Search

OBJECTIVES To determine the relative degree of revascularization obtained with bypass surgery versus angioplasty in a randomized trial of patients with multivessel disease requiring revascularization (Bypass Angioplasty Revascularization Investigation [BARI]), one-year catheterization was performed in 15% of patients. BACKGROUND Complete revascularization has been correlated with improved outcome after coronary artery bypass grafting (CABG) but not with percutaneous transluminal coronary angioplasty (PTCA). Relative degrees of revascularization after PTCA and surgery have not been previously compared and correlated with symptoms. METHODS Consecutive patients at four BARI centers consented to recatheterization one year after revascularization. Myocardial jeopardy index (MJI), the percentage of myocardium jeopardized by ≥50% stenoses, was compared and correlated with angina status. RESULTS Angiography was completed in 270 of 362 consecutive patients (75%) after initial CABG (n = 135) or PTCA (n = 135). Coronary artery bypass grafting patients had 3 ± 0.9 distal anastomoses and PTCA patients had 2.4 ± 1.1 lesions attempted at initial revascularization. At one year, 20.5% of CABG patients had ≥1 totally occluded graft and 86.9% of vein graft, and 91.6% of internal mammary artery distal anastomotic sites had

ObjectivesThis study was designed to determine predictors of restenosis after successful percutaneous mitral commissurotomy (PMC) and its relationship to late clinical outcome.BackgroundThe restenosis rate after PMC and its relationship to late clinical outcome is poorly defined.MethodsSerial echocardiography was performed in 310 patients who underwent PMC. Restenosis, defined as mitral valve area (MVA)

Objectives. This study sought to determine the long-term outcome of adult patients undergoing percutaneous balloon aortic valvuloplasty. Background. Percutaneous balloon aortic valvuloplasty has been offered as an alternative to aortic valve replacement for selected patients with valvular aortic stenosis. Although balloon aortic valvuloplasty produces an immediate reduction in the transvalvular aortic gradient, a high incidence of restenosis frequently leads to recurrent symptoms. Therefore, it is unclear whether balloon aortic valvuloplasty impacts on the long-term outcome of these patients. Methods. Clinical, hemodynamic and echocardiographic data were collected at baseline in 165 patients undergoing balloon aortic valvuloplasty and examined for their ability to predict long-term outcome. Results. The median duration of follow-up was 3.9 years (range 1 to 6). Ninety-nine percent follow-up was achieved. During this 6-year period, 152 patients (93%) died or underwent aortic valve replacement, and 99 (60%) died of cardiac-related causes. The probability of event-free survival (freedom from death, aortic valve replacement or repeat balloon aortic valvuloplasty) 1, 2 and 3 years after valvuloplasty was 40%, 19% and 6%, respectively. In contrast, the probability of survival 3 years after balloon aortic valvuloplasty in a subset of 42 patients who underwent subsequent aortic valve replacement was 84%. Survival after aortic valvuloplasty was poor regardless of the presenting symptom, but patients with New York Heart Association functional class IV congestive heart failure had events earliest. Univariable predictors of decreased event-free survival were younger age, advanced congestive heart failure symptoms, lower ejection fraction, elevated left ventricular end-diastolic pressure, presence of coronary artery disease and increased left ventricular internal diastolic diameter. Stepwise multivariable logistic regression analysis found that only younger age and a lower left ventricular ejection fraction contributed independent adverse prognostic information (chi-square 14.89, p = 0.0006). Conclusions. Long-term event-free and actuarial survival after balloon aortic valvuloplasty is dismal and resembles the natural history of untreated aortic stenosis. Aortic valve replacement may be performed in selected subjects with good results. However, the prognosis for the remainder of patients who are not candidates for aortic valve replacement is particularly poor.

OBJECTIVES We sought to compare the responses of patients with pulmonary hypertension from primary and secondary causes (PPH and SPH, respectively) to inhaled nitric oxide (iNO) in the cardiac catheterization laboratory. BACKGROUND Pulmonary hypertension can lead to right ventricular pressure overload and failure. Although vasodilators are effective as therapy in patients with PPH, less is known about their role in adults with SPH. Inhaled nitric oxide can accurately predict the response to other vasodilators in PPH and could be similarly utilized in SPH. METHODS Forty-two patients (26 to 77 years old) with pulmonary hypertension during cardiac catheterization received iNO. Demographic and hemodynamic data were collected. Their response to iNO was defined by a decrease of ≥20% in mean pulmonary artery (PA) pressure or pulmonary vascular resistance (PVR). RESULTS Mean PA pressures and PVR were lower during nitric oxide (NO) inhalation in all patients with pulmonary hypertension. Seventy-eight percent of patients with PPH and 83% of patients with SPH were responders to iNO. A trend was seen toward a greater response with larger doses of NO in patients with SPH. Nitric oxide was a more sensitive predictor of response (79%), compared with inhaled oxygen (64%), and was well tolerated, with no evidence of systemic effects. Elevation in right ventricular end-diastolic pressure appeared to predict poor vasodilatory response to iNO. CONCLUSIONS Nitric oxide is a safe and effective screening agent for pulmonary vasoreactivity. Regardless of etiology of pulmonary hypertension, pulmonary vasoreactivity is frequently demonstrated with the use of NO. Right ventricular diastolic dysfunction may predict a poor vasodilator response.

To assess the time course and magnitude of change in left ventricular (LV) wall stress and ejection performance indices, 24 patients undergoing aortic valve replacement (AVR) for aortic stenosis were prospectively evaluated. Each patient underwent resting radionuclide angiography (RNA), echocardiography, and cardiac catheterization (high fidelity pressure) before AVR, then RNA and echocardiogram at one week and six months after AVR. Patients were stratified by preoperative ejection fraction (EF) into reduced EF (l50%) and normal EF (≥50%) groups. Pre-operatively, peak positive dp/dt was lower in the reduced EF group (1300 vs 1700 mmHg/sec, p = 0.035), and wall stress was elevated similarly in both groups (p = NS). Temporal Relationships of EF and Wall Stress Pre-op 1 Week 6 Mos Normal EF (n = 14) Mean Ejection Fraction (%) 66 64 68 Mean Wall Stress (dyne/cm 2 × 10 3 ) 62 34 44 Reduced EF (n = 10) Mean Ejection Fraction (%) 38 37 57 Mean Wall Stress (dyne/cm 2 × 10 3 ) 78 52 61 Wall stress was reduced at one week post-operatively (p l 0.005) in both groups. Ejection fraction remained depressed in the reduced EF group. By six months, however, EF had dramatically improved in the reduced EF group (p = 0.002). Conclusion In patients with LV dysfunction, EF remains low one week after AVR despite rectification of afterload mismatch. At six months, however, ejection performance improves. Therefore, when measured by ejection phase indices, the surgical benefit from AVR is not evident until late post-operatively.

Purpose Digital image compression is a means of reducing storage and exchange requirements for coronary angiograms. In order to assess the diagnostic accuracy of image compression, digital coronary arteriograms were analyzed in compressed and noncompressed formats. Methods The effect on visual assessment of stenosis severity of digital coronary angiograms was evaluated on a set of 100 image sequences using lossy (15: 1) Joint Photographic Experts Group (JPEG) compression software. A panel of 3 angiographers reviewed 6200 frames from 10 clinical exams both with and without standard JPEG compression. Original and compressed versions of each sequence were viewed in random order by all panel members blinded to compression status. Images were viewed on the same display used for digital acquisition with the Philips Digital Cardiac Imaging (DCI) System. Panelists identified and graded severity of 99 stenoses in quartiles with g50% considered to be significant. Results There was no significant difference in the number of lesions identified with each modality. Overall agreement for severity of all lesions between compressed and non-compressed modalities was 0.60 and Kappa = 0.52. If lesions were dichotomized into “significant” (g50%) or “insignificant” (≤50%), agreement was 0.94 and Kappa = 0.88, suggesting that when disagreement occurred, it tended to be within one severity grade. These agreement statistics are consistent with previously reported intra-observer variability in the review of cine-coronary angiograms. Conclusions The significant reduction in digital storage and exchange requirements provided by lossy JPEG does not result in a decrease in diagnostic quality of digital coronary angiograms. Variability in visual assessment from original and compressed data formats is comparable to intra-observer variability from identical data formats. Therefore, JPEG compression does not result in loss of diagnostic information and is a valid means of reducing storage and exchange requirements of coronary angiograms.

BackgroundAlthough seratonin has been postulated as an etiologic agent in the development of carcinoid heart disease, no direct evidence for different ambient serotonin levels in cardiac and noncardiac patients has been reported to date.Methods and ResultsThe present study reviews the experience with 604 patients in the Duke Carcinoid Database. Nineteen patients with proven carcinoid heart disease (by cardiac catheterization and/or echocardiography) were compared with the remaining 585 noncardiac patients in the database with regard to circulating serotonin and its principle metabolite. 5-hydroxyindoleacetic acid (5-HIAA). No significant demographic differences existed between the cardiac and noncardiac groups; however, typical carcinoid syndrome symptoms (i.e. flushing and diarrhea) were almost threefold more common in the cardiac group (p