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Objective: To investigate the clinical outcomes in patients with ST segment elevation acute myocardial infarction (STEMI) treated with drug eluting stents (DES) versus a matched control group of patients with STEMI treated with bare metal stents (BMS). Methods: This registry included 122 patients with STEMI undergoing primary coronary angioplasty with DES implantation at our institution. The control group consisted of 506 patients implanted with BMS, who were matched for age, infarct location, and diabetic status. The incidences of major adverse cardiac events (MACE) including target vessel/lesion revascularization (TVR/TLR) and stent thrombosis were assessed up to 12 months. Results: Twelve months follow up showed a non-significant trend towards reduced deaths (3.3% versus 7.1%, P=0.1), significantly reduced recurrent MI (0.0% versus 6.1%, P=0.02), TVR (5.7% versus 15.2%, P=0.006) and TLR (2.5% versus 14.0%, P=0.004) events in the DES group as compared to BMS group. The composite incidences of MACE at 12 months follow-up was lower in the DES group (11.5%) as compared to the BMS group (21.3%, P=0.01). Conclusion: According to our experiences, the use of DES in STEMI is safe and effective as compared to BMS. DES was effective in reducing the incidence of restenosis outcomes and overall adverse cardiac events up to 12 months. [ABSTRACT FROM AUTHOR]

The cohort included 55 consecutive patients with first ST elevation acute myocardial infarction (STEAMI) who underwent reperfusion. Blood samples were drawn for N-terminal pro B-type natriuretic peptide (NT-proBNP), highly-sensitive C-reactive protein (hs-CRP), creatinine kinase (CK), cardiac troponin l (cTnl), and white blood cell (WBC) count within 24 hours of admission. Transthoracic echocardiography, performed within the same time frame, assessed left ventricular (LV) systolic function, as well as diastolic function. Variables significantly associated with poor systolic LV dysfunction were hs-CRP, peak CK, cTnl, and WBC. There was no significant correlation between NT-proBNP and systolic function early after STEAMI (p=0.49). Among patients with diastolic dysfunction, there was no significant correlation between NT-proBNP levels and peak mitral E-wave velocity to peak initial A-wave velocity (E/A ratio) (r =0.19, p=0.18) or E-wave deceleration time (r =0.22, p=0.15). Thus, NT-proBNP levels in the early phase after STEAMI were not indicative of systolic or diastolic function. [ABSTRACT FROM AUTHOR]

During and after myocardial infarction (MI), compensatory contractile and structural changes taking place in the remote uninvolved myocardial regions have been well described, in both experimental and clinical settings. However, quantitative information on the changes in perfusion in these regions in relation to their altered contractile function have not been available. This study was designed to assess the in vivo relationship between contractile function and perfusion in remote uninvolved hypercontractile myocardial regions, subtended by angiographically normal coronary arteries in patients with MI and single-vessel coronary artery disease. We utilized two-dimensional echocardiography and O-water positron emission tomography imaging to assess regional contractile function and myocardial blood flow, respectively. Measurements were performed in nine patients with single-vessel coronary artery disease and angiographically confirmed recanalization of the infarct-related artery, 1–2 days after MI (group A). Only patients demonstrating severely impaired wall motion of the infarcted area and reactive hypercontractility of the remote uninvolved regions were enrolled Seven patients with previous non-reperf used MI (6–8 months post-MI) served as a control (group B). Systolic wall thickening and regional myocardial blood flow data sets were created for the remote myocardial segments perfused by angiographically detected patent coronary arteries by assigning regions on the tomo grams to equivalent echocardio graphic segments. In the remote regions, wall thickening and regional myocardial blood flow were higher in group A patients by 26% (43 ± 6% vs 34 ± 4%; P=0.005) and 20% (1.06 ± 0.15 vs 0.89 ± 0.06 ml. g per minute; P=0.019), respectively. For both groups of patients, a significant correlation (r=0.67, P=0.004) between systolic wall thickening and regional myocardial blood flow was obtained. Infarcted regions in both groups showed no systolic wall thickening. In this selected group of patients these data demonstrate: (1) a proportionate increase in contractility and regional myocardial blood flow in uninvolved territories in patients with recent and old MI; (2) the in vivo relationship between contractile function and myocardial perfusion in man in these regions. When infarcted zones in both groups are equally affected, enhanced levels of catecholamines and sympathetic drive as well as different loading conditions may account for the hyperkinetic performance and consequently for the increased perfusion level in uninvolved segments in patients with recent MI. [ABSTRACT FROM PUBLISHER]

In a substantial percentage of patients with acute myocardial infarction, especially in those with inferior wall involvement, no ST elevation is detected on the electrocardiogram. In many of them, ST depression is found in leads oriented to remote segments of the heart. The importance of those reciprocal changes for early diagnosis of acute inferior myocardial infarction in patients without ST elevation has not been stressed. In order to find the prevalence of reciprocal ST depression, we evaluated the admission electrocardiograms of 107 consecutive patients with evolving first acute inferior mvocardial infarction. Ninety-three patients had ST elevation of at least 0.1 mV in at least one of the inferior leads: II, III or a VF (group A) and in 14 patients ST displacement did not reach 0·1 mV in any of these leads (group B). In both groups, reciprocal ST depression occurred more frequently in a VL than in any other lead. Only three patients had no ST depression in a VL. in eight patients (7·5% ST depression in a VL was the sole early electrocardiographic sign of the inferior infarction, a VL is the only lead that is facing the superior part of the left ventricle and thus is the only lead that is truly opponent to the inferior wall. It seems that ST depression in a VL, by contrast to that in the precordial leads, is found in the majority of patients with evolving inferior wall myocardial infarction and is not influenced by extension of the infarclion to the right ventricle or to the posterior wall. We conclude that transient ST depression in a VL is a sensitive early electrocardiographic sign of acute inferior wall myocardial infarction. [ABSTRACT FROM PUBLISHER]

We assessed predicting final infarct size (using predischarge Selvester score) by 3 electrocardiographic variables in 267 patients with first anterior wall acute myocardial infarction (AMI) undergoing (n = 86) or not undergoing (n = 181) thrombolysis. Patients with previous AMI or inverted T waves in leads with ST elevation were excluded. The sum (sigma) of ST elevation, the number of leads with ST elevation, and the initial electrocardiographic pattern were determined on the admission electrocardiogram (absence (QRS-) or presence (QRS+) of distortion of the terminal portion of the QRS in > or =2 leads (J point > or =0.5 of the R-wave amplitude in leads I, aVL, V4 to V6, or presence of ST elevation without S waves in leads V1 to V3). There was no association between sigmaST elevation and final infarct size in patients who did or did not receive thrombolytic therapy. Analysis of covariance showed that the number of leads with ST elevation (F = 19.6), thrombolysis (F = 25.2), and QRS+ initial pattern (F = 19.5) were all associated with final infarct size (p <0.0001 for all). Among patients who did not receive thrombolytic therapy, the average Selvester score was 19.7+/-9.9 for the QRS- patients and 26.1+/-10.4 for the QRS+ patients (p = 0.02). Among patients who received thrombolytic therapy, the average Selvester score was 11.7+/-9.8 for the QRS- patients and 24.2+/-10.1 for the QRS+ patients (p <0.0001). Thrombolysis reduced final Selvester score only in the QRS- group (p <0.00001), but not in the QRS+ group (p = 0.45). It is concluded that (1) final Selvester score in anterior wall AMI can be predicted by the number of leads with ST elevation, the initial electrocardiographic pattern, and thrombolysis, and (2) thrombolysis reduces final Selvester score only in patients with QRS- pattern. [ABSTRACT FROM AUTHOR]

Background: The last decade, regarded as the DES era in PCI, has witnessed significant advances in the management of coronary disease. We aimed to assess temporal trends in the practice and outcome of percutaneous coronary intervention (PCI) during the drug eluting stent (DES) era., Methods: We analyzed 18,641 consecutive PCI's performed between January 2004 and December 2016, distinguished by procedural date (Q 1 : 2004-2006, n = 4,865; Q 2 : 2007-2009, n = 4,977; Q 3 : 2010-2012, n = 4,230; Q 4 : 2013-2016, n = 4,569)., Results: At presentation, mean patients age was 65 (±11) years and 22.8% were females. Over time, there was a rise in the relative number of octogenarians (Q 1 : 10.7% vs Q 4 : 15.5%, P < 0.001) and an increase in the burden of most comorbidities (e.g., left ventricular dysfunction ≥ moderate and chronic kidney disease, P < 0.001 for both). Despite a 2-fold increase in the rate of complex interventions, and a 3-fold increase in the rate of unprotected left-main angioplasty (P < 0.001 for both), the radial approach was increasingly adopted (Q 1 : 2% to Q 4 : 63.5%, P < 0.001). DES implantation increased from 43% to 83% at the expense of bare metal stent (BMS) application, and accompanied by drug coated balloon sprout to 1.8%, P < 0.001. Kaplan-Meier survival curves revealed a time-based enhanced outcome, with a decreased rate of death, MI, target vessel revascularization and CABG over the years., Conclusions: In the last decade, PCI has evolved to offer better outcome to more elderly, sicker patient population, with more complex coronary disease interventions. The shift to second generation DES and to enhanced PCI techniques may explain part of this progress., (© 2017 Wiley Periodicals, Inc.)

Coronary artery calcium (CAC) is associated with poor angiographic results and higher rates of complications after percutaneous coronary intervention (PCI). Limited data are available regarding the impact of angiographically evident CAC on long-term outcomes after primary PCI in patients presenting with ST-segment elevation myocardial infarction (STEMI). In this single-center, registry-based retrospective cohort analysis, we analyzed 2,143 consecutive patients presenting with STEMI who underwent primary PCI within 12 hours of symptom onset. Patients were divided based on degree of CAC (determined by visual inspection of angiograms) as follows: (1) moderate-to-severe CAC (n = 306; 14.3%) and (2) minimal-to-none CAC (n = 1,837; 85.7%). The primary end point was all-cause mortality at 1-year after PCI. Patients with moderate-to-severe CAC were older, women, and had higher rates of hypertension, chronic kidney disease, and peripheral vascular disease. Moderate-to-severe CAC was associated with higher rates of anterior myocardial infarction, advanced Killip class, and poor final angiographic results. At 1-year follow-up, rates of all-cause mortality were higher in the moderate-to-severe CAC cohort than those in the minimal-to-none CAC cohort (8.5% vs 4.7%; p = 0.008). However, after accounting for major clinical and angiographic characteristics, moderate-to-severe CAC on presenting STEMI angiogram was no longer predictive of 1-year all-cause mortality. In conclusion, advanced CAC burden occurs in ∼15% of patients undergoing primary PCI for STEMI and reflects a marker of adverse prognosis late into follow-up after PCI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: While 'plaque rupture' is the paradigm of type 1 myocardial infarction (T1MI), T2MI is myocardial necrosis secondary to oxygen supply-demand mismatch. Being a heterogeneous and rather newly defined group, data are lacking about T2MI., Methods: A retrospective review of medical records of patients diagnosed with T2MI in the Rabin Cardiology Center, Israel between the years 2007 and 2012 was performed. Following a descriptive analysis, we used multivariate time dependent models to estimate the association of T2MI with the risk for 30-day, 1-year, and 5-year all-cause-mortality and major adverse cardiovascular events (MACE), and compared it to a T1MI group matched for age, gender and electrocardiographic changes., Results: The study included 107 T2MI (and 107 T1MI) patients. Sepsis, anemia, and atrial fibrillation were the most common etiologies. Triple anti-thrombotic therapy was given to 22% of T2MI patients (vs. 82% of T1MI patients, p<0.001). Twenty-five percent were managed using urgent percutaneous coronary intervention. Angiography unmasked acute plaque rupture in 29% of T2MI patients group. Compared to T1MI, T2MI was associated with higher all-cause-mortality rate: adjusted-hazard-ratio 7.14 (1.31-38.9) at 30 days, 3.42 (1.51-7.75) at 1 year, and 2.08 (1.14-3.81) at 5 years follow-up. MACE risk was consistent between T2 and T1MI patients., Conclusions: The most common T2MI triggers are sepsis, anemia, and atrial fibrillation. Compared to a T1MI population, T2MI is associated with higher short- and long-term mortality rates but equal cardiovascular mortality and MACE risk. As many as 30% may harbor plaque rupture and in fact have T1MI., (Copyright © 2015. Published by Elsevier Ltd.)

Antiplatelet responses to clopidogrel and prasugrel are highly variable and subject to significant rates of high on-treatment platelet reactivity (HTPR) after percutaneous coronary intervention (PCI). The proportion of circulating young reticulated platelets (RPs) inversely correlates with responsiveness to both agents. We aimed to determine the relationship between RPs and on-treatment platelet reactivity in ticagrelor-treated patients. Patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated with PCI and ticagrelor were tested for platelet reactivity using the VerifyNow P2Y12 assay and multiplate aggregometry. RPs levels were determined using flow cytometry with thiazole orange staining. Tests were performed at 2-4 and 30 days post-PCI. Fifty three patients were included (mean age 62.6 ± 9.8 years, 18.9 % women, 35.8 % diabetes), of which 41 patients (77 %) completed follow-up. Variability in response to ticagrelor was very low according to both assays with no identified cases of HTPR at either time-point. In addition, there were no differences in platelet reactivity, as analyzed by the VerifyNow P2Y12 assay, or in the proportion of RPs between the two time points (p > 0.5). With the multiplate assay, platelet reactivity increased between the two time-points (8.6 ± 6.0 vs. 15.5 ± 11 AU*min; p = 0.0007). There was no significant correlation between RPs and platelet reactivity at both time-points and using both assays (p > 0.5). There were no cases of HTPR up to 30-days post-PCI in patients with NSTE-ACS treated with ticagrelor. In this cohort, no correlation between % RPs and platelet reactivity was observed. Attenuation of RP-induced platelet reactivity as a novel mechanism for ticagrelor's benefit requires further investigation.

Reticulated platelets (RP) are young, hyperactive platelets that are increased during situations of enhanced platelet turnover such as acute myocardial infarction (AMI). The dynamics of RP levels after AMI is not established. We aimed to characterize the levels of circulating RP over time in patients with AMI. Patients with AMI treated with ticagrelor or prasugrel who underwent percutaneous coronary intervention (PCI) were tested for circulating RP using flow cytometry with Thiazole orange staining at 3 time points at 2-4 days, 30-60 days and 1 year post PCI. Platelet reactivity was assessed using the VerifyNow P2Y12 assay at these time points (results in platelet reactivity units-PRU). Thirty-five patients were included in the study (mean age 62.6 ± 9.1 years, 82.9 % males). Median RP levels were similar at the first and second time points (17.5 %, IQR 25-75: 10.8-22.4 % and 14.9 %, IQR 25-75: 9.7-26.8 %, respectively; p = 0.75). However, RP levels after 1 year were significantly lower as compared to the first and second time points (10.5 % (IQR 25-75: 5.3-18.1 %), p = 0.005 and p = 0.01, respectively). Residual platelet reactivity was very low at all 3 time points (median PRU 25, IQR 25-75: 7-53) and did not change significantly between them (p = 0.66). No significant correlation was found between levels of RP and PRU at any given time point. RP levels of patients with AMI treated with prasugrel or ticagrelor decrease over time after the acute event. However, RP levels over time do not correlate well with residual platelet reactivity.

High on-treatment platelet reactivity (HTPR) despite use of P2Y12 antagonists is associated with adverse cardiac events. The long-term variability in response to prasugrel and ticagrelor is unclear. Our aim was to assess residual platelet reactivity (PR) and rates of HTPR during treatment with prasugrel versus ticagrelor in patients with myocardial infarction (MI). 114 patients with MI treated with percutaneous coronary intervention (PCI) were included. Sixty-two patients were treated with prasugrel (mean age 58 ± 8 years, 21 % women, 29 % diabetes), and 52 patients with ticagrelor (mean age 63 ± 9, 19 % women, 37 % diabetes). Patients were tested for PR at 2-4 days and 30 days post-PCI, using the VerifyNow P2Y12 assay and the multiple-electrode aggregometry. Our results show a higher residual PR in patients treated with prasugrel than those treated with ticagrelor (VerifyNow: 65.4 ± 60.6 vs. 26.0 ± 24.2 P2Y12 reaction units, p < 0.001 at 2-4 days, and 67.3 ± 62.5 vs. 21.1 ± 26.1, p < 0.001 at follow-up). HTPR rates were higher in the prasugrel group (8.1-11.3 % vs. none with ticagrelor in the early test, and 8.7-10.9 % vs. none with ticagrelor at follow-up). In conclusion, in patients with MI undergoing PCI, treatment with ticagrelor resulted in greater platelet inhibition and lower HTPR rates compared with prasugrel, up to 30 days after the event.

In four selected patients presenting with ST-segment elevation myocardial infarction (STEMI), aspiration thrombectomy allowed for full filling defect angiographic 'cleaning' of the culprit arteries without need for stent implantation. Obtaining good angiographic results and uneventful early and long-term clinical outcome after thrombus aspiration alone raises the question as to whether stenting the infracted thrombotic artery is mandatory and routinely indicated in every single STEMI patient treated with primary percutaneous coronary intervention.

Objectives: The aim of this study was to determine whether response to prasugrel is associated with the proportion of circulating reticulated platelets (RPs) in patients with ST-segment elevation myocardial infarction (STEMI)., Background: Despite better pharmacodynamic properties and clinical efficacy of prasugrel compared with clopidogrel, antiplatelet responses to prasugrel are not uniform. The mechanism of this variability in response is not clear. RPs, young hyperactive forms, are increased during situations of enhanced platelet turnover., Methods: Patients with STEMI treated with primary percutaneous intervention (PCI) and prasugrel were tested for platelet reactivity using purinergic receptor P₂Y, G-protein coupled, 12 (P₂Y₁₂) assay and multiple electrode aggregometry (MEA). RP levels were determined using flow cytometry with thiazole orange staining. Tests were performed at 2 to 4 days and 30 days post-PCI. Platelet function was compared by varying levels of RPs, analyzed as continuous (regression analysis) and categorical (tertiles) variables., Results: Sixty-two patients were included (mean age: 57.5 ± 8 years; 21.2% women; 27.7% diabetes). At the early time point, RP levels were strongly correlated with platelet reactivity when evaluated by the P₂Y₁₂ assay (Spearman's correlation coefficient: 0.55 for P₂Y₁₂ reaction units, -0.49 for percent inhibition) and MEA (Spearman's: 0.50). The upper tertile of RPs displayed higher platelet reactivity compared with the middle and lower tertiles, according to P₂Y₁₂ assay and MEA. Similar results with strong correlations between RP and platelet reactivity were noted at 30 days post-PCI., Conclusions: The proportion of circulating RPs strongly correlates with response to prasugrel in patients with STEMI treated with PCI. High levels of RPs are associated with increased platelet reactivity despite prasugrel treatment., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Retroperitoneal bleeding (RPB) is an unusual but potentially fatal vascular complication occurring after cardiac catheterization (CC). Contemporary data of RPB in the era of dual antiplatelet therapy and vascular closure devices are lacking., Methods: We retrospectively examined all RPB cases that occurred after CC in the Rabin Medical Center between the years 2005 and 2011., Results: Of 26,487 patients who underwent CC, a total of 48 patients (mean age 60.9 ± 13.8 years, 52.1% female) with RPB were identified (0.18%). The indication for CC was acute coronary syndrome (43.7%), myocardial infarction (35.4%), stable angina pectoris (8.3%), hemodynamic studies for valvular heart disease (10.4%) and others (2.1%). Coronary intervention was performed in 34 patients (70.9%) and a vascular closure device (VCD) was used in 16 patients (33.3%). Seventy-seven percent of patients were treated with clopidogrel, 20.8% with glycoprotein IIb-IIIa inhibitors and 85.4% with anticoagulation during CC. Median time to diagnosis of bleeding was 9.0 h, while the median time to bleeding differed between patients with and without a VCD (12 vs. 5 h, respectively). The clinical presentation of RPB was hemorrhagic shock in 39.6% of patients and 50.0% required at least one blood transfusion. Patients were managed either with conservative treatment (79.2%), angiography stenting (14.6%) or vascular surgery (6.2%). A total of 3 patients died during hospitalization, of which RPB was the etiology in 2 (4.2%)., Conclusions: RPB which is a rare complication of CC is associated with younger age and female gender, as compared to patients without RPB. Onset of bleeding can be delayed in patients with VCDs. With careful and early diagnosis, most patients with RPB after CC can be managed conservatively., (Copyright © 2013 S. Karger AG, Basel.)

Background: Manual coronary thrombus aspiration was associated with improved outcomes of ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the outcome of aspiration in a "real-world" setting of primary percutaneous coronary intervention (PPCI)., Methods and Materials: We analyzed the outcome of STEMI patients who underwent PPCI (initial Thrombolysis in Myocardial Infarction flow grade 0/1), comparing patients who underwent aspiration (ASP) to those who had standard (STD) therapy. Various subgroups outcomes were further analyzed. Clinical end points included mortality and major adverse cardiovascular events (MACE) at 30 days and at 1 year., Results: One thousand thirty-five consecutive patients were included: 189 (18.26%) with ASP and 846 (81.74%) with STD. ASP patients were younger (58±12 vs. 61±13, P<.05) and had higher incidence of direct stenting compared to STD patients (34% vs. 16.7%, P<.05). No significant differences were noted in the outcome of ASP vs. STD at 30 days (mortality rate 4.2% vs. 4.5%, P=.9; MACE 6.9% vs. 9.8%, P=.2) and at 1 year (mortality rate 8.0% vs. 8.3%, P=.9; MACE 20.0% vs. 22.3%, P=.5). A significant advantage in favor of ASP was evident in patients with proximal culprit lesions, anterior infarcts, and right ventricular involvement., Conclusions: Although this was largely a negative study, when STEMI involved a large jeopardized myocardium, aspiration was associated with sustained improved clinical outcomes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: Patients with antiphospholipid antibody syndrome (APS) have an increased risk of atherothrombotic complications. There are limited data regarding the outcome of patients with APS who undergo percutaneous coronary intervention (PCI). Accordingly, we aimed to assess the long-term outcomes of these patients., Methods: Nineteen APS patients who underwent PCI between the years 2003 and 2008 were compared to 380 patients who had undergone PCI during the same period (PCI group) and were matched by age (±5 years), gender, diabetes and hypertension. In addition, APS patients were compared to 1,458 patients with ST segment elevation myocardial infarction (MI) who were treated with PCI during the same period. Six-month to 4-year clinical outcomes were evaluated., Results: The indication for PCI in the APS group was acute coronary syndrome in 52.6% of patients. After 1 year of follow-up, patients with APS had higher rates of target vessel revascularization than the other two groups, which translated to higher rates of major adverse cardiac events. There were no differences in MI or mortality rates between the groups., Conclusions: Patients with APS who undergo PCI have worse long-term clinical outcomes, driven by higher rates of revascularization, than other patients undergoing PCI. Further study is warranted to examine the mechanisms underlying these findings., (Copyright © 2012 S. Karger AG, Basel.)

Objectives: We aim to explore the clinical outcome of drug-eluting stents (DES) versus bare-metal stents (BMS) implantation in diabetics versus nondiabetic patients., Background: Diabetic patients sustain worse long-term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long-term clinical benefits, such as myocardial infarction (MI) or mortality is scant., Methods: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk-adjusted event-free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients., Results: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major-adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42-0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55-0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56-0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69-1.13, P = 0.3)., Conclusions: In a "real-world," unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population., (Copyright © 2011 Wiley-Liss, Inc.)

No-reflow is a frequent event during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and it may affect cardiac prognosis. We evaluated the occurrence of no-reflow as a predictor of outcomes in patients who underwent PCI for AMI. We prospectively collected data from 599 consecutive patients who underwent stent-based PCI for ST-elevation AMI by identifying those with no-reflow (Thrombosis In Myocardial Infarction [TIMI] grade <3 flow at completion of the procedure) and analyzing their baseline characteristics and clinical outcomes. Patients with no-reflow (n = 40, 6.7%) were older (67 +/- 13 vs 60 +/- 13 years, p = 0.002) and had longer ischemic times (5.5 +/- 3.7 vs 4.4 +/- 3.0 hours, p = 0.04) with more TIMI grade 0/1 flow at presentation (90% vs 64%, p = 0.001). No-reflow occurred mostly (73%) after stenting and often required intra-aortic balloon pump counterpulsation (30% vs 4.3%, p <0.001). Peak creatine kinase level was higher in patients with no-reflow (2,700 +/- 1,900 vs 2,000 +/- 1,800, p = 0.03) and more often associated with moderate or severe left ventricular dysfunction (68% vs 45%, p = 0.006) and increased 6-month mortality (12.5% vs 4.3%, p = 0.04). By multivariate analysis, no-reflow was an independent predictor of long-term mortality (odds ratio 3.4, p = 0.02). In addition, renal failure (odds ratio 4.39, p = 0.0025) and preprocedure TIMI grade 0/1 flow (odds ratio 2.1, p = 0.003) were independent predictors of no-reflow. In conclusion, the association of no-reflow with longer ischemic time and worse initial TIMI flow may indicate the presence of highly organized thrombus burden with higher propensity for distal embolization. Regardless of its mechanism, no-reflow was an independent predictor of increased mortality.

We measured body temperature in 40 consecutive patients treated for a first ST elevation acute myocardial infarction (AMI) with primary percutaneous coronary interventions. Left ventricular function was assessed by echocardiography, and blood samples were drawn for highly sensitive C-reactive protein (hs-CRP), white blood cell (WBC) count, fibrinogen, creatine kinase (CK), and cardiac troponin I levels (cTnI). The median (25th, 75th quartiles) peak 24-hour temperature was 37.4 degrees C (36.9 degrees C, 37.6 degrees C). Variables significantly associated with peak 24-hour temperature were CK (p = 0.01, r = 0.42), wall motion index (p = 0.01, r = 0.41), hs-CRP (p = 0.01, r = 0.41), and cTnI (p = 0.03, r = 0.35). There was no significant correlation between peak 24-hour temperature and WBC count (p = 0.39, r = 0.14) and fibrinogen (p = 0.12, r = 0.21). Thus, peak 24-hour body temperature after ST elevation AMI probably reflects infarct size rather than a nonspecific inflammatory response., (Copyright 2005 S. Karger AG, Basel.)

Background: Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines., Aim: To evaluate the in-hospital and 30-day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS., Methods and Results: Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co-morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In-hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non-cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48 hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age 75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0-1.24, P=0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95-1.0, P=0.05), were independent predictors of all cause mortality at 30 days., Conclusion: Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.

The role of small molecules anti-glycoprotein (GP) IIb/IIIa pharmacotherapy during acute myocardial infarction (AMI) has not been established. The purpose of our study was to evaluate the clinical outcomes of patients sustaining AMI who underwent emergent percutaneous coronary intervention (PCI) and who were distinguished by the use of the anti-GP IIb/IIIa agent eptifibatide. We studied a consecutive group of 216 patients who underwent PCI for acute ST-elevation myocardial infarction and compared the outcomes of patients who received eptifibatide just prior and following the procedure (n=167) to those who were not on anti GP IIb/IIIa inhibitors (n=49). On average, patients treated using eptifibatide were younger and were more likely to be men, hypertensive, and smokers. The eptifibatide treated patients were less likely to have diabetes and renal failure and had worse angiographic characteristics. There were no significant differences between the groups in any of the clinical outcomes, including the composite endpoint (e.g. death, MI, repeat revascularization) and the rate of sub-acute stent thrombosis. Nonetheless, there was a non-significant trend towards lower 30 day mortality in the eptifibatide group (4.8% versus 12%, P=0.09). We concluded that in our comparative study of periprocedural administration of eptifibatide during emergent AMI angioplasty, there was a non-significant trend towards better short-term survival among eptifibatide treated patients although the composite endpoint did not differ between patients distinguished by the use of anti GP IIb/IIIa small molecule pharmacotherapy.

Objective: The purpose of this study was to evaluate two different stent placement techniques for bifurcation lesions: 1) stenting of the main branch and balloon dilatation of the sidebranch versus 2) stenting of both branches., Background: Percutaneous coronary intervention (PCI) of coronary bifurcation lesions remains challenging, and limited information is available regarding whether stent placement is necessary in both branches of the bifurcation using bare-metal stents. Methods. We prospectively followed all patients who underwent PCI for symptomatic bifurcation lesions at our center. All patients were carefully followed for subsequent clinical events., Results: Between March 2001 and November 2002, a total of 50 patients were treated with either stenting of both vessels (double stent group; n = 32) or stenting of the parent vessel and balloon angioplasty of the sidebranch (single stent group; n = 18). Optimal angiographic success was 87.5% in the single stent group and 100% in the double stent group (p = 0.1). The post-procedure percent diameter stenosis of the sidebranch vessel was significantly higher in the single stent group (18 +/- 25% versus 4 +/- 8%; p = 0.005). At 6 months, the incidence of clinically driven repeat target lesion revascularization was 37.6% with 2 stents as compared to 5.6% using 1 stent (p = 0.01). Angiographic restenosis was documented in 40.6% using 2 bifurcation stents, as compared to 11% when using 1 stent (p = 0.05). By multivariable analysis adjusted for baseline differences, stenting the sidebranch was a borderline predictor for major adverse cardiac events at 6 months (odds ratio = 10.3; 95% confidence interval, 0.9-116; p = 0.053)., Conclusion: For the treatment of true bifurcation lesions, a strategy of stenting both vessels using bare metal stents seems to be associated with worse long-term results, as compared to stenting only the parent vessel.

We prospectively followed 238 patients who underwent percutaneous coronary intervention for acute ST-elevation myocardial infarction and compared the outcomes of patients who received heparin-coated stents (n = 124) with those of patients who received noncoated stents (n = 114). The clinical characteristics and adjunctive medications of the 2 groups were similar. The use of heparin-coated stents was associated with improved 30-day outcome but had no significant effect on 180-day outcome.

Background: Arterial access site management after percutaneous coronary intervention (PCI) is a matter of increasing importance in this era of potent antiplatelet pharmacotherapy. We evaluated the safety and efficacy of a 6 French (Fr) Perclose suturing device in achieving rapid hemostasis of the access site after PCI and thus improving patient comfort., Methods: The 6 Fr Perclose (Prostar) device consists of a suture-based closure device delivered via introducer sheath designed for suturing of the arteriotomy puncture site. Over a 3-month period, the device was used in 48 consecutive PCI treated patients (age, 62 13 years; 70% male; 44% post myocardial infarction) and in-hospital groin complication rate was compared to 48 consecutive patients (age, 64 12 years; 64% male; 33% post myocardial infarction) who had manual compression hemostasis., Results: Antiplatelet glycoprotein IIb/IIIa antagonists were used more frequently during and following the procedure in 58% of Perclose-treated patients versus 42% of the manual compression group (p = 0.019). Leg immobilization duration was 3 4 hours in all patients sutured by the device; in patients with manual compression, the sheath was removed at an average of 4.8 2.5 hours after termination of the PCI and an additional 6 hours of leg immobilization were subsequently required. No difference in overall major complication rate was found between groups (6.2% in suture-mediated patients versus 9.3% in manual compression group; p = 0.60). In 3 patients (6.2%) treated using the device, adjunctive manual compression was required in addition to groin suturing due to technical failure or residual oozing from the arteriotomy site., Conclusion: The 6 Fr Perclose device can be safely used to achieve rapid hemostasis and the device may hasten bed mobilization of PCI-treated patients despite frequent use of potent antiplatelet pharmacotherapy during coronary interventions.

To evaluate the feasibility of stenting without predilatation, we registered all interventional procedures over a 6-month period. Six hundred patients were registered, and 684 lesions were treated. Interventions were divided into four groups: stenting without predilatation (SWOP), 221 lesions (32.4%); primary stenting with predilatation (PDS), 161 lesions (23.5%); provisional stenting (PRS), 131 lesions (19.2%); and plain-old balloon angioplasty (POBA), 171 lesions (25%). Interventional strategy was at the discretion of the operator based on few simple angiographic criteria and his clinical judgment. Procedural success was similar in all stent groups. We conclude that when primary stenting is planned, about 60% of lesions can be treated by SWOP effectively with excellent procedural results and considerable cost saving.

Since its introduction to the market in March 1997, sildenafil acetate (Viagra) has been prescribed to 1.7 million people. Sixteen men who were taking the drug have died, 7 of them during or soon after sexual activity. Most of these data have been derived from the media and not from the scientific literature. There is a general impression that cardiovascular complications of sildenafil occur mainly when the drug is taken concomitantly with nitrates. We describe a 65-year-old man with known coronary artery disease who had an acute myocardial infarction shortly after taking sildenafil and engaging an sexual activity. The patient had not been using nitrates. We suggest that the emotional arousal induced by Viagra, followed by the heavy physical exertion during sexual activity, triggers plaque rupture that leads to acute myocardial infarction.

A prospective study was carried out to assess the occurrence and character of adverse cutaneous reactions in patients receiving ticlopidine hydrochloride to prevent subacute thrombosis after having undergone placement of coronary stents. During a 1-year period such patients were requested to report any adverse cutaneous reactions, and those with skin reactions were referred for dermatological evaluation. Among the 136 patients who underwent stent placement by one of the authors, 20 were referred for dermatological evaluation. Of these, 16 (11.8%) fit the case definition of ticlopidine-associated cutaneous reactions. In the first 8 consecutive patients ticlopidine was withdrawn (in 2 of these a rechallenge test was later performed); in the next 8 patients ticlopidine was not discontinued before completion of the intended 4-week period of treatment. Patients remained under weekly follow-up and underwent a weekly blood count. Skin biopsies were obtained in 5 patients with different types of eruptions. The skin reactions appeared from 2 to 21 days after commencement of ticlopidine (mean, 10 days), lasting from 2 to 30 days (mean, 5 days). Only 3 patients had other adverse effects: neutropenia in 1 and abdominal pain and nausea in 2. The most common presentations were urticaria, pruritus, and maculopapular eruption. In 3 patients there were previously unreported reactions: fixed drug eruption, erythromelalgia-like eruption, and erythema multiforme-like eruption. Of note was the rapid clearing of the skin eruption in most cases even when the drug was not withdrawn. It was concluded that adverse cutaneous reactions are relatively common in association with ticlopidine treatment but that serious reactions are rare and the disappearance of the signs and symptoms is rapid, suggesting that discontinuation of the drug is not usually imperative.

To assess the arterial injury triggered by polyurethane-coated vs. uncoated stents, six polyurethane-coated and six bare nitinol stents were implanted in rabbit carotid arteries. All animals were sacrificed 4 wk after stent placement. Sections were evaluated by histology and morphometric analysis. At 4 wk, both the coated and uncoated stent struts were entirely endothelialized. The spaces between the struts showed a relatively mild proliferative response, with a few sections demonstrating neovascularization around the struts. Polyurethane coating was associated with an inflammatory tissue response consisting of lymphocytic infiltration and foreign-body reaction, with the appearance of multinucleated giant cells. Lumen, intimal, and medial cross-sectional areas varied little between coated and uncoated stented vessels (2.45+/-0.19 vs. 2.47+/-0.47 mm2, 1.17+/-0.52 vs. 0.78+/-0.30 mm2, and 0.66+/-0.18 vs. 0.58+/-0.27 mm2, respectively). In the rabbit carotid artery model, polyurethane coating does not affect the degree of neointimal proliferation after endovascular stenting compared with the conventional stenting approach. However, the inflammatory tissue response may indicate a low intrinsic biocompatibility of this stable polymer, so that it may not be an ideal material for coating intravascular devices.

Objectives: We sought to provide short- and long-term clinical outcomes of a high risk cohort treated with stents in saphenous vein grafts (SVGs)., Background: Data on the long-term outcome of SVG stenting in high risk patients are limited., Methods: Johnson & Johnson stents were implanted in the SVGs of 186 patients (302 stents, 244 lesions). Ninety percent of patients presented with myocardial infarction (MI) or unstable angina (mean +/- SD ejection fraction [EF] 44 +/- 11%, patient age 71 +/- 9 years, graft age 9.4 +/- 5 years). Using a risk score classification, 155 patients (83%) were defined as high risk for repeat surgical repair or angioplasty., Results: The procedural success rate was 97.3%, with 2.7% major complications (death, Q wave MI, coronary artery bypass graft surgery [CABG]). Clinical follow-up was obtained in 177 patients (mean 19.1 +/- 13.5 months, range 7 to 59). Event rates were 10% for death; 9% for MI; 11% for repeat CABG; and 15% for repeat angioplasty (total events 45%). Kaplan-Meier estimated survival and event-free survival at 4 years were 0.79 +/- 0.06 and 0.29 +/- 0.07, respectively. Predictors of death were congestive heart failure (p < 0.01) and EF <44% (p < 0.05). Predictors of combined events of death, MI and CABG were low EF (p < 0.01) and high SVG age (>10 years, p < 0.01). There were 66 revascularization procedures (35% of patients), 24% of which were in nontarget lesions. Fifty-three percent of the cardiac events occurred during the first year of follow-up. Of the 160 survivors, 36% were free of angina, 49% were in Canadian Cardiovascular Society functional class I or II, and 15% were in class III or IV. Sixty-nine percent of patients were in class I or II according to the Specific Activity Scale, and 31% of patients were in class III or IV., Conclusions: Balloon-expandable stent implantation in the SVGs of high risk patients is associated with a low early complication rate. Expected survival rates are good, as are the anginal and functional classifications, but there is a high rate of recurrent events and need for repeat revascularization. Vein graft stenting is an acceptable palliative option in many high risk patients.

Objectives: We sought to assess the relation between glucose metabolism, myocardial perfusion and cardiac work after orthotopic heart transplantation., Background: The metabolic profile of the transplanted cardiac muscle is affected by the lack of sympathetic innervation, impaired inotropic function, chronic vasculopathy, allograft rejection and immunosuppressive therapy. In relation to myocardial perfusion and cardiac work, glucose metabolism has not previously been studied in heart transplant recipients., Methods: Regional myocardial blood flow (ml.min-1.g-1) and 18F-2-fluoro-2-deoxyglucose (18FDG) uptake rate (ml.s-1.g-1) were measured after an overnight fast in 9 healthy male volunteers (mean age +/- SD 32 +/- 7 years) and in 10 male patients (mean age 50 +/- 10 years) who had a nonrejecting heart transplant, normal left ventricular function and no angiographic evidence of epicardial coronary sclerosis. Measurements were made by using dynamic positron emission tomography (PET) with 15O-labeled water and 18FDG, respectively. Heart rate and blood pressure were also measured for calculation of rate-pressure product., Results: 18FDG uptake was similar in all heart regions in the patients and volunteers (intrasubject regional variably 12 +/- 8% and 16 +/- 12%, respectively, p = 0.51). Regional myocardial blood flow was similarly evenly distributed (intrasubject regional variability 14 +/- 10% and 12 +/- 8%, respectively, p = 0.67). Mean 18FDG uptake and myocardial blood flow values for the whole heart are given because no regional differences were identified. 18FDG uptake was on average 196% higher in the patients than in the volunteers (2.90 +/- 1.79 x 10(-4) vs. 0.98 +/- 0.38 x 10(-4) ml.s-1.g-1, p = 0.006). Regional myocardial blood flow and rate-pressure product were similarly increased in the patient group, but by only 41% (1.14 +/- 0.3 vs. 0.81 +/- 0.13 ml.min-1.g-1, p = 0.008) and 53% (11,740 +/- 2,830 vs. 7,689 +/- 1,488, p = 0.001), respectively., Conclusions: 18FDG uptake is homogeneously increased in normally functioning nonrejecting heart transplants. This finding suggests that glucose may be a preferred substrate in the transplanted heart. The magnitude of this observed increase is significantly greater than that observed for myocardial blood flow or cardiac work. In the patient group, the latter two variables were increased to a similar degree over values in control hearts, indicating a coupling between cardiac work load and myocardial blood flow. The disproportionate rise in 18FDG uptake may be accounted for by inefficient metabolic utilization of glucose by the transplanted myocardium or by the influence of circulating catecholamines, which may stimulate glucose uptake independently of changes in cardiac work load.

This study was designed to evaluate the feasibility of applying locally delivered polylactic acid microspheres for drug delivery to the arterial wall. To study drug persistence, rhodamine-loaded microspheres were infused into one carotid artery of 14 rabbits and plain rhodamine solution into the other by using a porous balloon. To study tissue response, plain microspheres and dexamethasone-loaded microspheres were infused into the carotid arteries of another group of rabbits. To study the antiproliferative effects of locally delivered drug, 20 rabbits were subjected to overstretch balloon injury to both carotid arteries and divided into 4 groups: injury alone, plain microspheres, dexamethasone-loaded microspheres, and microspheres containing colchicine and dexamethasone. Fluorescent microspheres persisted in the vessel wall for 4 wk, whereas rhodamine without microspheres disappeared at 72 h. Histopathologic studies in arteries infused with unloaded microspheres showed inflammatory cell infiltrate with polymorphonuclear cells at 1 wk and macrophages and giant cells at 4 wk. Arteries infused with dexamethasone-loaded microspheres did not show any inflammatory cell infiltrate. Local delivery of dexamethasone or dexamethasone plus colchicine did not result in significant change in the intima-to-media ratio or in residual lumen following balloon injury. Polylactic acid microspheres may be used for prolonged delivery of drugs or other bioactive agents locally to the arterial wall. They induce an inflammatory reaction that is suppressable by dexamethasone in the microspheres. Dexamethasone or dexamethasone and colchicine delivered via this system, however, failed to reduce the degree of intimal hyperplasia after overstretch balloon injury to the rabbit carotid arteries.

The objective was to assess the arterial wall response to temporary stenting with a removable nitinol stent in comparison with permanent stenting and balloon injury at 28 days in the rabbit carotid artery. Restenosis remains an important limiting factor after the implantation of permanent metallic stents and balloon angioplasty. We have developed a temporary nitinol stent that uses a bolus injection of warmed saline to collapse the stent for percutaneous removal. Vascular changes related to the thermal saline bolus injection required to remove a nitinol implanted stent were assessed in 12 rabbit carotid arteries at 7 and 28 days postinjection. Nitinol stents, inflated to 3.0 mm diameter, were implanted for 3 days (n = 6) and histology and quantitative histomorphometry examined at 28 days. Results were compared with permanently implanted stents (n = 5) and balloon injury (n = 9). Dual bolus injection of 10 ml at 70 degrees C created an acute necrotizing injury and chronic neointimal proliferation, whereas injections of 5 ml at 63 degrees C were minimally injurious. Temporary stenting resulted in the least neointimal proliferation measured by the intima to media ratio (0.22 +/- 0.10 vs. 1.59 +/- 0.31 for permanent stenting and; 0.49 +/- 0.14 for balloon injury; P < 0.001). Temporary stenting maintained a significantly larger lumen than balloon (1.53 +/- 0.72 mm2 vs. 0.64 +/- 0.14 mm2; P < 0.001), which could not be explained by absolute changes in intimal cross sectional area (0.14 +/- 0.07 mm2 vs. 0.21 +/- 0.06 mm2 respectively; P = 0.33). Temporary stenting resulted in a relatively larger vessel area within the external elastic lamina than with balloon (2.28 +/- 1.06 mm2 vs. 1.30 +/- 0.18 mm2; P = 0.007). The thermal stent recovery process can create necrotizing vascular injury and neointimal proliferation at higher temperatures and injectate volumes. Stent removal after 3 days using 63 degrees C saline bolus injection results in less neointimal proliferation than with permanent stents or balloon injury. In comparison to balloon injury, temporary stenting also may have a long-lasting beneficial effect on vessel recoil and remodeling, resulting in larger lumen size after stent removal.

Purpose: The aim of this study was to determine the proportion of patients with acute myocardial infarction (AMI) excluded from thrombolytic therapy on a national basis and to evaluate the prognosis of these patients by reasons of ineligibility and according to the alternative therapies that they received during hospitalization., Patients and Methods: During a national survey, 1,014 consecutive patients with AMI were hospitalized in all the 25 coronary care units operating in Israel., Results: Three hundred and eighty-three patients (38%) were treated with a thrombolytic agent and included in the GUSTO study. Ineligible patients for GUSTO were treated: (1) without any reperfusion therapy (n = 449), (2) by mechanical revascularization (n = 97), or (3) given 1.5 million units of streptokinase (n = 85) outside of the GUSTO protocol. The inhospital and 1-year post-discharge mortality rates were 6% and 2% in patients included in the GUSTO study; 6% and 5% in those mechanically reperfused; 15% and 10% in those treated with thromoblysis despite ineligibility for the GUSTO trial, and 15% and 13% among patients not treated with any reperfusion therapy., Conclusions: Ineligibility for thrombolysis among patients with AMI remains high. Patients ineligible for thrombolysis according to the GUSTO criteria, but nevertheless treated with a thrombolytic agent were exposed to an increased risk.

Acute myocardial infarction with ST elevation in lead aVL may represent involvement of the first diagonal or the first obtuse marginal branch. This study assesses the correlation among different electrocardiographic patterns of acute myocardial infarction with ST elevation in aVL and the site of the infarct-related artery occlusion. Patients who underwent coronary angiography within 14 days of infarction with an unequivocal culprit lesion were included. Fifty-seven patients were evaluated. The culprit lesion was in the left anterior descending coronary artery proximal to the first diagonal, first diagonal, and first obtuse marginal branches, in 38, 8, and 11 patients, respectively. ST elevation in aVL and V2 through V5 signifies left anterior descending artery occlusion proximal to the first diagonal branch (positive predictive value [PPV] and negative predictive value [NPV] of 95% and 94%, respectively). ST elevation in aVL and V2, not accompanied by ST elevation in V3 through V5, favors occlusion of the first diagonal branch (PPV, 89%; NPV, 100%). ST elevation in aVL accompanied by ST depression in V2 predicts obstruction of the first obtuse marginal branch (PPV, 100%; NPV, 98%).

We report clinical and angiographic results in 53 patients with 57 significant coronary or saphenous vein graft narrowings treated with directional excimer laser angioplasty. The target vessels were the left main (1%), anterior descending (32%), circumflex (19%), right coronary artery (39%), and vein grafts (9%). Lesions were morphologic class B1 (18%), B2 (79%), or C (3%), with 40 de novo and 17 restenotic lesions. Adjunctive balloon angioplasty was used in 53 lesions (93%). Mean pre- and postprocedural minimal lumen diameters were 0.6 +/- 0.3 and 1.9 +/- 0.7 mm (p < 0.001), corresponding to a mean diameter stenosis of 72 +/- 20% and 27 +/- 16%. Procedural success rate was 91%. Cumulative risk of death, Q-wave myocardial infarction, or emergency bypass operation was 9% (5 patients). Of patients who had a successful laser procedure, 28 (60%) with 30 lesions underwent angiographic follow-up at 6 +/- 3 months after the procedure. Restenosis rates (> 50% diameter restenosis or acute gain loss) were 37% and 23%, respectively. Four patients underwent bypass, 3 angioplasty, and 1 patient died from cancer. This study demonstrates the feasibility of directional application of laser energy to selected unfavorable narrowings for conventional excimer laser or balloon angioplasty. Further evaluation of this device using the now standard saline infusion technique is necessary to establish its ultimate role as a primary interventional device.

After successful stent implantation, the residual luminal diameter of the stented vessel is usually smaller than the maximal stent-expanded balloon diameter. The goal of this study was to determine whether immediate vessel diameter recoil after Palmaz-Schatz stenting is affected by the final expanding balloon diameter used during stent deployment. Single Palmaz-Schatz balloon expandable stents were successfully placed in 108 stenotic lesions. There were 68 patients with 75 saphenous vein graft (SVG) and 30 patients with 33 native coronary artery lesions, including 26 restenotic and 82 de novo occlusive (> 50% diameter stenosis) lesions. Quantitative coronary angiography was used for the assessment of stent recoil, defined as the difference between the minimal diameter of the fully expanded balloon and the postprocedure minimal lumen diameter divided by minimal diameter of the fully expanded balloon. A strong correlation (r = 0.94) was found between the minimal diameter of the fully expanded balloon and poststenting minimal lumen diameter. Immediate recoil was 11.3 +/- 7.5%, responsible on an average for 0.4 +/- 0.2-mm acute lumen loss. Recoil was less in SVG than in coronary arteries (9.7 +/- 6.6% vs. 14.0 +/- 7.8%; P = 0.004, and 0.3 +/- 0.2 vs. 0.4 +/- 0.2 mm; p = 0.01). Lesions were divided into four subgroups, based on the final stent expanding balloon diameter: (1) < or = 3.0 mm (n = 33); (2) > 3 < or = 3.5 mm (n = 43); (3) > 3.5 < or = 4 mm (n = 23); and (4) > 4 mm (n = 9).(ABSTRACT TRUNCATED AT 250 WORDS)