Class III-IV Angina Research Articles

Sex specificities of medical and social parameters in patients with coronary artery disease with different severity of depression

Aim. To determine the sex specificities of medical and social parameters in patients hospitalized due to coronary artery disease (CAD), class II, III, IV angina, aged 35-60 years and assess the significance of their relationship with different levels of depression.Material and methods. The study involved 312 patients aged 35-60 with documented CAD, class II, III, IV angina. Two comparison groups were identified: group I — 138 patients (men, 81; women, 57) with CAD and without depression (mean age, 47,8±4,6 years); group II — 174 patients (men, 60; women, 105) with CAD and depression (mean age, 48,3±5,3 years). Medical and social data, the severity of depression and distress tolerance, psychological status and quality of life was assessed. Statistical analysis was carried out, which are presented as the mean and standard error of the mean (M±m). The odds ratio (OR) and 95% confidence interval (CI) were calculated. Differences were considered significant at p<0,05.Results. The prevalence of depression among patients with CAD was 55,77%, while women were 1,5 times more likely to suffer it than men. Depression was significantly associated with hyperglycemia, hypercholesterolemia, and class III-IV angina, regardless of sex. Class III and IV angina prevailed in women, while class II angina — in men (OR, 2,16; 95% CI, 1,37-3,41, p<0,001)). Women were more prone to degree II-III disability (group II, 26,67%; group I 8,77%; p=0,008), compared with men (group II, 27,54%; group I, 11,11%; p=0,012). Sedentary lifestyle was also associated to a greater extent with the female sex than with the male (OR, 2,89, 95% CI, 1,46-5,70, p=0,003; OR, 2,31, 95% CI, 1,19-4,48; p=0,014, respectively). Both men and women showed a significant association of depression with atherosclerosis (p<0,001), however, sex differences did not reach significance. Indicators such as lack of job and higher education, as well as smoking and arrhythmias were characteristic of both sexes, but had a greater impact on the mental condition of men (p=0,002, p<0,001, p=0,0014 and p=0,01, respectively). For men, the relationship of depression with diabetes (8,7 vs 0%; p=0,008), obesity (42,03 vs 19,75%; p=0,004), subordinate status (82,61 vs 64,2%; p=0,016) and unmarried status (60,87 vs 40,74%; p=0,02).Conclusion. There are significant differences in factors contributing to depression in different sex groups. The association of depression with CAD has an adverse effect on the physical and psychological health of both males and females. At the same time, women are more prone to mental disorders than men. It is necessary to further study the sex characteristics of medical and social parameters in order to personalize treatment methods.

TCTAP C-051 Post-CABG Optimum Revascularization: PCI to Native Vessels Including Bifurcation Stenting by DK Crush Technique

### Patient Initials or Identifier Number MHMH ### Relevant Clinical History and Physical Exam A 65-year-old Bangladeshi male presented with CCS Class III-IV angina for 2 weeks, on optimum GDMT. He was hypertensive and a smoker, with a family history of coronary artery disease. Initial

Results of Coronary Artery Bypass Surgery Combined With Endarterectomy and Reconstruction of Anterior Descending Artery in Patients With Diabetes Mellitus

To assess results of coronary artery bypass surgery combined with endarterectomy (EAE) in patients with ischemic heart disease (IHD) and diabetes mellitus (DM), and impact of DM on clinical outcomes. We recruited in this study 152 patients with IHD (43 with and 109 without DM) subjected to coronary artery bypass surgery with EAE from anterior descending artery (ADA) between 2003 and 2010. Forty three patients had concomitant DM (main group) 109 - had not (control group). Mean age was 57+/-18 and 60+/-19 years, portion of patients with class III-IV angina - 71.1 and 73.3%, with history of myocardial infarction - 74.4 and 68.8%, in main and control group, respectively (p>0.05). In hospital mortality was 4.6 and 3.6% in main and control group, respectively. Number of patients examined in remote period was 127 (87.6%). Mean follow-up was 4.5+/-1.2 years. Survival was 90.7 and 100% (p>0.05). Graft angiography was performed in 12 and 43 patients (27.9 and 39.4%) with portions of patent arterial conduits 91.6 and 100%, patent venous conduits 90.0 and 90.3% in main and control group, respectively. Under conditions of strict control of glycemia coronary artery bypass surgery with EAE from ADA in IHD patients with DM is associated with acceptable hospital mortality and survival, moderate risk of remote cardiovascular complications, and satisfactory patency of conduits.

Experience of enhanced external counterpulsation application on dispensary-polyclinic stage rehabilitation of patients with refractory angina

The aim is to assess the efficacy and safety of enhanced external counterpulsation (EECP) application in patients with refractory class (RC) III-IV angina during the dispensary-polyclinic stage rehabilitation in real clinical practice.Materials and methods. EECP was held in 87 patients with RC III-IV effort angina as part of polyclinic stage of rehabilitation in the Department of prevention and rehabilitation Cardiology Dispensary. EECP was held using standard technique. Each patient received procedures prolonging for 35 hours. All patients underwent physical examination, stress testing, echocardiography, and the determination of highly-sensitive C-reactive protein (CRP) concentration and the speed of glomerular filtrate (SGF) rate was studied, before the inclusion in the study and after its ending.Results. On comparing the data received before and after the course of EECP we found the statistically significant improvement of patients’ functional status, the reduction in RC of angina, the reduction of the need for nitrate, the increase of the effort tolerance, the reduction of CRP concentration and increase of the SGF rate.Conclusion. The experience of EECP application in rehabilitation of patients with RC III-IV effort angina shows the high efficacy and safety.

Extracorporeal shockwave myocardial revascularization improves clinical symptoms and left ventricular function in patients with refractory angina

Medical therapy for refractory angina is limited and the prognosis is poor. Experimental data suggest that the use of extracorporeal shockwave myocardial revascularization (ESMR) can contribute to angiogenesis and improve symptoms of angina and left ventricular (LV) function. The objective of this study was to examine the effects of ESMR on clinical symptoms as well as LV function as assessed by cardiac MRI in patients with refractory angina. Patients with Canadian Cardiovascular Society (CCS) class III-IV angina despite medical therapy and ischemia documented on thallium or echo-dobutamine were eligible for the study. ESMR therapy was applied with a commercially available cardiac shockwave generator system under echocardiographic guidance. LV function was assessed before and 6 months after therapy by cardiac MRI. Twenty patients (four women, 16 men; mean age 64 years, range 45-83) were included in the study. The CCS class after treatment improved in all patients (16 patients angina pectoris CCS from III to II and four patients from IV to III). The use of sublingual nitroglycerin was significantly reduced as well. There was a significant improvement in LV ejection fraction as assessed by blinded MRI following therapy in the overall population (51 vs. 59%, P<0.05). This study demonstrates the potential efficacy of ESMR for the treatment of refractory angina pectoris. The patients showed both a significant clinical response as well as improved LV ejection fraction on serial MRI imaging. Larger studies are needed to adequately define the clinical utility of this novel therapy.

Multimorbidity, the Predominant Predictor of Quality-of-Life, Following Successful Spinal Cord Stimulation for Angina Pectoris

Patients suffering from severe chronic angina pectoris (AP) that has become therapeutically refractory to medication and revascularization can be adequately treated with spinal cord stimulation (SCS). However, following SCS implantation for angina, not all patients show a consistent improvement in quality of life (QoL). Therefore, we sought to study the association of baseline characteristics and chronic multimorbidities on QoL following SCS implantation. All patients treated with SCS for refractory AP (rAP) were registered in a local data base. Patients who had discontinued SCS therapy were excluded from further analysis. Baseline characteristics, such as exercise limiting morbidities (chronic obstructive pulmonary disease [COPD], rheumatic disease, diabetes mellitus [DM], obesity expressed as body mass index [BMI]>25) and demographic data, were retrieved from the data base. QoL was studied using the Seattle Angina Questionnaire and the RAND-36 questionnaire. During a 21-year registration period (1986-2008), we enlisted 127 patients with SCS for rAP in our data base. Eighty-two, of whom 59 died, had discontinued SCS and were lost to follow-up. Out of the remaining 45 patients, 33 returned their questionnaires (73.3%). At SCS implantation, 72.7% of the patients were male, mean age 58±8.5 years. Twenty-four patients were in class III-IV angina and nine in class II-III NYHA. After a follow-up of 6.4±4.1 years, men had better physical capacity and experienced less impairment in QoL resulting from physical or emotional restrictions (all p<0.05) compared with women. Patients without COPD reported a better general health compared with those with rAP and COPD (p<0.05). The association of DM on QoL was borderline significant. Patients with lower BMI scored better on emotional well-being and perception of disease than those with a higher BMI (p<0.05 and p<0.05, respectively). None of the patients reported other morbidities limiting their exercise. Men showed a larger improvement in QoL following SCS implantation, compared with women. As SCS improves rAP, other chronic morbidities such as COPD, DM, and BMI may become the limiting factors for exercise and subsequently adversely affect QoL following implantation of an SCS system. As a consequence of the present relatively small single-center study, we recommend studies regarding rAP and SCS to also address the effect of comorbidities on outcomes.

Enhanced external counter pulsation in treatment of refractory angina pectoris: two year outcome and baseline factors associated with treatment failure

BackgroundEnhanced external counter pulsation (EECP) is a non-invasive treatment option for patients with refractory angina pectoris ineligible to further traditional treatment. The aim of this study was to evaluate the effect of EECP on patients at a Scandinavian medical centre and to investigate if outcome can be predicted by analysing baseline factors.Methods86 consecutive patients (70 male, 16 female) were treated with EECP and followed for two years post treatment. Canadian cardiovascular society (CCS) class was analysed, and medication and adverse clinical events were researched prior to EECP, at the end of the treatment, and at six, 12 and 24 months thereafter. Patients responding to therapy by improving at least one CCS class were compared with those who failed to respond. Any differences in background factors were recorded and analysed.Results79% of the patients responded to therapy by improving at least one CCS class. In general, the CCS class improved by one class after EECP treatment (3.05 before versus 2.14 after treatment). A total of 61.5% of the initial responders showed sustained improvement at the 12 month follow-up while 29% presented sustained improvement after 24 months. Treatment was most effective among patients suffering from CCS class III-IV angina pectoris, while patients suffering from CCS class II angina pectoris improved transiently but failed to show sustained improvement after the 12 month follow-up. Diabetes mellitus and calcium channel antagonists were more common among the non-responders (p < 0.05).ConclusionThis study confirms the safety and efficiency of EECP as a treatment option for patients suffering from refractory angina pectoris. The therapy is most beneficial in patients suffering from severe angina (CCS III-IV) while sustained response to therapy could not be verified among patients suffering from CCS class II angina pectoris.

Spinal Cord Stimulation for Patients With Refractory Angina and Previous Coronary Surgery

Refractory angina pectoris is an exceptionally debilitating condition affecting patients who have typically failed multiple percutaneous and surgical revascularizations and optimal medical therapy and who are not amenable for further revascularization procedures. Spinal cord stimulation (SCS) has been adopted in this context at our institution and midterm mortality, anginal status, and quality of life have been evaluated. From 1998 to 2004, 51 patients with refractory class III-IV angina, who were not considered candidates for revascularization procedures, underwent SCS. All patients had already undergone previous surgical revascularization and a median of two percutaneous procedures. Transmyocardial laser revascularization had been previously performed in 8 cases (15.6%). Most of the patients (70.5%) had experienced a myocardial infarction. Mean ejection fraction was 0.42 +/- 0.121, Canadian Cardiovascular Society class 3.5 +/- 0.5, quality of life (Spitzer index) 4.5 +/- 1.2, and the median frequency of weekly angina episodes was 10. There were no SCS implantation-related complications. At follow-up (100% complete, mean 24 +/- 18 months), a significant improvement of anginal symptoms (>50% reduction of weekly anginal episodes) occurred in 45 patients (88.2%). In those patients (Responders), the quality of life improved significantly (6.8 +/- 1.5; p < 0.0001), CCS class decreased to 2 +/- 0.7 (p < 0.0001), and the median frequency of weekly angina episodes to 3 (p < 0.0001). At 3 years, Responders' survival was 91.8 +/- 4.6% and the freedom from cardiac events 72.6 +/- 8.42%. Spinal cord stimulation is a safe and effective procedure in truly no-option patients affected by refractory angina. A midterm sustained improvement of symptoms and quality of life have been documented with a satisfactory 3-year survival rate.

In‐hospital mortality among women undergoing contemporary elective percutaneous coronary intervention: A reexamination of the gender gap

Previous studies have indicated that, compared with men, women are at increased risk for in-hospital mortality following percutaneous coronary intervention (PCI); however, angioplasty techniques and mortality rates have improved since earlier reports. We sought to reevaluate and explore further the relationship between gender and angioplasty outcomes in contemporary "real world" practice. The influence of gender and other covariates on in-hospital mortality and other adverse events among all patients who underwent elective coronary angioplasty in New York State from 1999 to 2001 (n = 106,262) was examined. In-hospital mortality rates for elective angioplasty were low; however, women demonstrated a two-fold mortality excess compared with men (0.6 vs. 0.3%, p < 0.0001). Women were older and more likely than men to demonstrate certain higher-risk features (heart failure, class III-IV angina, renal failure, vascular disease); however, men were more likely to have depressed ejection fraction, prior myocardial infarction, and prior coronary revascularization. Using multivariate analysis adjusting for clinical risk factors, gender remained an independent predictor of in-hospital mortality at all ages. Women were also more likely to experience nonfatal adverse events following PCI, including more frequent need for emergency bypass surgery. Despite improvements in angioplasty outcomes with time, women remain at significantly higher risk of in-hospital death than men after elective PCI. This increased mortality is observed in every age group, even after adjusting for other significant comorbidities.

Two-year outcomes in patients with mild refractory angina treated with enhanced external counterpulsation.

In the International Enhanced External Counterpulsation Patient Registry (IEPR), approximately 85% of the patients treated are in Canadian Cardiovascular Society (CCS) class III-IV with no option for further invasive coronary revascularization procedures. This study sought to determine whether it is clinically important to establish whether the observed durable reduction in disabling severe angina with enhanced external counterpulsation (EECP) treatment can be extended to those with less severe CCS class II angina, who also have no option for further revascularization. This study evaluated the immediate response, durability and clinical events over a 2-year period after EECP treatment in 112 patients with Canadian Cardiovascular Society (CCS) class II angina versus 1346 patients with class III-IV angina using data from the International EECP Patient Registry (IEPR). Treatment with EECP significantly (by at least one CCS class) reduced angina frequency, nitroglycerin use, and improved quality of life in both groups. At 2-year follow-up, 74% of class II and 70% of class III-IV patients remained free of major adverse cardiovascular events (MACE) and continued to demonstrate a durable CCS class improvement over baseline. The robust effectiveness of EECP as a noninvasive device, together with its relatively low start-up and recurrent costs, makes it an attractive consideration for treating patients with milder refractory angina in addition to the patient with severely disabling angina treated in current practice.

First experience with hybrid percutaneous transmyocardial laser revascularization and angioplasty in patients with lesions at high risk for restenosis: Results of a phase I feasibility study

Background Prior studies have suggested that percutaneous transmyocardial laser revascularization (PTMR) may be effective as a sole treatment modality in reducing angina in patients with severe coronary artery disease and no revascularization alternatives. The safety and efficacy of the hybrid or adjunctive use of PTMR during the same procedure as percutaneous intervention (PCI) has not previously been reported. Methods A US phase I feasibility study was therefore performed to determine whether PTMR performed in the same myocardial territory as PCI is able to ameliorate symptomatic recurrence from restenosis. Results After successful and uncomplicated PCI in 26 patients with class III-IV angina and lesion(s) at high risk for restenosis, PTMR was performed in the same myocardial territories subtended by the treated vessel(s). Major periprocedural adverse events (death, Q-wave myocardial infarction, and bypass surgery) occurred in 3 (11.5%) patients, as the result of subacute vessel closure in 2 patients, and tamponade in the third. Cumulative 6-month mortality rate was 19.2%, including 2 late deaths between 3 and 4 months after discharge (1 death caused by late stent closure and 1 unexplained death during sleep.) Late repeat revascularization for restenosis in the PCI plus PTMR treated target vessel was required in 19.2% of patients, and an additional 11.5% of patients had class III-IV angina at 6-month follow-up. Conclusions These data demonstrate that in a patient population at high risk for restenosis, recently created PTMR channels are not protective against severe ischemia caused by acute vessel closure and that late symptomatic restenosis after PCI may still frequently occur despite PTMR in the same region. (Am Heart J 2001;142:679-83.)

Evaluation of Percutaneous Laser Myocardial Revascularization in Chinese Patients with Refractory Angina Pectoris

The study aims to evaluate the feasibility and effect of percutaneous laser myocardial revascularization (PMR) in patients with refractory class III-IV angina. Patients were selected by: (1) angina class ≥III; (2) unsuitable to CABG and PTCA; (3) LVEF ≥30%; (4) absence of myocardial infarction in 6 months; (5) maximum diastolic wall thickness of left ventricle (LV) ≥8 mm in echocardiography. Eclipse Holmium laser generator and catheter were used. Eighteen patients (17 male and 1 female) with age of 63.3±7.5 years and a history of angina for 9.6±7.0 years were studied. They were refractory to 5.8±0.7 antianginal drugs. The angina class was IV in 11 patients and III in 9 patients. Maximum diastolic LV wall thickness was 10.2±0.8 mm. LVEF was 41.2±6.2%. Eleven and 9 patients had triple vessel and double vessel diffuse disease, respectively. A mean of 19.7±6.3 endomyocardial channels were made. Procedure time was 78.2±12.5 minutes and radiation time 24.3±7.4 minutes. There were no complications. During the follow-up of 18.7±1.6 months, angina class decreased from 3.8±0.7 to 2.1±0.8 (P<0.05). Ischemia in SPECT was significantly improved. PMR using Eclipse Holmium laser generator and catheter is safe in Chinese patients. This results suggest that patients with refractory class III or IV angina could be controlled by conjunctive use of PMR and regular antiangina drugs.

Treatment of in-stent coronary restenosis with excimer laser angioplasty.

To evaluate the efficacy and safety of excimer laser coronary angioplasty (ELCA) with adjunctive balloon angioplasty in patient with in-stent restenosis. ELCA was performed in 20 patients of instent restenosis. All patients were symptomatic and had class III-IV angina. ELCA was performed with the Spectranetics CVX-300 System. The laser catheter of Vittesse C (concentric) and E (eccentric) with diameter of 1.4-2.0 mm was used. Laser catheter crossed all stenotic stents without difficulty. The lesion length was 4.6-51.2 mm, mean 20.7 +/- 13.7 mm, including 14 lesions > 10 mm. Laser treatment alone increased minimal lumen diameter (MLD) from 0.3 +/- 0.3 mm to 1.4 +/- 0.3 mm (P < 0.0001) and improved the diameter stenosis from 88.8% +/- 10.0% to 46.0% +/- 8.0% (P < 0.0001). Adjunctive balloon angioplasty further increased minimal lumen diameter to 2.3 +/- 0.7 mm and reduced diameter stenosis to 14.2% +/- 8.2% (P < 0.0001). At follow-up (1-17 months, mean 8.9 +/- 5.7 months), 17 (85%) patients had remained asymptomatic, 3 (15%) patients had mild to moderate exertional angina, 1 (5%) patient received CABG. ELCA with adjunctive percutaneous transluminal coronary angioplasty (PTCA) is an efficient and safe technique to debulk tissue in the patient with in-stent restenosis. The incidence of procedural related complication was low and ELCA may be used as a good method for in-stent restenosis treatment.

Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting

Background. Diabetes mellitus is an established independent risk factor for significant morbidity and mortality after coronary artery bypass grafting.Methods. The impact of diabetes on short- and long-term follow-up after coronary artery bypass grafting was studied by comparing the outcomes between 9,920 patients without diabetes mellitus and 2,278 patients with diabetes from 1978 to 1993.Results. Compared with nondiabetic patients, the group with diabetes was older (62 ± 10 years versus 60 ± 10 years), comprised more women (31% versus 19%), had a greater incidence of hypertension (61% versus 44%) and previous myocardial infarction (51% versus 48%), had class III-IV angina more commonly (69% versus 63%), showed a higher incidence of congestive heart failure (11% versus 5%) or triple-vessel or left main disease (60% versus 50%), and had lower ejection fractions (0.54 versus 0.57) (all, p ≤ 0.05). Diabetic patients had a higher incidence of postoperative death (3.9% versus 1.6%) and stroke (2.9% versus 1.4%) (both, p ≤ 0.05), but not Q wave myocardial infarction (1.8% versus 2.9%). Diabetics had lower survival (5 years, 78% versus 88%; 10 years, 50% versus 71%; both, p ≤ 0.05) and lower freedom from percutaneous transluminal coronary angioplasty (5 years, 95% versus 96%; 10 years, 83% versus 86%; latter, p ≤ 0.05), but diabetics did not have lower freedom from either myocardial infarction (5-years, 92% versus 92%; 10-years, 80% versus 84%) or additional coronary artery bypass grafting (5-years, 98% versus 99%; 10-years, 90% versus 91%). Multivariate correlates of long-term mortality were diabetes, older age, reduced ejection fraction, hypertension, congestive heart failure, number of vessels diseased, and urgent or emergent operation.Conclusions. Diabetics have a worse hospital and long-term outcome after coronary artery bypass grafting. The increased risk in such patients can only partially be explained by other demographic characteristics.

Safety of rapid administration of flumazenil in patients with ischaemic heart disease

The purpose of this study was to determine if higher (36 micrograms.kg-1) doses of flumazenil (a new benzodiazepine (BZ) antagonist) produced an effect on haemodynamics. Twelve patients with class III-IV angina were entered into this double-blind randomised placebo-controlled study. BZ were withheld for 2 weeks prior to surgery. Patients were placed on an ambulatory monitor 18 h prior to surgery to record changes in heart rate rhythm and ST segment changes. The patients were given secobarbital 100-200 mg and morphine 0.12 mg.kg-1 90 min prior to surgery. Flumazenil or placebo was given in divided doses every 3 min (1 mg, 1 mg, 1 mg). Complete haemodynamic profiles were obtained at baseline and 2 min following each injection of flumazenil. Flumazenil produced a minimal but statistically significant reduction in systolic blood pressure (147 +/- 13.9 to 137 +/- 18.4 mmHg) and diastolic blood pressure (74 +/- 14.8 to 67 +/- 13 mmHg). There was no consistent effect on heart rate, pulmonary capillary wedge pressure or cardiac index. We conclude that flumazenil is safe when administered in relatively high doses to patients with ischaemic heart disease who have not received benzodiazepines.

Improved survival of surgically treated patients with triple vessel coronary artery disease and severe angina pectoris: A report from the Coronary Artery Surgery Study (CASS) registry

We examined survival rates during a 6-year follow-up of patients in the registry of the Coronary Artery Surgery Study who had three vessel coronary artery disease and Canadian Cardiovascular Society class III-IV angina pectoris. All patients had a stenosis of 70% or greater in either the mid or proximal segment of all three coronary arteries. There were 679 medically treated patients and 1921 surgically treated patients in this nonrandomized comparison. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, the estimated probability of being alive at 6 years was 82% for surgically treated patients and 59% for medically treated patients (p less than 0.0001). Among patients with the most severe left ventricular dysfunction (left ventricular wall motion score of 16 to 30), the 6-year survival rate was 63% for surgically treated patients and 30% for medically treated patients (p less than 0.0001). Those with three proximal lesions (all gradations of left ventricular score) had an 81% 6-year survival rate with surgical treatment and 40% with medical treatment (p less than 0.0001). Ninety percent of surgically treated patients with normal ventricular function were living at 6 years and 78% of medically treated patients (p less than 0.0001). Among these patients, the survival rate was significantly better after surgical treatment than after only medical treatment if two or three proximal stenoses were present. If no proximal lesions were present (all categories of left ventricular function), 84% of surgically treated patients and 67% of medically treated patients were alive at 6 years (p less than 0.0001). In a multivariate (Cox) analysis of preoperative clinical, hemodynamic, and angiographic factors, early operation was a strong predictor of survival (estimated relative risk 0.38).

Time to first new myocardial infarction in patients with severe angina and three-vessel disease comparing medical and early surgical therapy: A CASS registry study of survival

We compared time to first new myocardial infarction during a 6-year follow-up in patients in the registry of the Coronary Artery Surgery Study who had three-vessel coronary artery disease and Canadian Cardiovascular Society Class III-IV angina pectoris. There were 679 medically treated patients and 1921 surgically treated patients in this nonrandomized comparison. A broad definition of myocardial infarction incorporating electrocardiographic and clinical criteria was used to include as many new infarctions as possible. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, 86% of surgical and 73% of medical patients were free of new myocardial infarction at 6 years (p less than 0.0001). This advantage of surgical treatment was observed in subgroups of patients with at least one proximal 70% (or greater) stenosis in the left anterior descending coronary artery and moderate or severe impairment of left ventricular function, as well as those patients with two proximal coronary artery narrowings. In a multivariate (Cox) analysis of preoperative clinical, hemodynamic, and angiographic factors, early operation was the strongest predictor of freedom from new myocardial infarction.

Efficacy of a New Angioplasty Catheter for Severely Narrowed Coronary Lesions

Conventional over the wire dilation catheters may be unsuccessful in crossing coronary lesions that are severely narrowed. Hence, a new, extremely low profile coronary angioplasty catheter specifically designed to dilate such lesions was investigated. The catheter features a 2.0, 2.5 or 3.0 mm (inflated diameter) balloon mounted on a guide wire. The deflated profile of the 2.0 mm balloon measures 0.020 +/- 0.001 in. (0.51 +/- 0.03 mm). The catheter can be used in conjunction with 7F angiographic or 8F guide catheters. The catheter was used in 61 patients, aged 43 to 86 years, with predominantly Canadian Cardiovascular Society class III-IV angina. Dilation was attempted in 77 lesions. Lesion length averaged 5.7 +/- 3.1 mm (mean +/- 1 SD), minimal diameter 0.51 +/- 0.25 mm and internal vessel diameter 2.27 +/- 0.43 mm. Sixty lesions (78%) were successfully dilated to less than 50% residual stenosis with this catheter alone; nine lesions were further dilated with a larger balloon catheter. The new catheter was unable to cross 13 lesions (17%); only 2 of these lesions were subsequently crossed with a conventional over the wire system. On the other hand, the catheter was used after failure of conventional dilating catheters in 21 lesions and was successful in 16. The new catheter was particularly valuable for distal lesions and those demonstrating 90 to 99% diameter reduction. For all lesions crossed, stenosis decreased from 76 +/- 11 to 29 +/- 12% after 2.9 +/- 2.7 inflations and peak inflation pressure of 8.0 +/- 2.9 bar. Complications were rare; coronary occlusion occurred in two lesions (3%) and dissection in three lesions (4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Combined myocardial revascularization and carotid endarterectomy: Operative and late results in 331 patients

Simultaneous coronary artery bypass and carotid endarterectomy were performed in 331 patients (mean age 61 years) at the Cleveland Clinic from 1973 through 1981. Of these, 195 (59%) had Functional Class III-IV angina pectoris, 308 (93%) had multiple-vessel coronary artery disease (CAD), 68 (21%) had over 50% stenosis of the left main coronary artery, and 185 (56%) had either segmental or diffuse impairment of left ventricular function. Asymptomatic carotid stenosis was documented in 173 patients (52%), and the remaining 158 had experienced either previous transient cerebral ischemia (38%) or completed strokes (10%). Single aorta-coronary grafts were placed in 59 patients (18%), double grafts in 131 (40%), and three or more grafts in 141 (42%). Nineteen patients (5.7%) died postoperatively in the hospital. Neurologic deficits occurred in 30 patients (9.0%) and produced permanent functional impairment in 15 (4.5%). Late results have been obtained for 312 operative survivors at a mean postoperative interval of 38 months. Thirty-eight patients (12%) have died, but the 5 year life-table survival rate of the study group was identical to that of the normal population aged 61 years. Significant differences in cumulative 5 year survival rates were identified among diabetic patients (p < 0.025) and among those receiving single rather than double (p < .005) or multiple (p < .01) coronary grafts. Although 18 patients (5.8%) have had late strokes, only five (1.6%) of these strokes have involved the cerebral hemisphere on the same side as combined carotid endarterectomy.