Importance of calibration for diameter and area determination by intravascular ultrasound

Intravascular ultrasound (IVUS) permits quantitative assessment of the lumen diameter and area of coronary arteries. The experimental study was performed to evaluate the accuracy of diameter and area measurements.Lumen quantitation (lumen diameter D and cross-sectional area A) in lucite tubes (lumen diameter 2.5 to 5.7 mm, Plexiglas) was performed using a mechanical IVUS system (HP console, 3.5 F catheter, Boston Scientific, 30 MHz). The influence of fluid type (blood, water and saline solution), fluid temperature (20 degrees C/37 degrees C), catheter to catheter variation, gain setting and ultrasound frequency (12, 20 and 30 MHz) was determined. In blood at 20 degrees C there was a constan…

Coronary Artery Shape and Flow Changes Induced by Myocardial Bridging.

Changes in coronary shape and blood flow induced by myocardial bridging were analyzed in a 56-year-old patient with symptoms of unstable angina after the exclusion of other heart disease. Coronary angiography demonstrated a 1.8-cm long myocardial bridge in the middle part of the left anterior descending coronary artery. In systole, an eccentric compression of the artery occurred, resulting in a stenosis that occupied 86% of the diameter and 96% of the area. Intraluminal ultrasound was performed with a 20-MHz transducer in a 4.8-Fr catheter sheath (Boston Scientific Corp.) connected to an ultrasound console (Diasonics Inc.). A side saddle catheter was introduced into the left anterior descen…

Assessment of image quality of intracoronary ultrasound systems with tissue-equivalent vessel phantoms

Imaging of vascular structures by intracoronary ultrasound (ICUS) is finding more and more applications in coronary diagnosis and in the assessment of interventional access. The authors describe a method for easy and quick production of tissue-equivalent vessel phantoms from a special hydrocolloid. The mechanical tolerance is less than 3/100 mm. With these phantoms the authors tested the calibration and measured the resolution properties of the SONOS intravascular ultrasonic system (Hewlett Packard). The measurements revealed a slight space related underestimation of diameters up to 280 /spl mu/m. Using cross correlation and auto correlation functions the authors analyzed digitized ultrason…

Aktuelle Komplikationsrate der perkutanen transluminalen Koronarangioplastie bei stabiler und unstabiler Angina

During a four-year period (1983-1986) percutaneous transluminal coronary angioplasty (PTCA) was performed on 930 patients with stable or unstable angina with a mortality rate of 0.4%. A transmural myocardial infarct developed in 1.1% and 1.0% of patients required an urgent aorto-coronary bypass. Thus the total rate of severe cardiac complications was 2.5%. Compared with the years 1983-1985, there was in 1986 a significant fall in the number of deaths and of myocardial infarcts from 2.2% to 0.5% (P less than 0.05), while there was a nonsignificant increase in emergency coronary bypass surgery from 0.7 to 1.3%. Patients with unstable angina compared with those with stable angina had a signifi…

Are Morphological or Functional Changes in the Carotid Artery Wall Associated With Chlamydia pneumoniae, Helicobacter pylori, Cytomegalovirus, or Herpes Simplex Virus Infection?

Background and Purpose —Chronic infection with Chlamydia pneumoniae , Helicobacter pylori , cytomegalovirus (CMV), and herpes simplex virus (HSV) has been implicated in the pathogenesis of atherosclerosis. The carotid intima-media thickness (IMT) can be taken to indicate early atherosclerosis, the presence of a carotid stenosis is a marker of a manifest carotid atherosclerosis, and an increase in arterial stiffness is used as marker of structural and functional changes in an atherosclerotic vessel wall. Methods —In 504 patients (75% men; mean age 62.9 [SD 10] years), we measured the IMT and the elastic pressure modulus (EP; n=445) of the common carotid artery and the prevalence of a intern…

A query language for medical statistical analysis

While standard query languages support primarily the definition of single queries, in the evaluation of medical studies one usually formulates large sets of interdependent queries. A set of this type is called an integrated transaction. Our system for the definition of integrated transactions is based on the observation that in medicine a large number of statistical evaluations is founded on a conceptional model that can be structured as a tree. We describe a screen oriented tree editor for the relational data base system DBase and report on our experience with its application in the evaluation of the success rate of PTCA interventions.

Neue Konzepte in der Prävention der Atherothrombose

Indications for early PTCA after thrombolysis

There are several ways to reopen an acutely occluded coronary artery. Thrombolysis can be achieved with various methods (1, 5, 7, 10). After thrombolysis we find that the residual thrombus can sometimes be seen, but in most cases, a more or less high grade coronary stenosis remains (2). It is also a question of whether it is always optimal to reopen the vessel, because if the vessel remains occluded, another occlusion cannot occur. With this situation one faces the possibility that the patient will suffer another infarction, and that the vessel will occlude again (4).

Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial

Summary Background Clopidogrel was superior to aspirin in patients with previous manifestations of atherothrombotic disease in the CAPRIE study and its benefit was amplified in some high-risk subgroups of patients. We aimed to assess whether addition of aspirin to clopidogrel could have a greater benefit than clopidogrel alone in prevention of vascular events with potentially higher bleeding risk. Methods We did a randomised, double-blind, placebo-controlled trial to compare aspirin (75 mg/day) with placebo in 7599 high-risk patients with recent ischaemic stroke or transient ischaemic attack and at least one additional vascular risk factor who were already receiving clopidogrel 75 mg/day. D…

Impact of routine angiographic follow-up after angioplasty

Abstract Background There is an ongoing controversy as to whether repeat coronary angiography should be routinely performed after successful percutaneous transluminal coronary angioplasty (PTCA). Methods We examined the 10-year outcome in 400 patients who had or had not undergone an angiographic control 6 months after successful PTCA and a subsequent event-free 6-month period. Our comparison was based on data gathered by questionnaire and telephone interview in 315 patients with (group A) and 85 patients without (group B) a routine 6-month angiographic control. Multivariate analysis (Cox model) was performed to identify predictors of adverse events. Results During the 10-year follow-up peri…

Myokardperfusion und -funktion nach Koronarinterventionen

Ein bei Belastung zunehmender Sauerstoffbedarf des Myokards kann im wesentlichen nur durch eine Steigerung der Koronardurchblutung gedeckt werden. Dies geschieht zu ca. 90% durch Dilatation der arteriolaren Widerstandsgefase und nur zu ca. 10% durch Dilatation der epikardialen Koronargefase, die angiographisch sichtbar gemacht werden konnen. Die Differenz zwischen Ruhe- und maximal moglichem Blutflus wird als Koronarreserve bezeichnet. Die Messung des koronaren Blutflusses, der Perfusion, des myokardialen Stoffwechsels sowie der Auswirkung auf die Myokardfunktion erfolgt durch verschiedenste Verfahren: Thallium-Szintigraphie, Positionen-Emissions-Tomographie, Magnetresonanztomographie, Clea…

Aktuelle Therapie der koronaren Herzkrankheit

In der vorliegenden Arbeit wird der gegenwartige Stand der Pravention und der medikamentosen Behandlung der koronaren Herzkrankheit aufgezeigt. Auf vielen verschiedenen Feldern konnten Erfolge erzielt und fruhere Ergebnisse durch experimentelle Forschung oder klinische Studien gesichert werden. Das gilt besonders fur den Einsatz von Azetylsalizylsaure zur Sekundarprophylaxe koronarer Ereignisse und kombiniert mit Fibrinolytika beim akuten Myokardinfarkt sowie kombiniert mit niedermolekularem Heparin beim akuten Koronarsyndrom. Direkte Thrombinantagonisten, Glykoprotein-Rezeptorantagonisten, Ticlopidin sowie neue und weiterentwickelte Fibrinolytika erbrachten grose Fortschritte. Der molekula…

Das akute Koronarsyndrom (ohne ST-Hebung)

Die Therapie bei akutem Koronarsyndrom sollte die moglichst fruhe Gabe von Acetylsalizylsaure 100 mg taglich (loading dose 250–500 mg) und Clopidogrel 75 mg taglich (loading dose 300 mg) umfassen. Daruber hinaus ist eine Antikoagulation mit unfraktioniertem oder niedermolekularem Heparin einzuleiten. Glykoprotein-IIb/IIIa-Rezeptorblocker konnen bei Patienten mit hohem Risiko (Troponin positiv) im Sinne einer Upfronttherapie (Eptifibatide/Tirofiban) oder gezielt nur bei Patienten mit Koronarintervention im Katheterlabor (Abciximab) verabreicht werden. In der Langzeittherapie ist Clopidogrel fur mindestens 9 Monate indiziert, ASS lebenslang. Alle Hochrisikopatienten sollten innerhalb von 48 S…

Recombinant hirudin as a periprocedural antithrombotic in coronary angioplasty for unstable angina pectoris

Percutaneous transluminal coronary angioplasty is often complicated by thrombotic abrupt vessel closure in patients with unstable angina pectoris. The present multicentre trial was performed to determine the feasibility of two-dose regimens of recombinant hirudin (r-hirudin) compared to standard heparin in patients undergoing coronary angioplasty for unstable angina, and to investigate the effects of the different treatment regimen on markers of coagulation activation. At five participating centres, 61 patients were randomly enrolled in one of two sequential groups of r-hirudin (group 1: 0.3 mg.kg-1 i.v. bolus, 0.12 mg.kg-1.h-1 i.v. infusion; 21 patients; group 2: 0.5 mg.kg-1 i.v. bolus, 0.…

Prognostic value of plasma tissue factor and tissue factor pathway inhibitor for cardiovascular death in patients with coronary artery disease: the AtheroGene study.

Summary. Background: Tissue factor (TF) and its specific inhibitor, tissue factor pathway inhibitor (TFPI), are important contributors to the initiation of the coagulation process. Objectives: To compare plasma levels of soluble TF (sTF) and free-TFPI (f-TFPI) between patients with stable angina pectoris (SAP) and acute coronary syndrome (ACS) and to assess the impact of the two variables on long-term prognosis. Patients/methods: Patients with SAPs (n = 1146) and acute coronary syndrome (n = 523) from the AtheroGene study were included and followed for 2.3 years. Because of the strong impact of unfractionated heparin (UFH) on f-TFPI levels, but not on sTF levels, patients having received UF…

Activated thrombin activatable fibrinolysis inhibitor levels are associated with the risk of cardiovascular death in patients with coronary artery disease: the AtheroGene study

Summary. Background: Thrombin activatable fibrinolysis inhibitor (TAFI) attenuates fibrinolysis. Results on the association between TAFI levels and the risk of coronary artery disease (CAD) are inconsistent. Objectives: We investigated the association between TAFI levels and the risk of cardiovascular events in CAD. Patients/Methods: 1668 individuals with angiographically proven CAD at baseline were followed for a median of 2.3 years, as part of the prospective AtheroGene cohort. Fifty-six deaths from cardiovascular (CV) causes and 35 non-fatal CV events were observed. Results: At baseline, three TAFI measurements were available: one evaluating the total amount of TAFI (t-TAFI), one measuri…

Evaluation of an automated chromogenic substrate assay for the rapid determination of hirudin in plasma.

Abstract A fully mechanized chromogenic substrate assay method for the rapid and specific determination of recombinant hirudin (r-hirudin) in citrated plasma on clinical chemistry analyzers (Hitachi 911 and Cobas Mira) is described. In a first step, 12 μl sample volume is mixed with the chromogenic substrate. Due to the almost immediate action of hirudin the inhibitory reaction and the cleavage of the substrate is started simultaneously when bovine thrombin is added in excess. This excludes interferences by antithrombin III or heparin cofactor II. The change in absorbance/min is recorded at 405 nm. The measuring range is about 0.2 – 4.0 mg/l r-hirudin on both analyzers. Precision is charact…

Moderne Therapie bei akutem Koronarsyndrom

Inhibition of platelet aggregation with aspirin and anticoagulation with unfractionated heparin can be considered the gold standard treatment of patients with acute coronary syndromes. Replacement of unfractionated heparins by low-molecular weight heparins seem to further improve the cardiovascular risk. Additional treatment with glycoprotein IIb/IIIa receptor blockers led to a further reduction of the clinical event rate, especially in patients undergoing coronary interventions during an acute coronary syndrome (more than 30% relative risk reduction). However, the latter substances did only lead to marginal improvements in the setting of a conservative stabilization of patients with acute …

Anomalous Origins of the Left Main Coronary Artery From the Noncoronary Sinus and of the Right Coronary Artery From the Left Sinus of Valsalva

A 70-year-old man was referred for recent-onset angina. The ECG showed a right-axis deviation and signs of an old anterior infarction with loss of R waves in leads V1 through V5. Chest radiograph demonstrated a markedly enlarged heart, which was shifted to the left side with discrete signs of pulmonary congestion. Transthoracic echocardiography, which was limited by poor imaging quality, revealed a normal left ventricular cavity with reduced ejection fraction (40%) due to hypokinesia of the anterior wall. Coronary angiography showed the dominant RCA to originate from the left sinus of Valsalva. It coursed between the aorta and the pulmonary artery to the right (Figs …

Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study

Summary Background Despite the use of aspirin, there is still a risk of ischaemic events after percutaneous coronary intervention (PCI). We aimed to find out whether, in addition to aspirin, pretreatment with clopidogrel followed by long-term therapy after PCI is superior to a strategy of no pretreatment and short-term therapy for only 4 weeks after PCI. Methods 2658 patients with non-ST-elevation acute coronary syndrome undergoing PCI in the CURE study had been randomly assigned double-blind treatment with clopidogrel (n=1313) or placebo (n=1345). Patients were pretreated with aspirin and study drug for a median of 6 days before PCI during the initial hospital admission, and for a median o…

Homocysteine concentration in coronary artery disease: Influence of three common single nucleotide polymorphisms.

Whether single nucleotide polymorphisms (SNPs) of homocysteine metabolism enzymes influence the rate of cardiovascular (CV) events in coronary artery disease (CAD) patients remains controversial.In this analysis, 1126 subjects from the AtheroGene study with CAD and 332 control subjects without known CAD were included. The following SNPs were investigated: methylentetrahydrofolate reductase (MTHFR-C667T), methionin synthetase (MS-D919G), and cystathionin beta synthetase (CBS-I278T). The endpoint was the combination of cardiovascular death, stroke, and non-fatal myocardial infarction (N = 286). The median follow-up time was 6.4 years. Kaplan-Meier curve analysis showed an increasing event rat…

High-Frequency rotablation of occluded coronary artery during heart catheterization

High-frequency rotation atherectomy of an occluded left circumflex coronary artery was performed in a 45-year-old man. Over a 0.009 inch flexible tip steel wire a diamond-coated brass burr fasten to a flexible drive shaft that rotates and tracks was advanced. The drive shaft was connected to a turbine and driven by compressed air with 150,000 rpm. After rotablation of the posterior lateral branch over 3 cm with a 1.5 mm burr and rotablation with a 1.75 mm burr of the posterior branch of the left circumflex coronary artery the vessel was reopened with a smooth surface without perforation and dissection. 24 h control and 6 mo control revealed an open coronary vessel. High frequency rotating c…

Manifestationen der Atherosklerose in verschiedenen Gefäßregionen

Aus pathologischen Untersuchungen ist bekannt, dass es sich bei der Atherosklerose um eine Erkrankung handelt, die den gesamten Gefasbaum betrifft. In der Framingham-Studie wurden Risikofaktoren der Atherosklerose ermittelt, die fur die Lokalisation der Atherosklerose in verschiedenen Gefasprovinzen eine unterschiedliche Wertigkeit besitzen. Patienten mit Manifestationen der Atherosklerose in Herz-, Hals- und Beinschlagadern haben im Vergleich zu einem Normalkollektiv eine schlechtere Prognose. Auserdem liegt eine hohe Koinzidenz von atherosklerotischen Lasionen in den verschiedenen Gefasregionen vor. Besonders ungunstig ist die Prognose fur Patienten, die zum Zeitpunkt der Untersuchung ber…

PTCA of the left main stem following protective coronary artery bypass grafting.

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 14 patients with significant left main stem stenosis following protective coronary artery bypass grafting (CABG). The procedure was successful in 13/14 patients (93%), achieving a decrease in mean diameter stenosis from 74% +/- 7% to 31% +/- 12% (P less than 0.01). Accordingly, the absolute stenosis diameter increased from 0.9 mm +/- 0.3 mm to 2.4 mm +/- 0.5 mm (P less than 0.01). Dissection of the left main stem artery and a transient significant fall of blood pressure each occurred in one patient. No other serious complications were noted. Eight of 13 patients (62%) with successful PTCA underwent control angiography. R…

Hochfrequenz-Rotationsatherektomie bei koronarer Herzkrankheit

Percutaneous high frequency coronary rotational ablation (PTCR) was used in 10 patients with significant coronary artery disease. PTCR removes arteriosclerotic material from the vessel wall. A diamond-coated (60-80 micron) brass burr-drill, fastened to a flexible drive shaft rotating and tracking along a central coaxial guide wire, was used. The turbine rotates the drive shaft in excess of 150,000-190,000 revolutions per minute. PTCR was successful in all patients, but in three additional percutaneous transluminal coronary angioplasty (PTCA) was then successfully performed. Coronary dissection occurred only once, requiring surgery which was successful. No vessel perforation was observed. Al…

SELPLG Gene Polymorphisms in Relation to Plasma SELPLG Levels and Coronary Artery Disease

P-selectin and P-selectin glycoprotein ligand (SELPLG, selectin P ligand) constitute a receptor/ligand complex that is likely to be involved in the development of atherosclerosis and its complications. While the genetic variability of P-selectin has already been investigated in depth, that of the SELPLG gene has not yet been extensively explored. The coding and regulatory sequences of the SELPLG were screened and nine polymorphisms were identified. The identified polymorphisms were genotyped in the AtheroGene study, a case-control study of coronary artery disease (CAD). Haplotype analysis revealed that two polymorphisms of SELPLG, the M62I and the VNTR, independently influenced plasma SELPL…

Sum of ST-segment elevations on admission electrocardiograms in acute myocardial infarction predicts left ventricular dilation.

In summary, ST-segment elevations on the admission electrocardiogram not only diagnose acute myocardial infarction but also provide predictive information with respect to developing infarct size and left ventricular remodeling as well as survival.

Left ventricular volume determination using colour superpositioning of contrast echocardiograms

Abstract Objective: To delineate the endocardium, selective colouring of contrast regions in left ventricular contrast echocardiograms was performed using digital image processing. Methods: Volume determinations were performed in end-diastolic and end-systolic frames before and after the injection of contrast agent into the left ventricle and were compared to cineventriculograms in 30 patients by two independent investigators. Results: The mean end-diastolic volume measured was 114 ± 44 ml in the native, 235 ± 79 ml in the contrast, 175 ± 70 ml in the color-superimposed (observer 1), and 187 ± 79 ml in the cineventriculographic images. Thus, native echocardiograms underestimated angiographi…

Comparison of Arterial and Venous Blood Flow Between Patients with Pressure Dressing or a New Hemostatic Puncture Closure Device After Cardiac Catheterization

The aim of the study was to compare arterial and venous flow volume in the punctured leg in patients given a conventional pressure dressing and those given a new hemostatic puncture closure device (Angio-Seal) after cardiac catheterization. We prospectively measured blood flow in 25 patients with pressure dressing (group A) and 25 patients with Angio-Seal (group B) after cardiac catheterization. Duplex sonographic measurements were performed at the superficial femoral artery and vein of the punctured leg. In group A measurements were performed before catheterization, during pressure dressing, and after removal of pressure dressing. In group B we performed the measurements before catheteriza…

Noninvasive Visualization of an Apparent Patent Intracoronary Stent by Transesophageal Echocardiography

In the area of increasing interventional techniques there is a need for noninvasive imaging modalities to provide postinterventional follow-up. We were able to visualize the apparent patency and measure the dimensions of an intracoronary Palmaz-Schatz stent in the left circumflex coronary artery using transesophageal two-dimensional echocardiography. This report indicates the potential of echocardiography to directly assess coronary stents.

Monitoring prothrombin fragment 1+2 during initiation of oral anticoagulant therapy after intracoronary stenting

Patients with intracoronary stent implantation are treated with aggressive anticoagulant and antiplatelet therapy consisting of high-dose heparin, phenprocoumon, acetylsalicylic acid, dipyridamole, and the infusion of dextran to prevent a subacute thrombotic occlusion of the stented segment. In an effort to optimize this treatment by reducing both imminent bleeding complications and subacute thrombotic occlusion, the concentrations of prothrombin fragment 1 + 2 (F 1 + 2) were determined after intracoronary Palmaz-Schatz stent implantation in 19 consecutive patients. The F 1 + 2 concentrations after stent implantation and before the initiation of oral anticoagulant therapy (OAT) were 0.35 nm…

A new thrombectomy catheter device (AngioJet) for the disruption of thrombi: An in vitro study

In this study we examined a new thrombectomy catheter device. Different kinds of in vitro generated thrombi and cadaver thrombi were disrupted in test tubes. The mean disruption rate (and disruption time for 1 g of thrombus) was 225 +/- 65 mg/sec (5 +/- 2 sec) for whole-blood, 117 +/- 60 mg/sec (12 +/- 9 sec) for fibrin, 41 +/- 18 mg/sec (30 +/- 18 sec) for mixed, 70 +/- 42 mg/sec (17 +/- 5 sec) for unorganized, 45 +/- 8 mg/sec (22 +/- 4 sec) for partly, and 5 +/- 1 mg/sec (216 +/- 29 sec) for completely organized cadaver thrombi (P0.05). More than 99% of fragmented particles of whole-blood thrombi were 0-12 microm in diameter. The particle size of fibrin, mixed, and cadaver thrombi was sim…

Tissue classification by texture and spectral analysis of intracoronary ultrasound radio-frequency data

Imaging of vascular structures by intracoronary ultrasound allows in principal the recognition of different lesion types due to the echomorphology in the B-mode image. The subjective visual diagnosis is often difficult, especially the differentiation between thrombi and non-calcified plaque. The aim of this study was the extraction of features from the ultrasound radio-frequency signal for an objective characterization of coronary tissue. Methods of texture analysis and frequency analysis were used to differentiate red and white thrombi in vitro. Eight texture parameters of first and second order significantly differentiated red and white thrombi. The backscatter transfer function of red th…

Emergency angioplasty of totally occluded left main coronary artery in acute myocardial infarction and unstable angina pectoris--institutional experience and literature review.

Acute occlusion of the left main coronary artery (LMCA) is a rare angiographic finding. We report five patients with acute myocardial infarction (AMI) and one patient with unstable angina, in whom reperfusion was achieved or attempted with percutaneous transluminal coronary angioplasty (PTCA). All patients had a long history of stable angina pectoris. The indication for emergency PTCA was cardiogenic shock in the five patients with MI. PTCA was successful in five of six patients. Three patients with reperfusion survived, three died. All survivors underwent coronary artery bypass grafting (CABG) and were still alive at 23 months, 3 and 8 years respectively in NYHA functional class II or III.…

Ten-year outcome after coronary angioplasty in patients with single-vessel coronary artery disease and comparison with the results of the Coronary Artery Surgery Study (CASS).

The 10-year results of randomized trials comparing percutaneous transluminal coronary angioplasty (PTCA) in patients with single-vessel coronary artery disease (CAD) with coronary artery bypass grafting (CABG) and medical treatment are not available yet. The aim of this evaluation was to compare our 10-year follow-up results after PTCA in patients with single-vessel CAD with the 10-year follow-up results after CABG and medical treatment in the Coronary Artery Surgery Study (CASS) trial. We evaluated the clinical outcome of 509 patients with single-vessel CAD 10 years after coronary angioplasty. The data were compared with the results of 214 patients with single-vessel CAD after CABG or medi…

Clinical predictors of unstable coronary lesion morphology.

We evaluated prospectively clinical and angiographic data in 400 patients, 200 with unstable and 200 with stable angina in order to determine which clinical markers could reliably predict unstable coronary artery lesions. Comparison of the angiogram of 200 patients with unstable and 200 with stable angina revealed a high-grade lesion (42% vs 23%, P < 0.0001), complex lesion morphology (49% vs 20%, P < 0.0001) and thrombus-containing lesions (7% vs 1%, P = 0.006) as typical findings in patients with unstable angina. A high-grade lesion and/or complex lesion (including thrombotic lesions but excluding total occlusion) was found in 61% of unstable and 34% of stable patients (P < 0.0001). Clini…

High-frequency rotational ablation following failed percutaneous transluminal coronary angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) failed in 29 of 1,150 patients (2.5%) after successful passage of the guide wire. The reasons for failure were inability to pass the lesion with a balloon in 28 patients and inability to dilate the lesion in 1 patient. In these patients (15 stenoses and 14 chronic occlusions) rotational ablation was performed. We were able to pass the burr through the lesion in all of them, resulting in a reduction of diameter stenosis from 87 +/- 15 to 51 +/- 18%. Rotational ablation alone was initially successful (stenoses reduction > 20% and residual stenoses < 50%) in 15 of 29 (52%) patients. Additional PTCA was performed in 21 of 29 (72%) patients, …

Modernes Reperfusionsmanagement bei akutem Myokardinfarkt

In der Regel liegt dem transmuralen Myokardinfarkt (ST-Hebungsinfarkt) die Ruptur einer atherosklerotischen Plaque mit nachfolgend thrombotischem Verschluss einer Koronararterie zugrunde. Seit Beginn der 1980er Jahre hat die Reperfusionstherapie bei akutem Myokardinfarkt zunehmend Eingang in die klinische Routine gefunden. Als Standardtherapie hat sich die intravenose Thrombolysetherapie durchgesetzt. Je fruhzeitiger die Reperfusion einsetzt, um so mehr Myokardgewebe kann vor der drohenden Nekrose bewahrt werden. Diese erzielbare Verringerung der Infarktgrose geht mit einer Verringerung der sonst drohenden linksventrikularen Funktionseinschrankung und einer Abnahme der Letalitat einher. Let…

Einfluß von qualitativen Stenosecharakteristika auf die Meßqualität verschiedener QCA-Systeme (Impact of lesion characteristics on the quality of measurements with different QCA systems)

Die neueren QCA-Systeme weisen bei In-vitro-Messungen eine vergleichbare Reproduzierbarkeit und Genauigkeit der Mesergebnisse auf. Wir untersuchten, welchen Einflus die Morphologie von Koronararterienstenosen und die Bildqualitat auf die Mesergebnisse von drei fuhrenden QCA-Systemen (AWOS, Cardio und CMS) hat. Hierzu wahlten wir 57 Stenosen aus, die eine klinisch reprasentative Verteilung bezuglich des Stenosegrades, verschiedener Lasionscharakteristika und der Bildqualitat aufwiesen. Prozedurale Fehlerquellen wurden, soweit moglich, eliminiert. Drei Untersucher fuhrten je Stenose funf Messungen mit jedem der drei Systeme durch. Bei drei Stenosen war eine Auswertung nicht moglich.

Effects of combined therapy of clopidogrel and aspirin in preventing thrombus formation on mechanical heart valves in an ex vivo rabbit model.

Abstract Background: The aim of our study was to investigate the efficacy of the combination of clopidogrel and aspirin in the prevention of thrombus formation on artificial heart valves in an experimental rabbit model as compared to anticoagulation with warfarin. Methods: Studies were performed after oral administration of clopidogrel and aspirin in group I (n=9) for 5 days, after 5±2 days treatment with warfarin in group II (n=9) and without medication in group III (n=9). Leaflets from Sulzer Carbomedics bileaflet valves were placed in a flow chamber. The flow chamber was filled with blood in a continuous circulation between the carotid artery and the jugular vein. Results: In group III, …

Brain-natriuretic-peptide (BNP) zur Verbesserung der Diagnosefindung in einer konservativen Notaufnahme

Dyspnoe ist einer der haufigsten Grunde fur eine Vorstellung in einer Notaufnahmestation. Die weitere differentialdiagnostische Abklarung erfordert Zeit und verbraucht Ressourcen. Wir untersuchten deshalb, ob die Bestimmung des Brain-natriuretic-peptide (BNP) mittels eines Schnelltests eine zusatzliche Information zur klinischen Einschatzung bietet. Wir untersuchten 100 Patienten, die sich in einer Notaufnahmestation mit dem Leitsymptom „schwere Dyspnoe“ vorstellten. Bei allen Patienten wurde aus dem Uberstand des Blutes, das fur die Routineuntersuchungen gewonnen wurde, mittels eines Schnelltests der Gehalt an BNP bestimmt. Das Ergebnis wurde dem behandelnden Arzt nicht mitgeteilt. Alle Pa…

Coronary Spasm in Patients Treated by Percutaneous Transluminal Coronary Angioplasty

The appearance of coronary spasm during PTCA was analyzed in 140 consecutive patients with stable and unstable angina. Coronary spasm was found in 27 patients (19%) and was more common in unstable than in stable angina pectoris (22 versus 5 patients). While coronary spasm could be seen in the first coronary angiogram in 5/27 patients, it developed during the diagnostic procedure in 6/27 patients. In 16/27 patients coronary spasm was induced by the balloon or the guide wire itself.

Sodium-hydrogen exchange inhibition: novel strategy to prevent myocardial injury following ischemia and reperfusion.

Activation of Na+/H+ exchange and subsequent calcium overload in cardiac myocytes appear to play an important role in myocardial tissue injury following ischemia and reperfusion. Results of several in vitro studies in isolated myocytes and heart preparations and in vivo studies in pigs and rats have suggested that inhibition of Na+/H+ exchange is an effective means to prevent lethal reperfusion injury, arrhythmia, and improve myocardial contractile dysfunction. In patients with acute myocardial infarction (MI), any preventive agent is administered immediately before or shortly after reperfusion, rather than before the occurrence of coronary occlusion. The direct interventional approach to t…

Comparison of ReoPro((R)) (abciximab) versus intracoronary thrombolysis for early coronary stent thrombosis.

AIMS: This study evaluated the treatment of early coronary stent thrombosis with intracoronary urokinase or the platelet glycoprotein IIb/IIIa receptor inhibitor ReoPro (abciximab). METHODS AND RESULTS: Seventy-four patients (126 stents) were treated immediately after identification of early (0-30 days) coronary stent thrombosis. Twenty-nine patients were treated with intracoronary urokinase (UK) (UK alone in 19; UK and additional balloon angioplasty in 10) and another 45 patients were given ReoPro((R)) (abciximab) (0.25 mg/kg as a bolus alone in 26, abciximab with additional balloon angioplasty in 19) within 30 days of stent implantation. TIMI grade 3 flow was obtained in 23 patients (79%)…

Angiographic follow-up results of a randomized study on angioplasty versus bypass surgery (GABI Trial)

Although several randomized trials have been performed to compare the outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with multivessel disease, there is little data available on angiographic follow-up results. The present substudy of the German angioplasty versus bypass surgery investigation (GABI Trial) compares the angiographic revascularization status in these two cases 6 months after treatment. Follow-up angiograms were available in 102 CABG patients and 117 PTCA patients. Although the protocol excluded patients with total occlusion, on follow-up 6 months after treatment we found total occlusion of 94 native arterie…

Interventional cardiology: Differences in the morphology of unstable and stable coronary lesions and their impact on the mechanisms of angioplasty. An in vivo study with intravascular ultrasound

The aim of this study was to compare the morphology of stable and unstable coronary lesions using intravascular ultrasound in patients undergoing coronary balloon angioplasty and to determine whether lesion morphology had any influence on the mechanism of balloon angioplasty. Thirty three (15 stable and 18 unstable) patients undergoing single lesion percutaneous transluminal coronary angioplasty were studied with intravascular ultrasound before and after intervention. All examinations, recorded on S-VHS video tape, were studied off-line and matched sites from the point of minimum lumen area after the procedure and the corresponding site prior to intervention were compared. The morphology of…

Revascularisation of a Giant Coronary Artery Aneurysm in Suspected Incomplete Kawasaki-Disease

Kawasaki disease leads to typical vascular complications in up to 20 % of untreated cases. We describe a 47-year-old patient with coronary vessel disease, involving the right coronary artery with a huge aneurysmatic dilatation, suspicious for an incomplete form of Kawasaki disease. We found little information about the surgical treatment and postoperative course of this disease in adults. Typically, these infrequent patients present with acute myocardial infarction and require interdisciplinary decision-making.

A plea for provisional stenting.

292 Rate of complications in the follow-up of patent foramen ovale occluder therapy 1998–2003: role of realtime 3D and transesophageal studies

Clinical application of a new rheolytic thrombectomy catheter system for massive pulmonary embolism

Recanalization of Totally Occluded Coronary Vessels by Percutaneous Transluminal Coronary Angioplasty

Since its introduction in 1977, percutaneous transluminal coronary angioplasty (PTCA) has become an effective approach for treatment of patients with single-vessel disease [1–3, 5]. Treatment of double- and multiple-vessel disease has also been attempted [5, 6]. In patients with angina pectoris total occlusion of coronary vessels is found, and PTCA has also been used in an attempt to restore coronary blood flow in such patients [8, 10]. Even main stem occlusions have been recanalized [11]. In patients with total occlusion of coronary vessels, collateral flow is sufficient to maintain cardiac function at rest but not during exercise [12–14]. Therefore, PTCA seems to be an ideal method for re…

Evaluation of post-myocardial infarction regional and global left ventricular function by monoplane ventriculography: superiority of right versus left anterior oblique projection at any infarct location.

OBJECTIVES To study the significance of serial quantitative regional wall motion analysis, volumes, and ejection fraction findings as well as their prognostic implications derived from cineventriculography in 30 degrees right anterior oblique (RAO) projection in comparison with 60 degrees left anterior oblique (LAO) projection in post-myocardial infarction patients. Ventriculographic left ventricular parameters are accepted surrogates of mortality in myocardial infarction. Nowadays, in contrast to a biplanar approach in most institutions and clinical trials, the investigation is reduced to monoplanar ventriculography. However, it is not known whether the relevance of the two established pro…

Intravascular ultrasound detected classification of coronary lesions as a predictor of dissections after balloon angioplasty.

Dissection after balloon angioplasty of coronary arteries may give rise to an unfavourable early outcome. Compared with coronary angiography, intravascular ultrasound (IVUS) allows more detailed characterisation of dissections. We investigated the incidence and type of dissections after balloon angioplasty in calcified coronary lesions. IVUS was performed in 43 patients with 48 lesions before and after percutaneous balloon angioplasty. Significant calcification was defined as an arc of more than 90 degrees with typical acoustic shadowing. Dissections were classified as type A when the media was not involved by the dissection and as type B when media involvement had occurred. In the group wi…

Nickel release after implantation of the Amplatzer occluder.

Background Transcatheter closure of atrial septal defects is a new and less traumatic technique than open heart surgery. In recent years, patients with a patent foramen ovale sustaining potential paradoxical embolism have also become candidates for interventional closure devices. One of the more popular occluding devices is the Amplatzer septal occluder, which, like many other occluders, is made of nitinol. Nitinol-based alloys are widely used in medical products, for example, in orthopedics and orthodontics. However, the clinical use of nitinol, which contains 55% nickel, is still controversial because of concerns about its biocompatibility. Therefore, we examined the systemic nickel relea…

Homozystein, Methylentetrahydrofolatreduktase/C677T-Genotyp und Risiko für koronare Herzkrankheit

Einfluss genetischer Variationen des Cholesterylestertransferproteingens auf die Pr�valenz der koronaren Herzerkrankung

Mehrere funktionelle Polymorphismen des Cholesterylestertransferprotein( CETP)-Gens beeinflussen die CETP-Aktivitat und die High-density-lipoprotein(HDL)-Cholesterin-Konzentration. Neben anderen funktionellen Varianten wird vornehmlich der Promotorpolymorphismus CETP/C-629A als Risikofaktor der koronaren Herzerkrankung (KHK) diskutiert. Wir untersuchten in einer grosen Fall-/Kontroll-Studie den Einfluss verschiedener CETP-Genotypen und Haplotypen auf die HDL-Konzentration sowie die Pravalenz der KHK. Bei 1214 Patienten mit dokumentierter KHK sowie 574 Populationskontrollen wurden neben den klassischen Risikofaktoren folgende CETP-Polymorphismen bestimmt: C-629A, TaqIB, I405V, R451Q und A373…

Impact of infectious burden on progression of carotid atherosclerosis.

Background and Purpose— Recent findings suggest a causative role of infections in the pathogenesis of atherosclerosis. The extent of atherosclerosis and the prognosis of patients with atherosclerosis seem to be increased by the number of infections to which an individual has been exposed. In a prospective study, we evaluated the effect of 8 pathogens and the aggregate pathogen burden on the progression of carotid atherosclerosis. Methods— In 504 patients (74.9% men; age, 62.9±10 years), we measured intima-media thickness and prevalence of carotid artery stenosis. Follow-up measurements after a mean of 2.5 years were available in 427 patients (85%). Blood samples were taken, and IgG or IgA …

Long term follow up after percutaneous closure of PFO in 357 patients with paradoxical embolism: Difference in occlusion systems and influence of atrial septum aneurysm

Abstract Background Percutaneous transcatheter closure of patent foramen ovale (PFO) in cryptogenic stroke or TIA is an alternative to medical therapy especially in patients with atrial septal aneurysm (ASA). The differences in time to complete occlusion for various closure devices in PFO alone and PFO plus ASA are of natural interest. Methods and results Between January, 1st 1998 and November, 30th 2006 percutaneous PFO closure was performed in 357 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer PFO-( n =199), Starflex-( n =48) and Helex Occluder ( n =110). All patients were assigned to a post-interventional protocol with contrast-enhanced transe…

Ein diagnostisch-therapeutischer Stufenplan bei instabiler Angina pectoris

Unter instabiler Angina pectoris wird 1. eine Crescendo-Angina-pectoris verstanden, die an Starke und Haufigkeit zunimmt oder sich auf eine bestehende typische Belastungs-Angina-pectoris aufpfropft, 2. eine Angina pectoris in Ruhe und bei minimaler Belastung und 3. eine neu auftretende Angina pectoris, die bei geringster Belastung ausgelost wird [3].

Einfluss eines gest�rten Glukosestoffwechsels auf Manifestationen und Prognose der Atherosklerose in verschiedenen Gef��regionen

Patienten mit kardiovaskularen Erkrankungen haben eine deutlich schlechtere Prognose, wenn ein Diabetes mellitus (DM) vorliegt. Bereits bei Vorliegen eines abnormalen Nuchternglukosewertes ist die Inzidenz kardiovaskularer Ereignisse erhoht. Ziel dieser Untersuchung war es, den Einfluss diabetischer Stoffwechselstorungen auf die Inzidenz atherosklerotischer Manifestationen und auf die Langzeitprognose von Patienten mit Atherosklerose in multiplen Gefasregionen zu erfassen. Wir schlossen 906 Patienten (73% Manner, mittleres Alter 62,5 ± 9 Jahre) vor geplanter Koronarangiographie prospektiv in die Untersuchung ein. Bei allen Patienten wurde der periphere Gefasstatus mittels Duplexsonographie …

Langzeitverlauf über 10 Jahre nach Ballondilatation bei stabiler und instabiler Angina pectoris

OBJECTIVE To assess the cardiac status of patients ten years after percutaneous transluminal coronary artery angioplasty (PTCA). PATIENTS AND METHODS Data of 534 patients (436 men, 98 women; mean age 53.2 +/- 8 years) in whom a PTCA had been performed between 1983 and 1986 were analysed, based on a questionnaire answered 121 +/- 11 months after the initial procedure. At the time of PTCA 184 patients (35%) had unstable angina, 350 (65%) stable angina. RESULTS 116 patients (63%) with unstable angina and 164 (47%) with stable angina had at least one cardiac event after the initial PTCA (repeat PTCA, bypass operation, myocardial infarction, death). None of these events occurred in 68 patients (…

Echocardiography in myocardial infarction

This paper discusses the usefulness of echocardiography in thrombolysis, its diagnostic value and drawbacks for therapy and the possibilities for follow-up studies. The diagnostic value is seen in the possibility of localizing and defining the extent of myocardial infarction, not only of the left but also of the right ventricle, and recognizing the complications of myocardial infarction as soon as possible 1, 2, 4.

Short-and long-term outcome after PTCA in patients with stable and unstable angina

Acute results and follow-up data over a period of 36 months after attempted PTCA in 406 patients with stable angina and 202 patients with unstable angina are reported. The rate of acute complications (death, myocardial infarction and bypass grafting (CABG) amounted to 1.5% in stable and 6.4% in unstable patients (P less than 0.005). Within the first week after PTCA a significantly lower percentage (1.7% vs 10.4%) of cardiac events (death, myocardial infarction, CABG and repeat PTCA) was observed in the stable group (P less than 0.001). During a 12-month follow-up period, another 16.3% of the patients in the stable group and 30.7% of unstable patients suffered a new cardiac event (P less tha…

Transthoracic three-dimensional echocardiographic volumetry of distorted left ventricles using rotational scanning

The purpose of this study was to evaluate the relation of transthoracic three- and two-dimensional echocardiographic left ventricular volumetry to cineventriculographic volumetry. Twenty-five patients with distorted left ventricles were included in the study. To demonstrate the impact of acquiring data by rotational scanning, we performed three- and two-dimensional echocardiography in 36 latex ventricles with data acquisition in different areas of the ultrasound sectors. Interobserver and intraobserver variability were calculated to test for reproducibility. The three-dimensional imaging system consisted of a rotation motor device, a transthoracic 2.5 MHz transducer, a conventional ultrasou…