The Dutch experience in percutaneous transluminal angioplasty of narrowed saphenous veins used for aortocoronary arterial bypass

Abstract Of 19,994 percutaneous transluminal coronary angioplasty procedures performed in The Netherlands between April 1980 and January 1989, the long-term follow-up of 454 patients who underwent angioplasty of ≥1 saphenous vein bypass graft was reviewed. In 46% of patients single graft angioplasty was attempted, and in 54% of patients sequential graft angioplasty was attempted. The clinical primary success rate was 90%. In-hospital mortality was 0.7%, 2.8% of patients sustained a procedural myocardial infarction, and 1.3% of patients underwent emergency bypass surgery. After a follow-up period of 5 years, 74% of patients were alive, and 26% were alive and event-free (no myocardial infarction, no repeat bypass surgery or repeat angioplasty). In patients in whom the initial angioplasty attempt was unsuccessful, only 3% were event-free at 5 years, versus 27% of successfully dilated patients. The time interval between the angioplasty attempt and previous surgery was a significant predictor for 5-year event-free survival. The event-free survival rates for patients who had bypass surgery 1 year before, between 1 and 5 years, and 5 years before angioplasty, were 45, 25 and 19%, respectively. Less than one-third of patients with previous bypass surgery who had angioplasty of the graft remained event-free after 5 years. In patients needing angioplasty within 1 year after bypass surgery, better long-term results were achieved

Computed tomography angiography for the interventional cardiologist

WOS:000339902400002In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden. More recently, this technique has become mature, with a large body of evidence addressing its prognostic validation. In addition, CT angiography has moved from the field of `imagers' and clinicians and entered the interventional cardiology arena, aiding in the planning of both coronary and structural heart interventions, being transcatheter aortic valve implantation one of its most successful examples. It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes. On the other hand, the increasing use of CCTA as a gatekeeper for invasive coronary angiography is expected to lead to an increase in the ratio of interventional to diagnostic procedures and significant changes in the daily cath-lab routine. In a foreseeable future, cath-labs will probably offer an invasive procedure only to patients expected to undergo an intervention, perhaps becoming in this change true interventional-labs.publishersversionpublishe

Argatroban During Percutaneous Transluminal Coronary Angioplasty: Results of a Dose-Verification Study.

Background. Thrombin is a key enzyme in thrombogenesis. In animals, specific antithrombotic therapy at the time of coronary angioplasty reduced the incidence of subacute occlusion and inhibited the restenosis response. Argatroban is a highly selective synthetic thrombin antagonist that binds in a competitive manner. This is a report of a dose-verification study, assessing the safety and feasibility of intravenous Argatroban administration in patients undergoing percutaneous transluminal coronary angioplasty. Methods. Before angioplasty an intravenous bolus of 30 g/kg argatroban was administered, followed by a continuous infusion of 3.5 g/kg/min for 72 hours. Bolus injection was repeated, and the infusion rate was increased in order to achieve an activated coagulation time (ACT) of over 300 seconds. Following interim analysis, the bolus and initial infusion rate for the subsequent treatment groups was determined. Study endpoints were the occurrence of adverse events, coagulation tests, and qualitative angiogram reading. Patients were monitored by continuous 12-lead electrocardiographic recording over 24 hours, and underwent control angiography 18–24 hours following angioplasty. Results. Four treatment groups, comprised of 2, 8, 9, and 11 patients, respectively, were studied. The first two patients were excluded from analysis, since the initial dose was ineffective to attain an ACT-authorizing coronary angioplasty. The group with the highest dosage received a 250 g/kg intravenous bolus of argatroban, followed by a 4 hour infusion of 15 g/kg/min. At 4 hours the infusion rate was lowered to 3.8 g/kg/min and was continued for 68 hours without adjustment for catheter removal. The adverse event profile included myocardial infarction, aortocoronary bypass graft, bailout procedures, and repeat coronary angioplasty. Thrombin-time (TT), activated partial thromboplastin time (APTT), and prothrombin time (PT) were significantly related to argatroban plasma concentration, as demonstrated by regression analyses (R-square 0.64, 0.71, and 0.84, respectively). Prothrombin fragments 1 and 2 and thrombin-antithrombin III complex did not fit into a mathematical model, but showed slightly increased levels after reduction or cessation of the infusion rate. Conclusions. This dose-verification study, including 30 patients at four dose levels, indicated that argatroban infusion in coronary angioplasty patients can be administered safely, and results in an adequate and predictable level of anticoagulation

Coronary vasodilatory action after a single dose of nicorandil

Coronary hemodynamics and vasodilatory effects on major epicardial arteries were investigated after a single dose of nicorandil in 22 patients undergoing cardiac catheterization for suspected coronary artery disease. Nicorandil, 20 mg, was administered sublingually to 11 consecutive patients and 40 mg to 11 others. Systemic blood pressure decreased significantly without affecting the heart rate. Coronary sinus blood flow did not change significantly. As the mean aortic pressure decreased significantly by 13% after 20 mg and 21% after 40 mg of nicorandil, the calculated coronary vascular resistance decreased but did not reach statistical significance. There was a decrease in myocardial oxygen consumption (-14% and -22%, respectively), and this was consistent with a significant decrease in the calculated pressure-rate product of 19% and 24%, respectively. A total of 103 selected coronary segments, including 17 stenotic segments, were analyzed quantitatively using a computer-assisted coronary angiography analysis system. After 20 or 40 mg of nicorandil, a significant increase of the mean diameter was observed in the proximal (+9% and +7%), midportion (+10% and +11%) and distal (+15% and +13%) parts of the left anterior descending coronary artery. Corresponding values for the proximal (+13% and +10%) and distal (+10% and +15%) segments of the circumflex artery were observed. An increase in the obstruction diameter was also observed in all but 3 of the analyzed stenotic segments. The results demonstrate that nicorandil, in the route and doses used, causes a significant vasodilation in the major epicardial coronary segments, including most stenotic segments, and decreases the myocardial oxygen demand with little effect on the resistance vessels

Coronary angioplasty early after diagnosis of unstable angina

Coronary angioplasty (PTCA) was performed early after diagnosis of unstable angina in 71 patients who responded favorably with initial pharmacologic treatment and who also had persistent exertional angina. The patients selected for PTCA had predominantly single-vessel disease and a normal or slightly abnormal left ventricular function. PTCA was successful in 87% (62/71) of the patients and unsuccessful in 13% (9/71). There were no deaths related to PTCA. The incidence of myocardial infarction during the procedure was 10% (seven of the 71 patients). Urgent bypass surgery was necessary in 11% (eight of 71 patients) of the patients. All patients were followed up for 12 months. There was one late death and one late nonfatal myocardial infarction. During 12 months of follow-up there was recurrence of angina pectoris in 25% of the patients (14/62). The restenosis rate was 25% (13/52) in the patients with an initial successful PTCA who underwent repeat angiography. Improved cardiac functional status after sustained successful PTCA was demonstrated by the normal exercise capacity on bicycle exercise testing and the absence of ischemia on thallium 201 scintigraphy studies in 70% of the patients. At the 1-year follow-up visit after attempted coronary angioplasty in all 71 patients, the total incidence of deaths was 1.5% (one patient), myocardial infarction 11% (eight patients), and the need for revascularization 25% (emergency surgery eight patients, late surgery three patients, and repeat PTCA seven patients); 91% (64 of 70 patients) were symptom free. It is concluded that PTCA in selected patients with unstable angina initially stabilized with medical treatment is an effective treatment with an acceptable complication rate and an excellent 1-year prognosis

Inter- and intra-observer variability in the qualitative categorization of coronary angiograms.

The ABC classification of the American College of Cardiology and the American Heart Association is a commonly used categorization to estimate the risk and success of intracoronary intervention, as well as the probability of restenosis. To evaluate the reliability of qualitative angiogram readings, we randomly selected 200 films from single lesion angioplasty procedures. A repeated visual assessment (> or = 2 months interval) by two independent observers resulted in kappa values of inter and intra-observer variability for the ABC lesion classification and for all separate items that compile it. Variability in assessment is expressed in percentage of total agreement, and in kappa value, which is a parameter of the agreement between two or more observations in excess of the chance agreement. Percentage of total agreement and kappa value was 67.8% and 0.33 respectively for the ABC classification, indicating a poor agreement. Probably this is due to the deficiency of strict definitions. Further investigation has to demonstrate whether improvement can be achieved using complete and detailed definitions without ambiguity, and consensus after panel assessment

Acute effects of intravenous nisoldipine on left ventricular function and coronary hemodynamics

The hemodynamic effects of nisoldipine were investigated in 16 patients with suspected coronary artery disease who underwent routine cardiac catheterization. Nisoldipine was given intravenously in a dose of 6 micrograms/kg over 3 minutes and measurements made before and after drug administration during spontaneous and matched atrial paced heart rate. During sinus rhythm, nisoldipine produced a significant increase in heart rate (19%, p less than 10(-5]. Left ventricular systolic pressure decreased 28% (p less than 10(-6) and left ventricular end-diastolic pressure did not change significantly (5%, difference not significant). Coronary sinus and great cardiac vein blood flow increased by 21% (p less than 0.02) and 25% (p less than 0.005), respectively, after nisoldipine administration. Simultaneously, mean aortic pressure decreased 33% (p less than 10(-6]; consequently, the global and regional coronary vascular resistances decreased by 50% (p less than 10(-4]. The decreases in global (-8%) and regional (-4%) myocardial oxygen consumption did not reach statistical significance. A 6% (not significant) increase in end-diastolic volume and an 11% (p less than 0.002) decrease in end-systolic volume resulted in an increase of 21% in stroke volume (p less than 10(-4] with a consistent increase in ejection fraction (+16%, p less than 10(-5]. Total systemic vascular resistance was reduced by 30% (p less than 0.0002). During spontaneous heart rate and matched atrial pacing, the time constant of isovolumic relaxation as assessed by a biexponential model, was significantly shortened.(ABSTRACT TRUNCATED AT 250 WORDS

Coronary vasodilatory action of elgodipine in coronary artery disease

The effects of intravenous elgodipine, a new second-generation dihydropyridine calcium antagonist, on hemodynamics and coronary artery diameter were investigated in 15 patients undergoing cardiac catheterization for suspected coronary artery disease. Despite a significant decrease in systemic blood pressure, elgodipine infused at a rate of 1.5 micrograms/kg/min over a period of 10 minutes did not affect heart rate and left ventricular end-diastolic pressure. The contractile responses during isovolumic contraction showed a slight but significant increase in maximum velocity (56 +/- 10 to 60 +/- 10 seconds-1; p less than 0.005), whereas the time constant of early relaxation was shortened from 49 +/- 11 to 44 +/- 9 ms (p less than 0.05). Coronary sinus and great cardiac vein flow increased significantly by 15 and 26%, respectively. As mean aortic pressure decreased, a significant decrease in coronary sinus (-27%) and great cardiac vein (-28%) resistance was observed, while the calculated myocardial oxygen consumption remained unchanged. In all, 69 coronary segments (including 13 stenotic segments) were analyzed quantitatively using computer-assisted quantitative coronary angiography. A significant increase in mean coronary artery diameter (2.27 +/- 0.53 to 2.48 +/- 0.53 mm; p less than 0.000001), as well as in obstruction diameter, (1.08 +/- 0.29 to 1.36 +/- 0.32 mm; p less than 0.02), was observed. The results demonstrate that elgodipine, in the route and dose described, induces significant vasodilatation of both coronary resistance and epicardial conductance vessels, without adverse effects on heart rate, myocardial oxygen demand and contractile indexes