Canadian Heart Association Research Articles

Clinical and prognostic effect of repeated ten-day courses of low-intensity laser exposure in patients with coronary heart disease

To assess the clinical and prognostic value of repeated courses of low-intensity LT in patients with CHD for 24 months. The study involved 40 men (mean age 56.6±8.2 years) with exertional angina pectoris with high (0-I functional class - 40%) and lower (II-III functional class - 60%) exercise tolerance (according to the classification of the Canadian Heart Association). Duration of the study was 24 months. All patients underwent 10-day courses of skin LT in the infrared radiation range every 6 months. Initially and after each course of LT, a bicycle ergometer test was performed with an assessment of the threshold values of blood pressure (BP), double product (DP=systolic BP×heart rate) and the ratio of DP to load power (DP/W). The blood levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) were studied after each course of LT. Patients had an improvement in their well-being during LT: a decrease in the number of angina attacks, the need for nitroglycerin, antianginal and antihypertensive drugs. A statistically significant increase in exercise tolerance by 33.2-40.1% was revealed since 1 month after each course of LT, according to the results of stress tests. At the same time, the threshold values of blood pressure remained at the initial level, which was regarded as a manifestation of the hypotensive effect. The decrease in the DP/W index by 18.2-29.6% compared with the initial data indicates the energy economization of cardiac activity. LT was accompanied by a statistically significant decrease in blood cholesterol from 6.15±1.26 to 4.84±1.28-5.25±1.53 mmol/l and LDL-C from 4.70±1.16 to 3, 29±1.26-3.96 mmol/l. Long-term clinical and preventive effect, good tolerability, availability, absence of side effects substantiate the possibility of widespread use of repeated courses of laser exposure in coronary heart disease.

Experience of post-infarction left ventricular aneurysm reconstruction with on-pump beating heart technique

Aim. To evaluate the results of surgical treatment of post-infarction left ventricular aneurysms with on-pump beating heart technique. 
 Methods. In our center from April, 2009 to January, 2014 169 patients had reconstruction of the left ventricle with on-pump beating heart technique. Among the patients 159 were males (94.1%) and 10 of them were females (5.9%), average age 53.8±8.9 years (39 to 72 years). Angina pectoris class I (according to the classification of Canadian Heart Association) was established in 7 (4.1%) patients, class II - in 49 (29.0%), class III - in 107 (63.3%), class IV - in 4 (2.4%), unstable angina in 2 (1.2%) patients. Chronic heart failure class I (according to New York Heart association functional classification) was diagnosed in 5 (3.0%) patients, class II in 37 (21.9%), class III in 124 (73.4%), class IV in 3 (1.8%) patients. Average ejection fraction of the left ventricle was 38.6±7.9% (25 to 67%). Mitral valve insufficiency stage 2-3 was revealed in 23 (13.6%) patients. 
 Results. Endoventriculoplasty of the left ventricle by Dor's technique was performed in 49 (29.0%) patients, auto-septoplasty of the left ventricle - 59 (34.9%) patients, linear repair in 40 (23.7%) patients. Combined surgical interventions were performed in 21 (12.4%) patients. In-hospital lethality was 2.4% (n=4). 
 Conclusion. Left ventricular reconstruction with on-pump beating heart technique without cardioplegic arest is effective and safe; the method allows performing remodelling of the left ventricle and reaching the target volume parameters.

THE INFLUENCE OF METABOLIC THERAPY ON CLINICAL AND HEMODYNAMIC PARAMETERS IN PATIENTS WITH STABLE ANGINA

Aims: The objective of our study is to investigate the antianginal activity of meldonium and its influence on the hemodynamics and clinical parameters in patients with stable angina who fall under III-IV functional classes according to the classification of the Canadian Heart Association. Methods:The study was carried out including 105 patients with stable angina pectoris who were in III-IV functional classes at the age of 42-72 years. The first group (n=52) was administered the standard treatment (beta-blockers, aspirin, atorvastatin). The second group of patients (n=53) were given a combination of basic therapy along with meldonium 10% solution of 5 ml intravenously for 10 days then 1000 mg per day orally for 10-12 weeks. Suitable healthy people were selected as the control group (n=36). Results: Patients with stable angina pectoris were characterized with the reduction of workload, double work, time loading on bicycle ergometer, increased specific and total peripheral vascular resistance, increased central sympathetic activity on heart, decreased vagal and humoral activity on heart rate. The analysis of the data indicated a decrease in the frequency of anginal attacks after treatment in the first group by 45% and reduced daily nitroglycerin requirement by 48%. Combination therapy resulted in a decrease of the parameters by 71.8% and 76%, respectively. Conclusion: After the treatment in both groups, we detected an improvement in physical exertion tolerance, reduction in total peripheral vascular resistance and sympathetic activity of the heart. Combination therapy with meldonium significantly reduced the central smypathetic activity and peripheral vascular resistance, also increased the workload, run time compared to the basic therapy.

Invited commentary

The ARCHeR trial represents an important contribution that provides data regarding the safety and efficacy of the Guidant Acculink and Accunet carotid stent and filter systems and also adds to the growing data pool on the results of carotid stenting in high-risk patients. It is important, however, that the limitations of this study be fully understood. The ARCHeR trial is not a prospective, randomized, controlled trial. It is not a comparative trial at all. It is an industry-sponsored, multi-institutional case registry. This registry was developed in order to accumulate a body of data on the performance of the Guidant products with a major goal of gaining Food and Drug Administration approval. It must be noted that the majority of the coauthors of this paper are either Guidant employees or consultants or receive financial support from Guidant. In order to garner Food and Drug Administration approval, the authors needed to show that the results of treatment with their product were not inferior to the results of standard treatment (carotid endarterectomy; CEA). As a basis for comparison, they used historical controls derived from selected series in the literature. By methods that are difficult to understand, they arrived at a control group (CEA) composite adverse event rate of 14.4%, to which they compare their stenting results (composite adverse event rate of 9.6%). Bias in selection of the series used to determine their control group adverse event rate is evident. The control group even included series of patients undergoing simultaneous coronary artery bypass grafting and CEA, a group in which stroke and mortality rates are high and in which the majority of strokes and deaths are not CEA related. In their appendix, the authors cite many series to support their control group adverse event rate, but they omit several series as well. For example, in 2003, Gasparis et al1Gasparis A.P. Ricotta L. Cuadra S.A. Char D.J. Purtrill W.A. Van Bemmelen P.S. et al.High risk carotid endarterectomy fact or fiction?.J Vasc Surg. 2003; 37: 40-46Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar reported on 228 high-risk CEA patients.1Gasparis A.P. Ricotta L. Cuadra S.A. Char D.J. Purtrill W.A. Van Bemmelen P.S. et al.High risk carotid endarterectomy fact or fiction?.J Vasc Surg. 2003; 37: 40-46Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Their definition of high risk was at least as stringent as that used by the ARCHeR team (age >80 years, myocardial infarction in the prior 6 months, New York Heart Association class III or IV angina, Canadian Heart Association (CHA) class III or IV congestive heart failure, steroid- or oxygen-dependent chronic obstructive pulmonary disease, creatinine of 3 mg/dl or greater, contralateral occlusion, carotid reoperation, prior neck irradiation, or high lesion). The 30-day results of CEA in these patients included mortality, myocardial infarction, and stroke rates of 0.4%, 0.9%, and 0.9%, respectively, with a combined stroke/death rate of 1.3%. There are other reports of CEA in high-risk patients that call into question the validity of the ARCHeR authors’ control group adverse event rate.2Reed A.B. Gaccione P. Belkin M. Donaldson M.C. Mannick J.A. Whittemore A.D. et al.Preoperative risk factors for carotid endarterectomy defining the patient at high risk.J Vasc Surg. 2003; 37: 1191-1199Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 3Ouriel K. Hertzer N.R. Beven E.G. O’Hara P.J. Krajewski L.P. Clair D.G. et al.Preprocedural risk stratification identifying an appropriate population for carotid stenting.J Vasc Surg. 2001; 33: 728-732Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar Even if the reader discounts the comparative data in this article, the results are interesting. In symptomatic patients, the 30-day stroke, death, and combined stroke/death rates were 10.9%, 2.2%, and 11.6%, respectively. In asymptomatic patients, the rates were 3.8%, 2.0%, and 5.4%. It should be noted that just as in the CEA trials, the results achieved in ARCHeR by experienced carotid interventionalists in large programs may not be reflective of the results likely to be achieved by less highly selected or experienced interventionalists. The data on durability are also notable. Although the target lesion revascularization rate at 1 year was only 2.2%, fully 26% of patients had 50% to 69% restenosis, and 5% had more than 70% restenosis at 1 year. In the relatively small number of patients followed up for 2 and 3 years, the incidence of 50% to 69% and greater than 70% restenosis did not increase. While the ARCHeR trial contains a wealth of data on the results of carotid stenting with the Guidant products, it does not provide a valid assessment of the relative merits of stenting and CEA in the management of high-risk patients. Definitive assessment of the relative merits of stenting and CEA awaits properly designed and conducted prospective randomized controlled trials.

Transmyocardial laser revascularization.

Transmyocardial laser revascularization is an alternative treatment option for patients with refractory angina who are not suitable candidates for more conventional coronary intervention or surgery. The laser creates channels that provide blood flow from the left ventricular chamber to areas of ischemic myocardium. Results have been impressive with patients reporting a reduction in angina of two classes according to the Canadian Heart Association Angina Classification. Care of the patient post transmyocardial laser revascularization procedure is comparable to that of other cardiac surgery patients. Innovations in this relatively new procedure include less invasive approaches and using it as an adjunctive or delivery modality for gene therapy.

Transmyocardial revascularization utilizing a holmium:YAG laser.

To evaluate the efficacy of transmyocardial revascularization performed on patients with refractory class IV or unstable angina with a holmium:yttrium-aluminum-garnet laser. Transmyocardial revascularization with a holmium:yttrium-aluminum-garnet laser was performed in 42 patients with refractory angina who were not candidates for percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Patients had either Canadian Heart Association class IV angina (n = 23) or unstable angina (n = 19) and were unable to be weaned from intravenous nitroglycerin. Preoperative thallium studies identified the extent and location of reversible ischemia. Operative exposure was via a limited left anterior thoracotomy. An average of 45+/-11 laser channels were created with a mean operative time of 106+/-38 min. Perioperative mortality was 12% (5/42) with no late deaths. Complications included ventricular 7.1% (3/42) and atrial 4.7% (2/42) arrhythmias, reoperation for chest-wall hemorrhage 2% (1/42), and respiratory failure requiring reintubation 2% (1/42). Intra-aortic balloon pump placement was required in 12% (5/42). The mean postoperative length of stay was 5.5+/-4.9 (1-25) days. Mean follow-up on 100% of patients is 5.4+/-3.0 (1-12) months. At 3 (n = 33) and 6 (n = 21) months follow-up the mean angina class was 1.5+/-0.1 (P < 0.002) and 1.1+/-0.1 (P < 0.001), respectively. Transmyocardial revascularization utilizing a holmium:yttrium-aluminum-garnet laser resulted in a significant reduction in angina class and was beneficial in patients with refractory angina untreatable by conventional methods.

Anesthesia for laser transmyocardial revascularization

NAKE MYOCARDIUM receives its blood supply through a network of channels that communicate directly with ventricle, rather than through epicardial vessels seen in humans. Transmyocardial revascularization (TMR) is an experimental procedure that attempts to duplicate this anatomy in patients with diffuse distal coronary artery disease unamenable to coronary artery bypass grafting (CABG) or angioplasty. For this reason, procedure has been called the snake and was first attempted in 1965 by Sen et al, 1 who used needle acupuncture to create multiple channels through ischemic myocardium. Unfortunately, these channels fibrosed and closed within weeks, offering little long-term benefit. More recently, carbon dioxide (CO2) and holmium:yttrium-aluminum garnet (Ho:YAG) lasers are being used as an alternative to needle perforations in hope that channels created by laser might epithelialize and remain patent longer. 24 If successful, this technique would provide an alternative treatment for patients with coronary artery disease refractory to conventional therapies. The following case is presented to illustrate anesthetic considerations for such a procedure. A 49-year-old, 80-kg man was experiencing class IV (Canadian Heart Association) angina, despite a four-vessel CABG operation 5 years ago and maximal medical therapy. Medical history was significant for an inferior myocardial infarction, and medications included nifedipine (20 mg three times daily), metoprolol (50 mg twice daily), isosorbide dinitrate (40 mg four times daily), amiodipine (10 mg/day), and aspirin (375 mg/ day). Recent cardiac angiography showed small, diffusely diseased coronaries, occluded vein grafts, and a patent internal mammary artery graft. Ejection fraction was 40%, and mild pulmonary hypertension was noted. Persantine-thallium scanning showed, on poststress images, defects in lateral and inferior walls of left ventricle. Reperfusion of lateral wall occurred, but inferior defect was fixed. Wall motion studies showed good motion of septum, but other walls showed considerable dyskinesia. Because patient was not considered an appropriate candidate for repeat CABG or angioplasty and his symptoms were persisting despite medical management, he was enrolled in a protocol for TMR treatment with holmium laser. Inclusion criteria for protocol were as follows: class IV angina (Canadian Heart Association); ejection fraction greater than 25%; greater than 10% reversibility in a myocardial defect located in inferior two thirds of left ventricle; and unsuitable for CABG or angioplasty. Patients were randomly assigned to either a TMR or medical treatment. In TMR group, entire left ventricle was treated with laser, not just areas of reversible ischemia.

Experience with the Gianturco-Roubin stent for abrupt vessel closure complicating percutaneous transluminal coronary angioplasty.

Emergency coronary artery bypass grafting (CABG) has previously been the only option in the treatment of refractory abrupt vessel closure complicating percutaneous transluminal coronary angioplasty (PTCA), and has been associated with high rates of morbidity and mortality. Intracoronary stenting now provides an alternative to emergency CABG. To assess our initial experience with emergency coronary artery stenting as a new technique. Retrospective case study review with clinical and angiographic follow-up. The Gianturco-Roubin (GR) stent was deployed in 13 patients in whom PTCA was complicated by abrupt vessel closure refractory to standard balloon techniques. Indications for PTCA were unstable angina (six), stable angina (six) and acute myocardial infarction (MI) (one). The arteries stented included left anterior descending (LAD) artery lesions (eight) and right coronary artery lesions (five). Two patients required urgent CABG, one due to failed stent deployment and one for inadequate control of vessel dissection. In seven of the stented patients the creatine kinase rose to greater than twice the upper limit or normal. Three patients had subacute thrombotic occlusion at seven to 19 days post stent deployment, managed with intravenous thrombolysis or repeat PTCA. At seven months follow-up, 11 patients were free of angina, two patients had Canadian Heart Association class II angina and there were no deaths. Eleven patients had repeat angiography at mean six months post stent. Five patients had evidence of restenosis managed with repeat PTCA in four and CABG in one. The GR stent is an effective alternative to urgent CABG in the treatment of refractory abrupt vessel closure complicating PTCA.

Surgical revascularization in acute myocardial infarction.

To determine the potential benefit of myocardial revascularizations in acute myocardial infarction we analyzed a consecutive series of 641/3397 patients with stable or unstable angina in Canadian Heart Association Class IV divided into five groups: A) unstable angina (ECG S-T modifications), B) evolving infarction (new Q-wave, CK more than 3 times normal), C) mechanical complications (ventricular septal defect (VSD), wall rupture, acute mitral regurgitation), D) coronary artery occlusion (crashed percutaneous transluminal coronary angioplasty (PTCA)), and E) stable angina class IV (control group). The mean follow-up was 72 +/- 33 months (range 24-144 months). Of the 641 patients 362 were unstable (A), 22 had evolving infarction (B), 20 suffered from mechanical complications (C), 48 had acute coronary artery occlusion (D), and 189 were in the control group (E). There was no difference for left ventricular (LV) ejection fraction before surgery (P < 0.05 = * as compared to control (E)), however cardiogenic shock was present before surgery in 13/362 (4%) for unstable angina, 5/22 (23%) for evolving infarction, 6/20 (30%) for mechanical complications, 4/48 (8%) for acute occlusion, and none of the controls. The number of bypasses was 3.8 +/- 1.3* for unstable angina, 3.6 +/- 1.3 for evolving infarction, 2.3 +/- 1.2* for mechanical complications, 2.0 +/- 1.2* for acute occlusion, and 3.4 +/- 1.5 for control. Intra-aortic balloon pumping was necessary in 26/362 (7%) for unstable angina, 5/22 (23%*) for evolving infarction, 7/20 (35%*) for mechanical complications, 7/48 (15%*) for acute occlusions, and 5/189 (3%) of the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Warm Blood Cardioplegia for Patients Undergoing Revascularization for Left Main Coronary Artery Disease

Between February 1991 and June 1992, 62 patients (50 males) underwent coronary artery bypass (CAB) operation for significant left main coronary artery disease. Age varied between 47 and 81 years. 53 patients had unstable angina, 16 had recent myocardial infarction, and 16 had heart failure. 22 patients were in functional capacity class IV (Canadian Heart Association) and 2 patients were in unstable hemodynamical condition before the operation. Intraaortic balloon pump was inserted before the operation in 3 patients. Six patients had previous CAB surgery. All the patients were operated using myocardial protection with warm blood cardioplegia, given antegradely and retrogradely in 58 and only antegradely in 4 patients. Body temperature was maintained at 30 +/- 1.8 degrees C. Number of distal anastomoses averaged 4.3 +/- 0.9. One patient underwent additional resection of a left atrial myxoma and another aortic valve replacement. LIMA (left internal mammary artery) was used to bypass the LAD in 58 (94%) patients. Early mortality was 3 cases (4.8%). Major and minor postoperative complications occurred in 17 patients. These data suggest that warm blood cardioplegia provides superior myocardial protection in patients with left main coronary artery disease.

Initial results and long-term outcome of coronary angioplasty in chronic mild angina pectoris

To analyze the clinical and anatomic findings of patients undergoing coronary angioplasty for mild angina, and determine the short- and long-term outcome, a retrospective data bank analysis of 3,729 patients who underwent coronary angioplasty at the Mayo Clinic between July 31, 1980 and January 30, 1991 was performed. Of these patients, 217 (6%) had stable Canadian Heart Association class I or II angina at the time of the procedure and constitute the study population. Patients were followed for a median of 37 months after the procedure. The mean age of patients was 60 years; 82% were men. Prior myocardial infarction occurred in 22% of patients. Multivessel disease was present in 68% of patients, and mean left ventricular ejection fraction was 65 ± 11%. Angioplasty was clinically successful in 196 patients (90%), 271 of 318 lesions (85%) were successfully dilated. There were no in-hospital deaths. Coronary artery bypass was performed during hospitalization in 12 patients (5.5%), and myocardial infarction occurred in 3 (1.4%); bypass or infarction occurred in 13 patients (5.9%). During follow-up of the 196 successfully treated patients, there were 9 deaths (4.5%), 16 patients (7%) developed myocardial infarction, 30 (15%) underwent coronary artery bypass surgery, and 36 (17%) developed severe angina. The probability of having any of these adverse cardiac events after 6-year follow-up was 39%; an additional 24% of patients developed recurrent mild angina during follow-up. It is concluded that mild stable angina was an infrequent indication for coronary angioplasty at the Mayo Clinic. Although coronary angioplasty was successful in most patients with mild angina, and complications were infrequent, most patients developed recurrent mild angina or had an adverse cardiac event during 6-year follow-up.

Outcome of Noncardiac Operations in Patients with Severe Coronary Artery Disease Successfully Treated Preoperatively with Coronary Angioplasty

HUBER, K. C.; EVANS, M. A.; BRESNAHAN, J. F.; GIBBONS, R. J.; HOLMES, D. R. JR. Author Information

Outcome of Noncardiac Operations in Patients With Severe Coronary Artery Disease Successfully Treated Preoperatively With Coronary Angioplasty

The risk of perioperative myocardial infarction and death was evaluated in 50 patients (mean age, 68 years) with severe coronary artery disease who underwent a noncardiac operation after revascularization had been achieved by successful percutaneous transluminal coronary angioplasty. Before angioplasty, all patients were thought to be at high risk for perioperative complications on the basis of assessment of clinical variables and findings on specialized diagnostic tests. Of the 50 patients, 31 had Canadian Heart Association class III or IV angina or unstable angina. All patients who underwent functional testing had positive results. At catheterization, 38 patients (76%) had multivessel disease. The 50 patients underwent 54 noncardiac operations at a median of 9 days after angioplasty. The overall frequency of perioperative myocardial infarction was 5.6%, and the mortality was 1.9%. Two nonfatal non-Q-wave infarctions and one fatal Q-wave infarction occurred. In patients who have undergone successful angioplasty for severe coronary artery disease, the risk of major cardiac complications associated with a noncardiac surgical procedure is low.

Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry.

Percutaneous balloon aortic valvuloplasty has been used as a therapeutic option for relief of valvular stenosis. This study describes patients undergoing initial percutaneous aortic balloon valvuloplasty enrolled in the National Heart, Lung, and Blood Institute (NHLBI) Balloon Valvuloplasty Registry. Extensive baseline procedural and postprocedural data were tabulated in 674 patients during a 24-month period. Functional status was captured using standard methods and an overall functional scoring system. Complications were defined and divided into procedural, acute (within 24 hours), in-hospital, and within 30 days of the procedure. The patient population was elderly and symptomatic, with 83% greater than 70 years of age. New York Heart Association functional class (FC) III or IV congestive heart failure (CHF) was present in 76%, syncope or presyncope was present in 34%, and Canadian Heart Association class III or IV angina was present in 23%. Using an overall functional scoring system (0-100), 54% exhibited scores less than 50. Comorbid disease was common. Forty-five percent possessed at least one serious noncardiac disability as a reason for valvuloplasty. Eighty percent of those seen by a cardiothoracic surgeon were believed inappropriate for aortic valve replacement. Hemodynamically, the aortic valve area increased from 0.5 +/- 0.2 cm2 to 0.8 +/- 0.3 cm2 (p less than 0.0001), accompanied by a fall in mean and peak aortic valve gradient from 55 +/- 21 and 65 +/- 28 mm Hg to 29 +/- 13 and 31 +/- 18 mm Hg, respectively (both p less than 0.0001). Small but significant increases were observed in cardiac output, heart rate, and mean aortic pressure with minor declines in the pulmonary artery (PA) systolic and left ventricular (LV) end-diastolic pressure. One hundred sixty-seven (25%) experienced at least one significant complication within 24 hours, and 211 (31%) experienced a significant complication before discharge. Complications before hospital discharge included the need for transfusion (23%), vascular surgery (7%), cerebrovascular accident (3%), other systemic embolus (2%), myocardial infarction (2%), acute tubular necrosis (1%), or cardiac surgery (1%). Seventeen (3%) patients died during the procedure; 16 of those were due to cardiac causes. By hospital discharge, there was an additional 52 total deaths; 37 were due to cardiovascular causes. Between hospital discharge and 30 days, 23 additional deaths occurred; 18 were due to cardiac disease. At 30 days, therefore, there was a grand total of 92 (14%) deaths; 71 (11%) were due to cardiovascular-related causes. Univariate and logistic regression analysis of mortality revealed that death was most frequent in patients suffering multiorgan failure and poor LV systolic function. Thirty-day mortality was associated with a predefined high-risk subset of hypotension and NYHA class IV CHF (risk ratio, 4.4), blood urea nitrogen (BUN) greater than 30 mg/dl (risk ratio, 3.7), use of an antiarrhythmic (risk ratio, 2.9), and cardiac output less than 3.0 l/min (risk ratio, 2.4). Of the survivors (86%) at 30 days, symptomatic improvement was generally present. Seventy-five percent experienced at least one functional class improvement in CHF, and 53% experienced at least a quartile improvement in overall functional status score. These data reveal that percutaneous aortic balloon valvuloplasty in an elderly and debilitated population can be done with low mortality but substantial morbidity. Mortality is greatest in patients with multiorgan failure resulting from poor cardiac output. In patients with reasonably preserved LV function who are otherwise inappropriate surgical candidates because of comorbid factors, survival and early improvement in symptomatic status are frequently observed after percutaneous aortic valvuloplasty.

Multivessel coronary angioplasty early after acute myocardial infarction

Coronary angioplasty has been applied in patients with recent myocardial infarction, but results of angioplasty of multiple vessels early after myocardial infarction in patients with severe multivessel disease have not been reported. Coronary angioplasty of multiple vessels was performed in 105 patients 0 to 15 days (mean 5 ± 4) after recent myocardial infarction. There were 77 men (73%) and 28 women (27%), with a mean age of 57 years. All patients had severe multivessel disease, 68% with two vessel and 32% with three vessel disease. Twenty-eight patients (27%) had successful thrombolysis before angioplasty and 70 (67%) had postinfarction angina. Mean left ventricular ejection fraction was 58 ± 10% end was <45% in 13 patients (12%).Angioplasty was attempted in 319 lesions (mean 3 lesions per patient, range 2 to 9) and 252 vessels (mean 2.4 vessels per patient, range 2 to 4), with success in 302 lesions (95%) and 237 vessels (94%); angioplasty was done in two stages in 59 patients (56%). Clinical success was achieved in 102 patients (97%). Complications included myocardial infarction in six patients (5.7%) (one Q wave, five non-Q wave), urgent bypass surgery in two (1.9%) and death in one (0.9%); overall, seven patients (7%) had a major complication.All patients had a follow-up duration >1 year (mean 31 months, range 12 to 73). Clinical recurrence developed in 24 patients (23%), of whom 21 had repeat angioplasty, 1 had bypass surgery and 2 were managed medically. Ten patients (9.8%) had a late infarction and 5 (4.9%) died of cardiac death during the follow-up period. Including patients who underwent repeat angioplasty, 88 patients (86%) remain improved (75 asymptomatic, 13 in Canadian Heart Association functional class I) without need of bypass surgery. The actuarial survival rate was 94% at 24 months and the event-free survival rate (no myocardial infarction, death or bypass surgery) was 85% at 2 years.These initial and long-term results indicate that coronary angioplasty of multiple vessels is a safe and effective therapy in selected patients with severe multivessel disease after recent myocardial infarction.

One-year outcome after therapy with tissue plasminogen activator: Report from the Thrombolysis and Angioplasty in Myocardial Infarction trial

To evaluate the long-term effects of reperfusion with tissue plasminogen activator (t-PA) and an aggressive strategy of revascularization with angioplasty and coronary artery bypass grafting, we obtained 1-year follow-up results from 386 consecutive patients enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI I) trial. All patients were treated with 100 to 150 mg of t-PA intravenously over 6 to 8 hours, and coronary angiography was performed within 90 minutes of initiation of therapy. In 197 patients with suitable anatomic characteristics, angioplasty was either performed immediately or was deferred for 7 to 10 days on a randomized basis. The remainder of the patients were treated as considered clinically appropriate. The in-hospital mortality rate was 7%, and only 1.9% of patients died in the first year after discharge from the hospital; three patients died of cardiac events and four died of noncardiac causes. Ninety-four percent of patients discharged alive from the hospital remained alive and had no myocardial infarctions during the first 12 posthospital months. Revascularization procedures after discharge from the hospital included angioplasty in 8% of patients and coronary artery bypass grafting in 5%. The high survival rates were evident in high-risk groups defined by age, ejection fraction, and extent of coronary artery disease. At 1-year follow-up 64% of patients less than 65 years of age were employed and only 10% reported that they were disabled; 94% of patients were in Canadian Heart Association class I or II. These low rates of follow-up events suggest a change in the "natural history" of the first year after acute myocardial infarction.

Long-term follow-up of 100 patients with left anterior descending artery lesions treated with percutaneous transluminal coronary angioplasty

In order to analyse late outcome, we reviewed the data on the first 100 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending artery (LAD) in our institution. Their ages ranged between 40.0 and 82.3 years (mean 66.6, males 75%, females 25%). All patients were treated with the non-steerable system between September 1980 and February 1983, and followed up for 6.2-9.6 years (mean 8.5 years). The primary success rate was 73%. We were unable to cross the lesion in 19%, and 8% of the patients required emergency bypass surgery because of acute occlusion or dissection. Elective bypass surgery was required in 18% of the patients. The clinical restenosis rate was 22%. Risk factors in this patient group were: smoking 66%; hypertension 37%; elevated serum cholesterol 32% and diabetes mellitus in 7%. After an initially successful PTCA, 12 out of 73 patients required a second PTCA of the same vessel because of restenosis and three, PTCA of a new lesion in another vessel because of recurrence of angina. Fifty-four patients were asymptomatic during the follow-up period of 8.5 years. Ninety-four of the 100 patients are still alive. Canadian Heart Association anginal classification of the study group was: class 0: 80 patients; class I: 11 patients; class II: three patients; class III and IV: no patient. Six patients died, there were four non-cardiac deaths because of cancer; one patient died 24 h after a myocardial infarction as a result of cardiogenic shock and ventricular septal rupture and one died suddenly 6 years after the initial PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Triple vessel coronary angioplasty: Acute outcome and long-term results

Triple vessel coronary angioplasty, defined as angioplasty of one or more lesions in each of the three major coronary arteries (left anterior descending, left circumflex, right coronary artery) was performed in 50 (11%) of 469 patients who had angioplasty of multiple vessels. There were 32 men and 18 women with a mean age of 56 years. All 50 patients had severe three vessel coronary disease and represent approximately 5% of patients with three vessel disease who had revascularization in this institution; 8 (16%) had previous coronary bypass surgery, and 23 (46%) had previous myocardial infarction. Unstable angina was present in 33 patients (66%) and 96% had Canadian Heart Association class III or IV angina; mean left ventricular ejection fraction was 57 ± 11%.Angioplasty was performed in 176 vessels (3.5 vessels per patient, range 3 to 6) and in 250 lesions (5 lesions per patient, range 3 to 9); angiographic success was achieved in 240 lesions (96%) and 166 vessels (94%). Success in all vessels attempted was achieved in 40 (80%) of the 50 patients. Clinical success (angiographic success associated with clinical improvement) was obtained in all 50 patients in whom triple vessel angioplasty was performed; none of them required urgent bypass surgery and 5 patients (10%) had a non-Q wave myocardial infarction. In four other patients triple vessel angioplasty was planned but not performed because of failure to dilate the primary vessel; urgent bypass surgery was required in one of these, who developed a Q wave infarction. Thus, overall clinical success in 54 patients was 93%; the incidence rate of myocardial infarction was 11%, and that of urgent surgery 1.8%.All 50 patients who had successful triple vessel angioplasty were followed up > 6 months (range 6 to 63, mean 18.4). Clinical recurrence developed in 17 patients (34%), of whom 15 had successful repeat angioplasty and 2 (4%) underwent elective bypass surgery. Two patients (4%) had late myocardial infarction, two (4%) died suddenly and one underwent cardiac transplantation during follow-up. Actuarial event-free survival (no myocardial infarction, death or bypass surgery) was 90% at 2 years. With inclusion of the 15 patients who had repeat angioplasty, 90% of patients are in improved condition (74% are asymptomatic and 16% are in functional class I) without requiring bypass surgery during follow-up. These immediate and long-term results indicate that triple vessel angioplasty is a safe and effective therapy in selected patients with three vessel coronary disease.

Comparison of effects of medical and surgical therapy on survival in severe angina pectoris and two-vessel coronary artery disease with and without left ventricular dysfunction: A coronary artery surgery study registry study

This nonrandomized study compared the results of early coronary artery bypass grafting to those of initial medical therapy in a group of 2,023 patients with severe angina pectoris and 2 major epicardial coronary arteries having ≥70% diameter luminal narrowing. Medical therapy was selected for 706 patients, and 1,317 patients were treated by coronary artery bypass grafting. The 6-year survival rate was 76% for patiente treated medically and 89% for patients treated surgically (p < 0.0001). Cox multivariate analysis showed that surgical treatment was a beneficial independent predictor of survival (p < 0.001). For patients with 2-vessel coronary artery disease who had Canadian Heart Association class III and IV angina at presentation, surgical therapy provided a survival advantage for patients with impaired left ventricular function and proximal narrowing of 1 or more coronary arteries.

Three year anatomic, functional and clinical follow-up after successful percutaneous transluminal coronary angioplasty

Because the long-term anatomic effects of percutaneous transluminal coronary angioplasty are unknown, follow-up evaluations including coronary angiography, treadmill exercise testing and rest and bicycle exercise radionuclide angiography were performed in 46 patients 6.3 +/- 2.0 and 37.6 +/- 3.6 (mean +/- SD) months after they had undergone successful single lesion angioplasty. The severity of the coronary stenosis decreased significantly at each evaluation; the mean diameter stenosis was 66 +/- 13% before angioplasty, 30 +/- 13% immediately after and 26 +/- 16% and 19 +/- 13% at 6 months and 3 years, respectively. Exercise time increased from 9.8 +/- 4.4 minutes before angioplasty to 18.3 +/- 4.5 minutes immediately after the procedure and remained at that level at 6 months (20.3 +/- 4.6 minutes) and 3 years (18.2 +/- 4.5 minutes). Left ventricular ejection fraction during exercise decreased 4 +/- 6% compared with rest before angioplasty, but increased 7 +/- 7% immediately after angioplasty and this increase was maintained at 6 months (+/- 6 +/- 7%) and 3 years (+/- 4 +/- 6%). Before angioplasty, 1 patient was in Canadian Heart Association functional class 0, 15 were in class II, 24 in class III and 6 in class IV. Three years later, 25 were in class 0, 10 in class I, 7 in class II and 4 in class III. These results indicate that the short-term anatomic and functional success of coronary angioplasty is maintained for at least 3 years.