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ST-elevation myocardial infarctions (STEMI) caused by proximal left-anterior descending (LAD) lesions have more myocardium at risk and worse outcomes than those located in other segments. The aim is to compare outcomes of patients with STEMI and proximal-LAD lesions treated with bare-metal stents (BMS) versus everolimus-eluting stents (EES).The EXAMINATION trial randomized 1498 STEMI patients to BMS versus EES. The primary end point was the patient-oriented combined of all-cause death, any-recurrent myocardial infarction (MI) and any-revascularization. The secondary end point included the device-oriented combined of cardiac death, target-vessel MI and target-lesion revascularization (TLR).STEMI with a proximal-LAD occlusion was observed in 290 patients (BMS = 132 and EES = 158). Both groups were similar except for diabetes (12.9% vs 24.1%; P = .016). At 1 year, the primary end point was observed in 18.9% and 9.5% of patients treated with BMS and EES, respectively (P = .023). The secondary end point was observed in 11.4% and 5.1%, respectively (P = .053). There were no differences in cardiac death (4.5% vs 3.8%; P = .750) and MI (1.5% vs 0%; P = .121). BMS had higher rate of TLR compared to EES (6.8% vs 1.3%; P = .014). Patients with proximal-LAD STEMI had higher mortality than patients with non proximal-LAD STEMI (5.5% vs 2.9%; P = .027). Proximal-LAD lesions treated with BMS tended to increase the risk of the primary end point compared with other segments (18.9% vs 13.0%; P = .079). However, EES implanted in proximal-LAD had similar outcomes compared with other locations (9.5% vs 12.0%; P = .430). Adjusting for confounders, the interaction between BMS and proximal-LAD location was associated with the primary end point.Patients with STEMI and proximal-LAD lesions treated with EES have better outcomes compared with BMS at 1 year. Although further investigations are required, it seems reasonable to consider EES for proximal-LAD STEMI-lesions.

The implications of the American College of Cardiology/American Heart Association (ACC/AHA) lesion classification in patients with in-stent restenosis (ISR) are unknown.Four hundred fifty patients included in the RIBS randomized study were analyzed. A centralized core laboratory assessed ISR classifications including ACC/AHA, the classification of Mehran et al (Circulation 1999;100:1872-8), diffuse/focal, and a new quantitative ISR index (lesion length/stent length). Logistic regression models were constructed for prespecified outcome measures including (1) unsatisfactory acute results and (2) recurrent restenosis rate.Complex (B2/C) lesions (78%) more frequently obtained unsatisfactory acute results (20% vs 8%, P = .007), smaller minimal lumen diameter after the procedure (2.45 +/- 0.5 vs 2.73 +/- 0.5 mm, P = .001) and at follow-up (1.48 +/- 0.8 vs 1.94 +/- 0.8 mm, P = .0001), and had a higher restenosis rate (43 vs 24%, P = .001) than simple (A/B1) lesions. On logistic regression analysis, all classification schemes were useful to predict unsatisfactory initial results (area under the curve: 0.63, 0.61, 0.59, and 0.62) and recurrent restenosis (area under the curve: 0.60, 0.64, 0.61, and 0.63). The predictive ability of these schemes persisted despite adjustment for potential confounders. Although the ACC/AHA classification was a better predictor of acute results, the classification of Mehran was superior to predict restenosis.The ACC/AHA classification provides a useful tool to determine acute procedural results and the long-term angiographic outcome of patients with ISR.

Combined mitral and t r icuspid stenosis are rarely encountered in pat ients with rheumat ic hear t disease. 1 In spite of being a recently introduced technique, balloon valvuloplasty in noncalcified mitral stenosis has been found to be consistently effective in the t rea tment of this condition. 2 Successful double balloon valvuloplasty in t r icuspid stenosis 3, 4 has recently been reported. We repor t a case in which balloon valvuloplasty was performed on both the mitral and tr icuspid valves during the same procedure, with good immediate and midte rm results, A 48-year-old woman pat ien t with New York Hear t Association (NYHA) functional class I I I was admi t t ed to the hospital for the evaluation of rheumatic mitral and tr icuspid stenosis. Physical examinat ion showed a typical mitral facies with p inkish-purple patches on the cheeks, elevated jugular venous pressure, and mild hepatomegaly. A loud first hear t sound and an opening snap were heard at the apex, with a low-pitched diastolic murmur. There was also a diastolic rumble along the lower left sternal border combined with a systolic murmur , both increasing on inspiration. The electrocardiogram (ECG) showed atr ial fibrillat ion and right-axis deviation. The chest x-ray film showed left and right atr ial enlargement with increased upper lobe vascular markings and enlargement of the pulmonary arteries. Echo-Doppler technique showed pure mi t ra l stenosis. The valve was flexible, with no evidence of calcification. Mit ra t valve area, calculated from the mitral flow using the pressure halft ime method as described by Hatle et al., 5 was 1 cm 2. Direct p lanimetry of the mitral orifice gave a valve area of 1.1 cm. 2 The left a t r ium was moderately enlarged and the left ventricle was normal. The tr icuspid valve showed a combinat ion of stenosis and mild incompetence. Tricuspid pressure halft ime was 366 msec. In the light of these findings, we decided to a t t empt percutaneous balloon valvuloplasty on both valves if the assessment was corroborated by diagnostic catheterization. Wri t ten consent was obtained from the pat ient . The catheterizat ion included the measurement of the mitral valve gradient, cardiac outpu t ( thermodilution), and calculation of the area using Gorlin's formula. A left ventriculogram was performed in the right anterior oblique view. Simultaneous recordings of

Background ST-elevation myocardial infarctions (STEMI) caused by proximal left-anterior descending (LAD) lesions have more myocardium at risk and worse outcomes than those located in other segments. The aim is to compare outcomes of patients with STEMI and proximal-LAD lesions treated with bare-metal stents (BMS) versus everolimus-eluting stents (EES). Methods The EXAMINATION trial randomized 1498 STEMI patients to BMS versus EES. The primary end point was the patient-oriented combined of all-cause death, any-recurrent myocardial infarction (MI) and any-revascularization. The secondary end point included the device-oriented combined of cardiac death, target-vessel MI and target-lesion revascularization (TLR). Results STEMI with a proximal-LAD occlusion was observed in 290 patients (BMS = 132 and EES=158). Both groups were similar except for diabetes (12.9% vs 24.1%; P = .016). At 1 year, the primary end point was observed in 18.9% and 9.5% of patients treated with BMS and EES, respectively ( P = .023). The secondary end point was observed in 11.4% and 5.1%, respectively ( P = .053). There were no differences in cardiac death (4.5% vs 3.8%; P = .750) and MI (1.5% vs 0%; P = .121). BMS had higher rate of TLR compared to EES (6.8% vs 1.3%; P = .014). Patients with proximal-LAD STEMI had higher mortality than patients with non proximal-LAD STEMI (5.5% vs 2.9%; P = .027). Proximal-LAD lesions treated with BMS tended to increase the risk of the primary end point compared with other segments (18.9% vs 13.0%; P = .079). However, EES implanted in proximal-LAD had similar outcomes compared with other locations (9.5% vs 12.0%; P = .430). Adjusting for confounders, the interaction between BMS and proximal-LAD location was associated with the primary end point. Conclusion Patients with STEMI and proximal-LAD lesions treated with EES have better outcomes compared with BMS at 1 year. Although further investigations are required, it seems reasonable to consider EES for proximal-LAD STEMI-lesions.

We studied 203 patients with mitral stenosis treated by transarterial valvuloplasty. Forty two (group A) had undergone closed ( n = 30) or open n = 12) surgical commissurotomy 15 ± 5 years before. The remaining 161 had not undergone previous surgery (group B). There were no significant differences between both groups in terms of age, sex, functional class, left atrial size, two-dimensional anatomic features of the valve, incidence of mild basal mitral regurgitation, or ejection fraction. A comparative analysis of both groups showed no significant differences in terms of changes in the mean gradient, mitral valve area, and incidence of severe postvalvuloplasty mitral regurgitation (9.5% versus 5.5%). Echo-Doppler follow-up studies (11 ± 7 months) showed persistent gradient relief in either group. We conclude that the immediate and short-term results of balloon valvuloplasty in patients who had undergone previous surgery are similar to those observed in patients who had not had commissurotomy.

Background The implications of the American College of Cardiology/American Heart Association (ACC/AHA) lesion classification in patients with in-stent restenosis (ISR) are unknown. Methods Four hundred fifty patients included in the RIBS randomized study were analyzed. A centralized core laboratory assessed ISR classifications including ACC/AHA, the classification of Mehran et al ( Circulation 1999;100:1872-8), diffuse/focal, and a new quantitative ISR index (lesion length/stent length). Logistic regression models were constructed for prespecified outcome measures including (1) unsatisfactory acute results and (2) recurrent restenosis rate. Results Complex (B2/C) lesions (78%) more frequently obtained unsatisfactory acute results (20% vs 8%, P = .007), smaller minimal lumen diameter after the procedure (2.45 ± 0.5 vs 2.73 ± 0.5 mm, P = .001) and at follow-up (1.48 ± 0.8 vs 1.94 ± 0.8 mm, P = .0001), and had a higher restenosis rate (43 vs 24%, P = .001) than simple (A/B1) lesions. On logistic regression analysis, all classification schemes were useful to predict unsatisfactory initial results (area under the curve: 0.63, 0.61, 0.59, and 0.62) and recurrent restenosis (area under the curve: 0.60, 0.64, 0.61, and 0.63). The predictive ability of these schemes persisted despite adjustment for potential confounders. Although the ACC/AHA classification was a better predictor of acute results, the classification of Mehran was superior to predict restenosis. Conclusions The ACC/AHA classification provides a useful tool to determine acute procedural results and the long-term angiographic outcome of patients with ISR.