Ubeydullah Deligonul

Multilesion coronary angioplasty: Clinical and angiographic follow-up

Determination of the restenosis rate after multilesion percutaneous transluminal coronary angioplasty is an important consideration in defining expanded indications for the procedure. Of 209 patients who underwent successful multilesion coronary angioplasty, 55 symptomatic and 74 asymptomatic patients were restudied an average of 7 +/- 4 months after dilation. The restenosis rate was 82% (45 of 55) in the symptomatic patients and 30% (22 of 74) in the asymptomatic patients (p less than 0.001). Only 4% of the asymptomatic patients had restenosis at more than one dilation site. When only patients who developed a restenosis were considered, the restenosis occurred at more than one dilation site in 47% (21 of 45) of the symptomatic group versus 14% (3 of 22) of the asymptomatic group (p less than 0.05). When all recurrent stenoses were examined, the severity of the luminal narrowing was greater than or equal to 70% in 64% (45 of 70) of the stenotic lesions in the symptomatic patients versus 31% (8 of 26) of the stenotic lesions in the asymptomatic patients (p less than 0.05). Proximal left anterior descending coronary artery disease, increased length of the stenotic narrowing, male gender and diabetes were associated with an increased incidence of restenosis by multivariate analysis. Patient-related variables were not predictive of multilesion restenosis. In conclusion, the majority of patients are clinically improved after multilesion coronary angioplasty. Recurrent symptoms after multilesion coronary angioplasty are frequently associated with multilesion restenosis and a more severe degree of restenotic narrowing. Restenosis at more than one dilation site is uncommon in the asymptomatic patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous adenosine : continuous infusion and low dose bolus administration for determination of coronary vasodilator reserve in patients with and without coronary artery disease

To assess the use of adenosine as an alternative agent for determination of coronary vasodilator reserve, hemodynamics and coronary blood flow velocity were measured at rest and during peak hyperemic responses to continuous intravenous adenosine infusion (50, 100 and 150 micrograms/kg per min for 3 min) and intracoronary papaverine (10 mg) in 34 patients (17 without [group 1] and 17 with [group 2] significant left coronary artery disease), and in 17 patients (11 without and 6 with left coronary artery disease) after low dose (2.5 mg) intravenous bolus injection of adenosine. The maximal adenosine dose did not change mean arterial pressure (-10 +/- 14% and -6 +/- 12% for groups 1 and 2, respectively) but increased the heart rate (15 +/- 18% and 13 +/- 16, respectively). For continuous adenosine infusions, mean coronary flow velocity increased 64 +/- 104%, 122 +/- 94% and 198 +/- 59% and 15 +/- 51%, 110 +/- 95% and 109 +/- 86% in groups 1 and 2, respectively for each of the three doses. Mean coronary flow velocity increased significantly after 100 and 150 micrograms/kg of adenosine and 10 mg of intracoronary papaverine (48 +/- 25, 52 +/- 19 and 54 +/- 21 cm/s, respectively; all p less than 0.05 vs. baseline) and was significantly higher than in group 2 (37 +/- 24, 32 +/- 16, 41 +/- 23 cm/s; all p less than 0.05 vs. group 1). The coronary vasodilator reserve ratio (calculated as the ratio of hyperemic to basal mean flow velocity) for adenosine and papaverine was 2.94 +/- 1.50 and 2.94 +/- 1.00, respectively, in group 1 and was significantly and similarly reduced in group 2 (2.16 +/- 0.81 and 2.38 +/- 0.78, respectively; both p less than 0.05 vs. group 1). Low dose bolus injection of adenosine increased mean velocity equivalently to that after continuous infusion of 100 micrograms/kg, but less than after papaverine. There was a strong correlation between adenosine infusion and papaverine for both mean coronary flow velocity and coronary vasodilator reserve ratio (r2 = 0.871 and 0.325; SEE = 0.068 and 0.189, respectively; both p less than 0.0005). No patient had significant arrhythmias or prolongation of the corrected QT (QTc) interval with adenosine, but papaverine increased the QT (QTc) interval from 445 +/- 44 to 501 +/- 43 ms (p less than 0.001 vs. both maximal adenosine and baseline) and produced nonsustained ventricular tachycardia in one patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Immediate and short-term benefit of multilesion coronary angioplasty: Influence of degree of revascularization

The safety and short-term therapeutic benefit of multilesion percutaneous transluminal coronary angioplasty was assessed in 135 patients, 66 of whom had a minimum of 6 months of follow-up study. Primary success, defined as successful dilation of the most critical lesion or all lesions attempted without major in-hospital complications was obtained in 117 (87%) of the 135 patients. Cardiac complications associated with the procedure were uncommon; prolonged angina occurred in 5% and myocardial infarction in 3%; emergency coronary bypass surgery was performed in 4% of the patients. There were no deaths. Complete revascularization was achieved in 46% of the 117 patients with a primary success. Of the 66 patients eligible for 6 month follow-up, 80% had an uncomplicated course and required no further procedures. Clinical improvement by at least one angina functional class was observed in 90% of the patients. Cardiac events such as the need for a second revascularization procedure were significantly more common in patients who had incomplete versus complete revascularization (35 versus 9%; p = 0.018). Repeat coronary angiography performed an average of 5 months after angioplasty revealed restenosis in 18 of 22 symptomatic patients and 3 of 9 asymptomatic patients. Restenosis occurred at the site of a single dilation in 12 patients, at two sites in 8 patients and at three sites in 1 patient. Thus, multilesion coronary angioplasty is an important therapeutic option for selected patients with multivessel disease and can be performed with relatively low risk. Improvement in angina status can be expected even in patients who have incomplete revascularization.(ABSTRACT TRUNCATED AT 250 WORDS)

Early ambulation after 5 French diagnostic cardiac catheterization: Results of a multicenter trial☆

Because earlier ambulation and discharge after cardiac catheterization may result in the increased utilization of outpatient facilities, a prospective five center clinical pilot trial assessing the safety and outcome of early ambulation after routine left heart catheterization was performed in 287 patients. Catheterization routines at each clinical center were unchanged throughout the study. After the diagnostic catheterization using 5 French (F), preformed, large lumen catheters and arterial puncture compression (mean 15 min, range 5 to 52), 260 patients were ambulated by a physician at a mean time of 2.6 h (range 1.8 to 3.1) after catheterization. Follow-up examination or a phone call 24 to 72 h later was performed to assess late results. The mean age of the patients was 58 years (range 25 to 91); 166 (58%) were men. Left ventricular ejection fraction was 54 +/- 15%. One hundred twenty-seven patients (44%) received intravenous heparin (1,500 to 5,000 U as an intravenous bolus) and 136 (47%) received aspirin. Major complications included transient ischemic attack (one patient) and ventricular tachycardia requiring cardioversion during ventriculography (two patients). A small hematoma (less than 5.0 cm) after ambulation occurred early (from compression to standing) in 14 patients (5%; 9 received heparin, 8 were taking aspirin) and later (after standing to 72 h) in 9 patients (3%; 2 receiving heparin, 2 taking aspirin). Five patients with a hematoma had studies with a 6F sheath. No patient required surgical intervention for early or late hematoma. Only three patients (1%) needed a 7F or 8F catheter because of suboptimal 5F coronary angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired coronary vasodilator reserve in the immediate postcoronary angioplasty period: Analysis of coronary artery flow velocity indexes and regional cardiac venous efflux

The ratio of peak hyperemic/basal mean coronary flow velocity, an index of coronary vasodilator reserve, immediately after coronary angioplasty normalizes in less than 50% of patients. To evaluate other indexes of coronary vasodilator capacity, both intracoronary arterial velocity and cardiac venous efflux were measured at rest and during vasodilator-induced coronary hyperemia (intracoronary nitroglycerin and papaverine) before and after angioplasty in 27 patients; 17 patients had measurements of intracoronary velocity alone and 10 had thermodilution measurements of great cardiac vein flow. Coronary flow velocity responses were also measured in 6 angiographically normal segments in patients undergoing angioplasty and in 10 normal left coronary artery segments in patients with normal coronary arteries or isolated right coronary artery disease. Despite significant angiographic (72 +/- 12 to 23 +/- 11% diameter narrowing) and hemodynamic (49 +/- 12 to 19 +/- 12 mm Hg aortocoronary gradient) improvement, coronary vasodilator reserve ratios for both arterial velocity and venous flow after angioplasty were only minimally affected. Angioplasty did not significantly increase rest coronary vein flow or artery flow velocities, but did result in significantly higher papaverine responses after angioplasty. Mean and phasic coronary velocity, diastolic coronary flow velocity integral and measured great cardiac vein flow ratios were significantly lower when compared with those in 16 angiographically normal coronary artery segments. These data indicate that maximal hyperemic coronary flow velocity is increased after angioplasty, but the reserve ratios, calculated by any of several flow velocity indexes, remain minimally improved. Angiographic correlations (percent coronary diameter, absolute diameter or cross-sectional area) with variables of coronary blood flow or velocity suggest that no single variable is useful in assessing angioplasty results. However, postangioplasty arterial mean velocity and diastolic flow velocity integral are nearly normalized in most patients, whereas relative changes remain attenuated. These findings are important in studies assessing coronary vasomotor responses in patients with atherosclerotic coronary disease, especially after angioplasty.

Increased frequency of restenosis in patients continuing to smoke cigarettes after percutaneous transluminal coronary angioplasty

The influence of continued cigarette smoking on restenosis after percutaneous transluminal coronary angioplasty (PTCA) was retrospectively determined through a study of 160 patients with primary success who underwent follow-up angiography after a mean of 7 +/- 7 months. The average number of narrowings at risk for restenosis was 1.7/patient in the 84 patients who continued to smoke (group 1) and 1.9/patient in the 76 patients who stopped smoking at the time of PTCA (group 2) (difference not significant). The 2 patient groups at baseline were similar with respect to gender, frequency of diabetes mellitus, number of pack/year smoking, angina class and number of diseased coronary arteries. The location of the dilated narrowings, the residual luminal diameter stenosis and the transstenotic gradient after the procedure were similar in both groups. The recurrence of angina greater than or equal to class II was the reason for restudy in 43% and 36% of group 1 and group 2 patients, respectively. Restenosis, defined as the presence of greater than or equal to 50% narrowing at the site of previous successful dilatation at follow-up angiography, was significantly higher in group 1 compared with group 2 patients (55% vs 38%, p = 0.03). Continued smoking was selected as an independent predictor of restenosis by logistic regression analysis. The incidence of coronary artery disease progression (14% vs 10%) was not significantly different between the 2 groups. In conclusion, continued smoking after successful PTCA is associated with an increased risk of restenosis. The higher restenosis rate in smokers emphasizes the need to strengthen educational programs after PTCA.

Smoking is a risk factor for coronary spasm in young women.

BackgroundRisk factors for pure coronary spasm are not known. Clinical observations have pointed to cigarette smoking, a known risk factor for obstructive coronary artery disease. Methods and ResultsWe conducted a case-neighborhood control study of premenopausal women, a population segment with the lowest prevalence of obstructive coronary artery disease. The cases were 21 premenopausal women (age range, 36–41 years) with angiographically proven coronary spasm. All coronary arteriograms were analyzed by two independent experienced cardiologists on two occasions. There were no differences between analyses; all cases had normal baseline coronary angiogram except for two, who had less than 20% coronary luminal stenosis in segments other than the site of the focal vasospasm. All cases had normal hemodynamics at rest, normal left ventricular function, and were in sinus rhythm. Ascertainment of the cases was done by angiographic demonstration of focal coronary spasm spontaneously or by ergonovine provocation. Six cases developed spontaneous coronary spasm before catheter engagement, and in 15, coronary spasm was induced by ergonovine provocation. Each case was asked to name as many as possible female neighborhood acquaintances of similar age and racial background who were willing to answer the same standardized questionnaire. The same standardized questionnaire was completed for each case and each control (n = 63). The standardized questionnaire was designed to obtain information on health characteristics, habits, socioeconomic status, and education. Only cigarette smoking was significantly more prevalent among coronary spasm cases. Cigarette smokers were 13 cases (62%) and 11 controls (17.5%) (p<0.001). The odds ratio was 7.7, with a 95% confidence interval of 2.6–23.1. ConclusionsThese findings suggest that there is a very strong association between cigarette smoking and pure coronary spasm in young women.

Percutaneous transluminal coronary angioplasty in octogenarians

Abstract Extensive data are available on the results of nonoperative coronary revascularization using percutaneous transluminal coronary angioplasty (PTCA) in patients over the age of 65, 1–3 but few data are available in the subgroup of patients in their octogenarian years. We attempted to ascertain clinical data and results in patients older than 80 years of age undergoing PTCA in our hospital.

Detection of coronary collateral flow by a Doppler-tipped guide wire during coronary angioplasty

Coronary collaterals may not be apparent during routine coronary angiography or during coronary angioplasty as a result of a variety of physiologic and anatomic factors.‘-” The dynamic nature of the collateral circulation has been demonstrated by newly appearing angiographic collaterals during contralateral vessel occlusion.3 An elevated coronary occlusion wedge pressure during angioplasty balloon inflation has also been an accepted indication of acutely recruitable collateral circulation6 In some patients coronary collateral flow may reduce ischemia by providing distal perfusion pressure equal to that of the systemic circulation through angiographically insignificant collateral

Coronary angioplasty: a therapeutic option for symptomatic patients with two and three vessel coronary disease

Coronary angioplasty is a widely applied revascularization procedure for patients with multivessel coronary artery disease. However, follow-up in this patient subgroup is relatively limited. From 1983 to 1986, coronary angioplasty was performed in 349 and 121 patients with, respectively, two- and three-vessel coronary disease with a primary success rate of 83 and 88%. The in-hospital mortality rate was 2.8% (13 of 470 patients). Complete revascularization was achieved in 128 patients. Among the 397 patients with a successful outcome, 373 (94%) were followed up greater than or equal to 1 year; 79% were free of death, nonfatal myocardial infarction or the need for coronary bypass grafting, and 82% of patients had symptomatic improvement by at least one angina functional class. A second coronary angioplasty procedure was required in 13% of patients. After a mean follow-up period of 27 months, an increased incidence of coronary bypass grafting was noted in patients with incomplete versus complete revascularization (16 versus 7%, p less than 0.05). Among the 222 patients who had repeat cardiac catheterization performed an average of 7 months after angioplasty, 103 were symptomatic; 50% of the 222 patients had at least one vessel with greater than or equal to 50% restenosis and 14% of patients had multiple restenoses. In conclusion, coronary angioplasty can be performed with a high initial success rate and marked symptomatic improvement in patients with multivessel coronary disease. However, in this groups experience, the majority of patients selected for coronary angioplasty with multivessel coronary disease will have incomplete revascularization that can be predicted in the majority of patients before the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)