at the distal anastomosis, while in 9 patients, the lesion was located in the body of the graft. Median graft age was 9 months. The procedural success rate was 88%. The unsuccessful procedures were due to: inability to cross with wire/device due to excessive vessel tortuosity (5), major dissection (2), and inability to dilate (1). No patient experienced an in-hospital re-occlusion, distal embolization or CABG. Angiographic follow-up was obtained in 78% of successful procedures at a mean interval of 8 months. Restenosis (g50% luminal diameter narrowing) occurred in 9 patients (19%). A sub-analysis by lesion site revealed a restenosis rate of 15% (6/40) at the distal anastomosis and 43% (3/7) in the body of the graft. At a mean clinical follow-up of 14 months, 76% of patients had Class I or II angina, and event-free survival was 86%. Conclusion Angioplasty of IMA grafts is associated with excellent acute and long-term outcome. The restenosis rate of IMA anastomotic lesions appears to be lower than either native arteries or saphenous vein grafts.