Search

Background: It is unclear whether modulation of inflammatory markers by glycoprotein IIb/IIIa receptor inhibition after percutaneous coronary intervention (PCI) is caused by an interaction with the alpha(v)beta3 and alpha(M)beta2 receptor or it correlates with ischemic events during PCI. This study investigates the inflammatory profile after elective, nonacute PCI and whether and how administration of the glycoprotein IIb/IIIa receptor antagonist tirofiban modulates the postinterventional inflammatory myocardial response., Methods: The time course of inflammatory parameters (C-reactive protein [CRP], interleukin-1 [IL-1], interleukin-6 [IL-6], and tumor necrosis factor alpha [TNF-alpha]) of patients receiving peri- and postinterventional placebo (n = 46) or tirofiban infusion (n = 50) was analyzed by use of enzyme-linked immuno assays. Samples were collected before and 30 minutes, 2.5 hours, 6.5 hours, 12 hours, 24 hours, and 48 hours after elective PCI., Results: Among the inflammatory markers analyzed, TNF-alpha, IL-6, and CRP levels increased significantly. However, the latter markers followed individual time courses in patients given placebo and patients treated with tirofiban after PCI, compared with pre-PCI levels (P <.01), with no significant differences between the placebo and tirofiban-treated groups. However, by subgroup analysis, significant differences were revealed in TNF-alpha, IL-6, and CRP levels of patients who were troponin T-positive versus patients who were troponin T-negative after PCI., Conclusions: The administration of the selective glycoprotein IIb/IIIa receptor antagonist tirofiban has no direct impact on the inflammatory profile after elective PCI. Change of the inflammatory profile was only related to the presence or absence of postinterventional troponin.

Objectives: The Troponin in Planned PTCA/Stent Implantation With or Without Administration of the Glycoprotein IIb/IIIa Receptor Antagonist Tirofiban (TOPSTAR) trial investigated: 1) the amount of troponin T (TnT) release after nonacute, elective percutaneous coronary intervention (PCI) in patients pretreated with aspirin and clopidogrel; and 2) the effect of additional glycoprotein (GP) IIb/IIIa receptor inhibiton on postinterventional TnT release., Background: No data are available yet as to whether additional administration of a GP IIb/IIIa receptor antagonist might be beneficial in patients undergoing elective PCI already pretreated with aspirin and clopidogrel., Methods: After bolus application of the study medication (tirofiban [T] or placebo [P]), PCI was performed followed by an 18-h continuous infusion of T/P. Primary end point of the study was incidence and amount of TnT release after elective PCI after 24 h., Results: A total of 12 h after PCI troponin release was detected in 63% of the patients receiving P and in 40% of the patients receiving T (p < 0.05), after 24 h in 69% (P) and 48% (T) (p < 0.05) and after 48 h in 74% (P) versus 58% (T) (p < 0.08) of the patients. No differences were observed regarding major bleeding, intracranial bleeding or nonhemorrhagic strokes. After nine months a reduction of combined death/myocardial infarction/target vessel revascularization could be observed in the tirofiban group ([T] 2.3% vs. [P] 13.04%, p < 0.05)., Conclusions: Troponin T release occurs after successful intervention in 74% of the patients undergoing elective PCI after 48 h even after pretreatment with aspirin and clopidogrel. The GP IIb/IIIa receptor antagonist tirofiban is able to decrease the incidence of troponin release significantly in this patient population.

Objective: Our purpose was to identify angiographic and procedural predictors for acute and late side branch occlusion after coronary stent implantation., Methods: We evaluated 185 patients with 185 lesions with 255 side branches with a mean reference diameter of 1.45 +/- 0.38 mm; the lesions were covered by 240 stents. Angiographic follow-up was completed in 99 patients with 133 side branches 206 +/- 120 days after stent implantation and clinical follow-up was available in 136 patients. Side branch occlusion (SBO) was defined as a Thrombolysis In Myocardial Infarction (TIMI) flow < or =1., Results: Acute SBO affected 54 side branches in 49 patients and was not associated with death or Q-wave infarction. By logistic regression, independent predictors for acute SBO were (1) the reference side branch diameter (RLD) at baseline (OR [odds ratio] 0.217, 95% CI 0.07-0.67, P =.008); (2) an ostial side branch stenosis before stenting (OR 2.96, 95% CI 1.26-6.95, P =.013); (3) the involvement of the side branch origin within the lesion of the parent vessel (OR 2.77, 95% CI 1.17-6.57, P =.021); and (4) the balloon-to-artery ratio (OR 4.66, 95% CI 1.18-18.42, P =.028). Among the initially occluded side branches, 81.8% were spontaneously reperfused at follow-up. Late SBO involved 12% of the side branches without impaired antegrade flow after stenting and was predicted by the initial RLD of the side branch (OR 0.07, 95% CI 0.01-0.8, P =.032). Chronic SBO occurred in 13.5% of cases and was also predicted by the baseline RLD (OR 0.13, 95% CI 0.02-0.8, P =.028)., Conclusions: Acute SBO after stenting occurred in 21.2% of cases and had a benign course. Most acutely occluded side branches underwent late spontaneous reperfusion. A baseline side branch diameter >1.4 mm predicted a preserved antegrade flow immediately after stent implantation, as well as during follow-up.

Background and Objective: Symptomatic patients with multivessel coronary disease (MVD) benefit from both coronary artery bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA). The >>German Angioplasty Bypass Investigation<< (GABI-I) trial randomized patients to one of these treatment strategies between 1986 and 1991. In order to evaluate the impact of current technology, in particular coronary stents, the GABI-II trial was initiated, which in 1996 and 1997 prospectively enrolled patients according to the initial GABI-I criteria., Patients and Methods: Into the study 136 consecutive patients (108 men, 28 women; 63 +/- 12 years) were included. Patients from GABI-I served as controls., Results: A mean of 2.1 +/- 0.5 vessels were treated per patient (vs. 1.9 +/- 0.5 vessels in the PTCA arm of GABI-I) and 63 % of the lesions were covered with stents. With respect to the primary endpoint less patients remained with a CCS class III or IV in GABI-II after 12 months (1,5 % vs. 8 % in the PTCA arm of GABI-I, p<0,01). No patient required emergency or urgent bypass operation in GABI-II (vs. 9 % in GABI-I, p < 0.01). After 12 months, 8 % of the patients were sent for bypass surgery (CABG) vs. 21 % in GABI-I (p < 0.001), and 20 % (vs. 23 % in GABI-I) of the patients underwent Re-PTCA. The percentage of patients without reinterventions was 72 % vs. 56 % in GABI-I (p < 0.01), but remained lower compared to patients randomized to CABG in GABI-I (94 %, p < 0.001)., Conclusion: PTCA in patients with MVD is still associated with a higher reintervention rate as compared with CABG. However, in contrast to angioplasty a decade ago, PTCA in conjunction with stents significantly lowered the need for subsequent revascularization, which was mainly driven by the reduced necessity for bypass surgery.

Background: We studied whether lipid-lowering therapy with atorvastatin (target LDL cholesterol [LDL-C] <100 mg/dL) compared with a moderate treatment regimen that used other lipid-lowering drugs led to a lesser progression of atherosclerosis and to different changes in plaque echogenicity in patients with coronary artery disease., Methods and Results: This study was a 12-month, open-label, randomized, multicenter trial, which used serial 3D intracoronary ultrasound to calculate plaque volume and plaque echogenicity. After transcatheter therapy, 131 patients were randomized (atorvastatin n=65, usual care n=66). The target plaque had to be a minor lesion (ie, a diameter stenosis of <50% on angiography). After 12 months, mean LDL-C was reduced from 155 to 86 mg/dL in the atorvastatin group and from 166 to 140 mg/dL in the usual care group. Mean absolute plaque volume showed a larger increase in the usual care group compared with the atorvastatin group (usual care 9.6+/-28.1 mm(3), atorvastatin 1.2+/-30.4 mm(3); P=0.191). The hyperechogenicity index of the plaque increased to a larger extent for the atorvastatin group than for the usual care group, with a significant treatment effect for the percent change (atorvastatin 42.2%, usual care 10.1%; P=0.021)., Conclusions: One year of lipid-lowering therapy to <100 mg/dL LDL-C most likely led to a slowdown of plaque growth of minor lesions. The significantly larger increase in plaque hyperechogenicity is most likely due to a change in plaque composition.

Purpose: In earlier studies it was shown that patients with vascular disturbances (e.g. sudden hearing loss) had white-noise field campimetry abnormalities despite normal visual fields. The aim of this study was to clarify whether patients with coronary heart disease (CHD) have such disturbances in the white-noise field campimetry, too., Patients and Methods: Twenty-four patients (m:f = 23:1; mean age 58 +/- 9 years) with an angiographically documented CHD and 30 healthy controls (m:f = 29:1; mean age 54 +/- 7 years) were examined. In order to evaluate the morphological and functional ocular status, we examined the following parameters: morphological status, visual acuity, intraocular pressure, perimetry (Tübinger Automatic Perimeter 2000 ct, Oculus) and white-noise field campimetry (Tübinger Electronic Campimeter, Oculus)., Results: Fifteen patients had had a cardiac infarction. Twenty-one patients, but only 6 controls had alterations in perilimbal vessels of the conjunctiva and sixteen patients had a tortuousity of retinal vessels. The visual acuity, the intraocular pressure, the cup/disc ratio and the visual fields were within normal ranges. However, twenty patients and 5 controls were abnormal in the white-noise field campimetry., Discussion: Although patients with CHD appeared unaffected in the standard eye examinations, the disturbances in the white-noise field campimetry indicated a functional visual impairment. Together with the changes in the perilimbal vessels of the conjunctiva and the retinal vessels, a disturbed ocular microcirculation as the underlaying cause could be discussed.

Impedance cardiography (ICG) is a noninvasive method for evaluating cardiac function. Left ventricular stroke volume (SV) is the basic hemodynamic parameter derived from thoracic bioimpedance curves. Issues of our study were to investigate the diagnostic value of other indices of left ventricular systolic performance, such as ejection fraction (EF), index of contractility (IC), peak flow index (PFI), and acceleration index (ACI), which can also be calculated by ICG. Forty patients (PTS) with suspected coronary artery disease (CAD) were monitored by automated ICG during pharmacologic stress testing with dobutamine. All PTS underwent subsequent cardiac catheterization. In PTS with single vessel disease, the dobutamine-induced changes of SV, EF, IC, PFI, and ACI were comparable to those of PTS without CAD. In PTS with multivessel disease, the impaired systolic performance during dobutamine stimulation could be clearly demonstrated. We conclude that automated ICG is a useful method for monitoring SV and other indices of left ventricular systolic performance for detecting PTS with ischemic left ventricular dysfunction during cardiovascular stress.

Aims: Coronary artery dissections are common findings following percutaneous transluminal coronary angioplasty and occur with an incidence of approximately 20% to 40%. The purpose of this study was to evaluate the impact of intravascular ultrasound for the prediction of severe dissections by pre-interventional analysis of lesion morphology and plaque composition., Methods and Results: Pre- and post-interventional intravascular ultrasound was performed in 197 patients with 205 lesions. Using intravascular ultrasound criteria, 24 lesions were classified as soft (hypo- or iso-echogenic), 73 as intermediate (hyper-echogenic) and 108 as calcified (calcific arc > 90 degree of the vessel circumference). Additionally, calcium localization was defined as subendothelial, central or deep. The incidence of dissections was 37.5% in patients with soft lesions, 24.7% in patients with intermediate and 36.1% in patients with calcified lesions. In calcified lesions, the occurrence of severe dissections was not dependent on the localization of calcium deposits. The procedural parameters were similar in all patients. The minimal inflation pressure, however, was significantly higher in calcified lesions (P < 0.01)., Conclusion: Assessment of lesion morphology by intravascular ultrasound cannot predict the occurrence of severe dissections following percutaneous transluminal coronary angioplasty. Furthermore, despite significantly higher inflation pressures in heavily calcified lesions, the incidence of dissections was found to be comparable in all lesions.

Aims: Recent randomized clinical trials have reported a reduction in restenosis with intracoronary stents and have suggested that this restenosis reduction is a result of the higher immediate luminal gain, in comparison to conventional percutaneous transluminal coronary angioplasty (PTCA). The hypothesis of this study is based on the assumption that PTCA results may be optimized by determining vessel dimensions before intervention, using intravascular ultrasound. This may lead to long-term PTCA results equivalent to PTCA and the additional placement of a stent. The purpose of this prospective non-randomized single-centre study was to evaluate (1) the safety and efficacy and (2) the long-term outcome of vessel-size adapted PTCA in patients with native coronary artery obstructions., Methods and Results: From January 1995 to December 1995 the morphological dimensions of target lesions were determined in 144 patients with 152 lesions by intravascular ultrasound prior to conventional balloon angioplasty. Quantitative assessment of the vascular dimensions were assessed on-line and the diameter of the balloon catheter was adapted to the external elastic membrane diameter at the lesion site. Using this strategy, mean balloon diameter was 4.0 +/- 0.5 mm and mean pressure for complete balloon expansion was 7 +/- 2 atmospheres. Acute and one year follow-up results were obtained in all 144 patients. Acute events occurred in two patients (one death and one acute surgical revascularization). During one year follow-up, 16 patients (12%) had a clinical event including one cardiac death, two transmural myocardial infarctions, 10 repeat PTCAs within the target lesion and three elective coronary artery bypass grafts (CABG). In 75% (n:112) control angiography was performed and revealed an angiographic restenosis rate of 21% using the NHLBI criteria of a diameter stenosis > 50%., Conclusion: Intravascular ultrasound provides an accurate and precise description of vascular dimensions at the site of the stenotic lesion. The use of balloon diameters following these measurements appears to be (1) safe in the acute setting with a low number of in hospital events and (2) gives a low restenosis rate and number of clinical events at one year follow-up. These promising results warrant verification in larger-scale randomized trials.

Stress-echocardiography (SE) has been proven to be a valuable method for the diagnosis of coronary artery disease. For patients who cannot exercise, pharmacological stress-echocardiography represents an alternative method for the induction of cardiovascular stress. Few studies exist concerning the value of dipyridamole-SE for the detection of restenosis in patients after primary successful PTCA. It has been demonstrated that the addition of atropine can significantly increase the diagnostic potential of dipyridamole-SE, especially in patients with 1- or 2-vessel disease. The purpose of our study was to investigate the diagnostic value of high-dose dipyridamole-SE plus atropine (DASE) for the detection of restenosis after primary successful PTCA. We investigated 65 patients 3-6 months after PTCA before a control angiography was performed. Restenosis was defined as > 70% lumen narrowing, determined by quantitative coronary angiography. In 20/27 patients with restenosis, the DASE was pathological (sensitivity 74%); in 34/38 patients without restenosis the DASE was normal or showed no induced WMA (specificity 89%). Patients with tight restenosis (> 90%) were always correctly detected by DASE. Concerning the different vessels, restenosis of the LAD was correctly predicted by DASE in 11/12 patients, restenosis of the LCX in 6/9 patients and restenosis of the RCA in 8/11 patients. From the results of our study we conclude that DASE is a reliable diagnostic method for the non-invasive evaluation of patients after PTCA. DASE can identify patients with relevant restenosis after PTCA and help to select those patients who will probably benefit from further coronary interventions, for repeat angiography.

This study investigated the effect of extracorporal lipid-lowering therapy by low-density lipoprotein (LDL) apheresis on coronary artery disease in a population characterized by early development and rapid progression of atherosclerosis. We treated 32 patients aged between 15 and 63 years with drug-refractory familial hypercholesterolemia, treated once a week by immuno-specific LDL apheresis for 3 years in a controlled prospective and non-randomized trial; 25 patients (14 females and 11 males) completed the study. Noninvasive data were obtained by physical examination, 12-lead ECG and exercise testing. Invasive cardiological data were obtained by cardiac catheterization according to a standardized protocol in four cardiological centers. Left ventricular ejection fraction was calculated using planimetry. Coronary stenoses were measured quantitatively in 23 defined coronary segments by a panel of four investigators with an electronic digital caliper. In addition, overall coronary atherosclerosis was visually qualified. Final decisions on a classification into one of three groups (regression, no change, progression) of coronary atherosclerosis were based on panel consensus. Six cardiac events occurred throughout the study: percutaneous transluminal coronary angioplasty in one patient, coronary bypass grafting in three and two deaths. Statistical analysis of exercise testing yielded no significant change for maximum power and work capacity during the study period. Hemodynamic data revealed no significant change; mean ejection fraction was calculated as 65.8 +/- 15.9% at study entry and 67.0 +/- 12.7% at completion. Quantitative measurement of 111 circumscribed coronary stenoses showed a mean stenosis degree of 45 +/- 26% at entry cineangio-film and 43 +/- 22% at final cineangio-film demonstrating no significant change.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to develop a predictive model for the risk of early lesion deterioration following successful coronary balloon angioplasty (PTCA) based on clinical, pre-angioplasty and procedural characteristics, 154 lesions in 146 consecutive patients undergoing successful PTCA for stable/unstable angina were examined by quantitative coronary analysis immediately after and within 24 h of angioplasty. An angiographic complication score was used prospectively, classifying the lesion morphology post-PTCA into class 0: no complication and classes 1 to 3, according to purely descriptive morphological characteristics. Significant deterioration, defined as a decrease in minimal luminal diameter of more than 2 standard deviations of duplicate measurements post-intervention (0.54 mm; 95% confidence limit for variability using quantitative angiography) was found in 28 lesions (18%), and a total reocclusion in seven lesions (5%). The angiographic complication score (P = 0.019), prior to myocardial infarction (P = 0.076), minimal luminal diameter immediately post-intervention (P = 0.021) and gain of PTCA (P = 0.042) were found to be independently predictive of early lesion deterioration by multiple logistic regression analysis. Identification of these factors and their associated risk should improve success, and understanding of the early vascular response following coronary angioplasty. Moreover, these results have implications for clinical restenosis studies, particularly those assessing the effect of pharmacological interventions on late restenosis rates.

Objectives: This prospective trial was performed to evaluate the impact of the morphologic complications of angioplasty on the reliability and results of quantitative angiographic assessment of the residual stenosis., Background: Postintervention quantitative coronary analysis is limited by a variety of such complications., Methods: In 199 patients undergoing an early control angiographic study within 24 h after coronary balloon or excimer laser angioplasty (24-h study), detailed quantitative angiographic measurements were performed on the target lesion immediately after intervention and at the 24-h study. Reproducibility of quantitative arteriography was determined by repeat measurements on the same angiogram., Results: Intraobserver/interobserver variability was significantly higher (p < 0.0001/p < 0.03) for the postintervention angiogram than for the 24-h angiogram. Patients were classified into three subgroups with respect to the occurrence of angiographic complications or chest pain after intervention. In patients with angiographic complications after balloon angioplasty alone/stand-alone laser angioplasty/laser angioplasty with adjunctive balloon dilation, a significant difference in mean minimal lumen diameter (p = 0.0001/p = 0.03/p = 0.035) was observed between the immediate postintervention and 24-h angiogram. In patients without angiographic complications or patients with recurrent chest pain undergoing balloon angioplasty, stand-alone or adjunctive laser angioplasty, mean minimal lumen diameter remained nearly unchanged (p = NS)., Conclusions: Angiographic measurements of the target lesion immediately after angioplasty were significantly less reliable than measurements obtained at 24 h after angioplasty in patients with angiographic complications. The occurrence of postintervention vascular complications was associated with significant early lesion changes between the immediate postangioplasty and the 24-h angiogram.

Of 523 consecutive patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA) and 83 patients treated with coronary excimer laser angioplasty (ELCA), 17 (3.3%) had in-laboratory occlusion following PTCA and 25 (30%) following ELCA; they were enrolled into a prospective study. Successful management (reopened vessel, patency at repeat angiography within 24 h, no death, no myocardial infarction (MI), no emergency bypass surgery) including repeat lasing, subsequent PTCA, use of intracoronary nitroglycerin or streptokinase was achieved in 24 (96%) of the 25 patients with acute occlusion during ELCA. An anterior MI occurred in one patient of the laser group. Repeat balloon dilatation was successfully performed in seven of the 17 patients (41%) with acute closure during PTCA. Among the 10 patients with persistent occlusion after PTCA, five developed a limited myocardial infarction (35%). One patient required emergency CABG, and died peri-operatively. Severe spasm prior to occlusion defined by a new coronary flow depression without evidence of dissection or thrombus showed a significant positive association with acute occlusion during ELCA (P = 0.0008). Thus, in contrast to occlusion during PTCA, subsequent balloon dilatation was successfully performed in the majority of patients with acute occlusion during ELCA, implying that different underlying mechanisms are responsible for this complication. In this limited patient group, occlusion after excimer laser angioplasty was much more frequent than closure during PTCA, but was infrequently associated with major events such as myocardial infarction or death.

To compare the negative inotropic effects of the four dihydropyridine-calcium-channel-blockers nifedipine (NIF), isradipine (ISR), nisoldipine (NIS) and felodipine (FEL) in man, the drugs were infused within 30 min intravenously in an equihypotensive dosage (NIF 2 mg, ISR 0.5 mg, NIS 0.5 mg, FEL 0.6 mg; 10 patients in each group) in patients with coronary heart disease. As a control, an additional 10 patients received isotonic saline solution following an identical protocol. The afterload reduction was submaximal (reduction of peripheral resistance: NIF -23 +/- 9%, ISR -24 +/- 10%, NIS -28 +/- 6%, FEL -27 +/- 6%; no significant difference for group comparison) with a similar kinetic and a steady state of the afterload reduction after one-half of the infusion period to achieve a comparable sympathetic reflex activation. Preload parameters (PAP, LVEDP) were unchanged in all groups. A reflex tachycardia occurred in all treatment groups after 15 min of drug infusion. Due to its negative chronotropic properties, the reflex tachycardia was significantly attenuated after isradipine as compared to the other drugs (heart-rate changes: NIF +13 +/- 7%, p < 0.01; ISR +4 +/- 7%, not significant; NIS +20 +/- 10%, p < 0.01; FEL +17 +/- 12%, p < 0.01). Because of the baroreflex and sympathetic reflex activation the left-ventricular dp/dtmax increased after isradipine (+14 +/- 10%, p < 0.01) and nisoldipine (+16 +/- 13%, p < 0.01). The lack of a significant dp/dtmax increase in spite of a comparable afterload reduction after felodipine (+5 +/- 8%, not significant) or nifedipine (-3 +/- 6%, not significant) must be a consequence of the cardiodepressive properties of these drugs. Therefore, in an equihypotensive dosage, the strongest negative inotropic effects were observed after nifedipine, lesser effects after felodipine (p < 0.03), and the weakest cardiodepressive effects after isradipine (p < 0.01) and nisoldipine (p < 0.01). For clinical applications the lesser cardiodepressive properties of the new dihydropyridine-derivatives should be advantageous in patients with already reduced left-ventricular performance or for use in combination with other negative inotropic drugs, e.g., betablockers.

A 56-year-old patient with recurrent episodes of angina pectoris at rest was admitted for left-heart catheterization. The coronary angiogram revealed two-vessel disease with a subtotal stenosis in the circumflex artery and a long 90% stenosis in the proximal part of the left anterior descending artery. On the basis of symptoms and coronary morphology laser angioplasty was performed. After a total of 99 s of energy delivery extravasation of dye occurred at the site of ablation. Due to acute vessel occlusion subsequent PTCA was performed, resulting in a satisfactory angiographic result. Extravasation of dye was terminated after PTCA and was absent at short-term follow-up angiography. No signs of pericardial effusion were detectable by two-dimensional and M-mode echocardiography. A control angiogram disclosed the identical result the day after the acute intervention, and the patient could be discharged with a normal exercise test 1 week later.

Catheter-induced coronary artery spasms are rare during diagnostic coronary angiography, and they occur more often after PTCA because of local vessel wall injury. These spasms are rapidly reversible after administration of nitroglycerine and are normally no cause of serious complications. We report about a catheter-induced occlusive spasm of the entire left anterior descending and circumflex coronary artery in a 56-year-old patient with coronary double-vessel disease, 70% restenosis of the LAD, and a history of two coronary angiographic procedures and one PTCA without any complication. The spasm occurred immediately after the intubation of the left main stem with a 9F PTCA guiding catheter before the coronary guide wire or balloon was advanced into the LAD. Cardiac resuscitation was necessary due to acute left heart failure. The spasm was spontaneously reversible, but reproducible. Therefore, life-threatening coronary artery spasm can occur during coronary angiography or PTCA, but the tendency of spontaneous spasm relief seems to be high.

To determine whether a transient ischemia of the right ventricle leads to right ventricular impairment and whether RV function can also be influenced by septal ischemia caused by an occlusion of the left anterior descending coronary artery (LAD), RV function before and at the end of 60 s of ischemia during PTCA was assessed in 15 patients with single-vessel disease of either the right coronary artery (RCA, n = 10) or the LAD (n = 5). The RV-enddiastolic pressure and the pulmonary capillary wedge pressure (PCW) were recorded continuously. The RV ejection fraction was determined from ventriculograms performed before and during coronary occlusion. An increase of RVEDP from 3.7 +/- 1.2 to 8.3 +/- 1.8 mm Hg (p less than or equal to 0.001) and a decrease of the RV-ejection fraction from 52 +/- 3 to 33 +/- 8% (p less than or equal to 0.001) occurred during RCA occlusion with a predominant ischemia of the RV free wall only, and not during LAD occlusion with left ventricular and septal ischemia. The extent of the RV dysfunction was independent of an additional increase of RV afterload (PCW increase). Comparable to ischemic effects on left ventricular function, an acute right ventricular myocardial ischemia results in a severe RV contractile failure.

Available preliminary clinical studies have shown that ablation of atherosclerotic plaques can be achieved by means of pulsed excimer laser coronary angioplasty via flexible energy transmission systems. The goal of current studies using improved catheter technology is to enhance the acute success rate since, based on initial studies, it can be assumed that only about 40 to 45% of the patients can be successfully treated. The on-going investigations were carried out primarily with three different excimer laser systems which employ a wavelength of 308 nm but differing pulse widths and transmission systems. In the first American multicenter study by Litvack and Margolis a catheter system was used with a pulse width of 180 to 220 ns. The fibers have a shaft diameter of 100 microns with a conically-thickened distal end measuring 200 microns, the ablative area encompasses 35 to 45% of the total catheter tip surface. The excimer laser used in the second American multicenter study by Sanborn and Isner has a pulse width of 120 ns. This catheter is relatively unflexible due to the 200 microns fiber diameter. The ablative catheter tip area is 25 to 30%. In Tübingen a system was used with a pulse width of 60 ns. The energy is transmitted through fibers with a diameter of 100 microns. The effective ablative area in the first series of patients was about 15%, in the second series about 25 to 30%. At present, the energy density of all three systems is comparable with at least 25 to 35 mJ/mm2. Since there is currently no means for accurate assessment, the question of whether a shorter pulse width of comparable energy density is more effective than the longer pulse width, remains an open issue. The flexibility of the systems used by Margolis and in Tübingen enable ablation not only of proximal, but also arteriosclerotic plaques located in the middle-third of vessels. The flexibility and steerability, however, are inferior to balloon catheter systems. In the study carried out by Litvack and Margolis, in which more than 600 patients have been treated, and the results from 514 patients reported, there was no patient selection in the first series. The study by Sanborn and Isner included 88 patients. Due to the relatively unflexible catheter system, only those patients were treated who had proximal stenosis of the left anterior descending or right coronary artery or marginal branches of the circumflex artery without marked tortuosity.(ABSTRACT TRUNCATED AT 400 WORDS)

To verify the efficacy and safety of percutaneous coronary excimer laser angioplasty in patients with coronary artery disease a prospective study was conducted in 60 patients. The application of laser light was possible in 55 of the 60 patients. A novel 1.4-mm diameter catheter with 20 quartz fibers of 100-microns diameter, each arranged concentrically around a central lumen suitable for an 0.014-inch flexible guide wire was used. The light source was a commercial excimer laser emitting energy at a wavelength of 308 nm, with a pulse duration of 60 ns. The laser was operated at 20 Hz; mean energy transmission was 30 +/- 5 mJ/mm2. In 23 of the 55 patients treated with excimer laser energy the qualitative angiographic results were sufficient. In 32 patients additional balloon angioplasty was necessary, either because of an insufficient result or due to vessel closure after laser ablation. In 47 of the 55 patients control angiography was performed within the 6-month follow-up period. Rate of restenosis was higher in patients treated with laser ablation and subsequent balloon angioplasty (16 of 28) than in patients treated with laser ablation alone (6 of 19). Results of the 6-month observation period suggest that 1) coronary excimer laser angioplasty in combination with subsequent balloon angioplasty results in a considerable increase of the restenosis rate; 2) the exclusive use of laser ablation also results in a restenosis rate comparable to balloon angioplasty alone; and 3) the impact of this new method using improved application systems and higher energy transmission has to be determined in further studies.

It has been speculated that ACE inhibitors may have beneficial effects in patients with coronary artery disease not only by their vasodilator properties but also by an effect on an assumed local renin-angiotensin system in atherosclerotic coronary arteries. Thus, the aim of the present study was to evaluate the effect of a single intravenous infusion of captopril on haemodynamics and coronary diameter at rest and during myocardial ischaemia induced by rapid atrial pacing. The study was performed in 12 patients with coronary artery disease and exertional angina pectoris despite medical therapy. Central haemodynamics (PAO, PAP) and left ventricular end-diastolic pressure were measured. Biplane cineventriculography and coronary arteriography were performed during control pacing (10% above the normal heart rate) before and after 15 min of captopril infusion, as well as during angina pectoris induced by rapid atrial pacing before and after captopril (six patients 0.15 mg kg-1, six patients 0.3 mg kg-1). Mean aortic pressure was not significantly decreased by either 0.15 mg kg-1 or 0.3 mg kg-1, whereas mean pulmonary pressure was significantly reduced by captopril by 28% at rest and 34% during rapid atrial pacing. Neither the endsystolic volume index nor left ventricular ejection fraction was significantly affected by captopril. Left ventricular end-diastolic volume index was reduced by 9% at rest and 7% during pacing-induced angina. Left ventricular end-diastolic pressure decreased from 11 +/- 9 mmHg to 4.8 +/- 4.1 mmHg at rest after captopril, and from 10 +/- 11 mmHg to 5.1 +/- 5.0 mmHg during pacing-induced angina after captopril.(ABSTRACT TRUNCATED AT 250 WORDS)

Isradipine is a new dihydropyridine calcium antagonist with myocardial effects significantly different from those of nifedipine, as shown by in vitro and animal experimental data. Isradipine selectively inhibits the sinus node but not the atrioventricular conduction and its negative inotropic action is much less if administered in a dose of comparable peripheral effects. To study these effects in man, 40 patients with coronary artery disease were divided into 2 groups receiving either a continuous 30-minute intravenous infusion of 2 mg of nifedipine or 0.5 mg of isradipine, doses that resulted in a comparable afterload reduction (decrease of systemic vascular resistance: nifedipine -22.1%, isradipine -25%, p less than 0.001). Ten patients in each group received an additional intravenous bolus of 5 mg of propranolol at the end of the calcium antagonist administration to antagonize its induced adrenergic reflex mechanisms. The heart rate significantly increased after nifedipine only (+9.2%, p less than 0.001), experienced no change after isradipine and the nifedipine and propranolol combination and decreased after the combination of isradipine and propranolol (-9.6%, p less than 0.001). This resulted in a significant decrease of the rate pressure product with isradipine (-12.5%, p less than 0.001) but not with nifedipine. As a result of the afterload-induced adrenergic reflex mechanisms, the maximal derivative of the left ventricular pressure increased after isradipine administration (+13.5%, p less than 0.001) and was unchanged after nifedipine, which demonstrates the significantly less negative inotropic properties of isradipine as compared with nifedipine.

Percutaneous transluminal laser coronary angioplasty (PTLCA) was undertaken in five patients (four men and one woman, aged 44-72 years) with coronary artery stenosis. The vessel diameter was increased in all patients after PTLCA; complete ablation of the atheromatous plaque succeeded in three. In the other two the catheter could not be advanced across the entire stenotic region. After PTLCA the stenoses were 40-50% of normal lumen. Balloon dilatation was additionally done in all five patients. In three this caused dissection of the vessel wall distal to the stenosis and possible intracoronary thrombus formation: this would suggest that balloon dilatation after laser angioplasty is not recommendable. PTLCA widens the spectrum of invasive methods for treating coronary artery stenosis.

To determine the accuracy of two-dimensional echocardiography (2-D echo) for assessment of exercise-induced wall motion abnormalities in patients with coronary artery disease, the results of stress echocardiography were compared with exercise cineventriculography. In 56 consecutive patients, biplane cineventriculography at rest and immediately after supine bicycle exercise was performed. Cross-sectional echo was obtained using the apical two- and four-chamber-views for left ventricular imaging under identical conditions. In 6 of the 56 patients 2-D echo, in 8 patients cineventriculogram, and in 2 patients both methods were of inadequate quality at rest or during exercise. Of the remaining 40 patients, 34 had coronary artery disease. Local wall motion in 360 wall segments from these patients was analyzed. In 49 segments (14%) in 24 of these patients exercise-induced ischemic wall motion abnormalities were evident during cineventriculography. Only 24 of these 49 asynergies (49%) were also recognized by 2-D echo. Using cross-sectional echocardiography, ischemia-related wall motion abnormalities were best detected septal, whereas apical asynergies were identified in only 3 of 12 segments (25%). Thus, the clinical value of exercise 2-D echo as a screening method in patients suspected of having coronary artery disease is limited and restricted to patients where excellent visualization of the left ventricular endocardium is possible.

In 28 patients with unstable angina pectoris biplane coronary angiography was performed in the acute stage. Arteriography of the ischemia-related vessel was subsequently repeated in 14 patients after intracoronary infusion of 0.2 mg nifedipine and ten minutes later after 10 mg sublingual nifedipine (group I) and in 14 patients after intracoronary infusion of 0.4 mg 3-N-morpholinosyndnonimine (SIN-1) (group II). 17 patients were on intravenous nitroglycerin and 11 patients on high-dose oral isosorbide dinitrate therapy at the time of angiography. Pre- and postintervention, the degree of coronary stenosis of the ischemia-related vessel was determined by three morphometric methods: rmin, minimal diameter of the stenosis, Amin, planimetered area under the stenosis and minimal diameter ratio (min diam ratio), ratio of the minimal diameter of the stenosis and the pre- and poststenotic diameter. An increase in lumen was considered to be significant when two of the three parameters increased by more than 5%. Nifedipine application resulted in an increase in lumen in 13 patients of group I. After i.c. nifedipine the lumen increased by 16% and after s.l. nifedipine by an additional 9%. Combined i.c. and s.l. nifedipine increased the lumen of the critical stenosis by 24 +/- 6.8%. In 10 patients of group II, SIN-1 application was successful and resulted in a luminal increase of 28 +/- 2.6%. In more than 80% of our patients with unstable angina pectoris application of nifedipine and SIN-1 resulted in an increase of the lumen. Thus, coronary vasoconstriction seems to be the predominant mechanism next to organic stenosis in unstable angina.

The influence of isradipine (PN 200-110), a new dihydropyridine calcium antagonist, in comparison to nifedipine and placebo on hemodynamics and left ventricular function was investigated in patients with coronary artery disease (10 patients in each group). The drugs were infused intravenously within 30 min in a dosage which led to a comparable afterload reduction (nifedipine [N] 2 mg, isradipine [I] 0.5 mg, AOP mean decrease: N, 14.7%, I, 13.1%). Increase of cardiac output (N +12.5%, I +15%) and decrease of systemic vascular resistance (N -29.2%, I -25%) were equal in both groups. Nifedipine caused a significant reflex increase of heart rate (+9.2%, p less than 0.001), which was not present with isradipine. The consequence was a significant decrease of the rate-pressure product with isradipine only (-12.5%, p less than 0.001) and not with nifedipine. Although afterload reduction was equal in both groups, isradipine caused a more pronounced decrease of LV volumes (EDVI: N -10%, I -16%) and an increase of ejection fraction (N +8%, I +14%). A significant increase of dp/dtmax, as a result of the afterload reduction, occurred after isradipine only (+13.5%, p less than 0.001) with no changes of dp/dtmax after nifedipine. Since changes of parameters (preload, afterload, HR, LVSP), which influence dp/dtmax independent of the inotropic state, were equal in both groups, the increase of dp/dtmax after isradipine should be a result of less negative inotropic properties of isradipine compared to nifedipine.

To determine the accuracy of echocardiography in assessment of exercise-induced wall motion abnormalities, the results of stress-echocardiography were compared with exercise-cineventriculography. In 56 consecutive patients biplane cineventriculography at rest and immediately after supine bicycle exercise was performed. Cross-sectional echocardiography was obtained using the apical 2- and 4-chamber view for LV imaging under identical exercise conditions. In 6 of the 56 patients 2-D echo, in 8 patients LV-angio, and in 2 patients both methods were of inadequate quality during exercise. Thus, in 40 patients (34 patients had coronary artery disease) local wall motion of 360 wall segments was analysed. 49 segments (14%) of 24 patients showed exercise-induced ischemic wall motion abnormalities during cineventriculography. Only 24 of these 49 asynergics (49%) were also detected by 2-D-echo. Using cross-sectional echocardiography, ischemia related wall motion abnormalities were best detected laterally and septaly, whereas apical asynergies were identified in 3 of 12 segments only. Thus, the clinical value of exercise 2-D echo as a screening method in patients suspected to have coronary artery disease is limited and restricted to patients with excellent visualization of the left ventricular endocardium.

The acute hemodynamic effects of carvedilol, a new vasodilating betablocker, were assessed in comparison to the response to nifedipine or a combination of nifedipine and propranolol in patients with coronary artery disease. Either 5 mg carvedilol, 2 mg nifedipine or 2 mg nifedipine + 5 mg propranolol (N + P) were administered intravenously in a not randomized study within 30 min to 10 patients for each drug. Carvedilol reduced (comparable to the effect of N + P) the left ventricular afterload with a decrease of AOPm of 12.6%, p less than 0.001 (N + P -11.8%, p less than 0.001) and systemic vascular resistance of 9.1%, p less than 0.02 (N + P -10.0%, p less than 0.01) and no change of cardiac index. Single treatment with nifedipine leads to a reflex increase of heart rate which could not be observed after carvedilol or N + P as a result of the betablocking properties of carvedilol and propranolol. Therefore, the rate-pressure-product at rest was unchanged after nifedipine but decreased significantly after carvedilol (-10.9%, p less than 0.01) and N + P (-12.4%, p less than 0.01). Negative inotropic effects were significantly lower after carvedilol, with a 6.3% (p less than 0.05) decrease of LV dP/dtmax, compared to N + P (-12.0%, p less than 0.01). Since preload, afterload, and heart rate changes were equal in both groups negative inotropic effects can be compared on the base of dP/dtmax changes. The acute hemodynamic effects (vasodilation without reflex tachycardia, negative inotropic effects) of the new vasodilating betablocker carvedilol are comparable to a combined treatment with nifedipine and propranolol in patients with coronary artery disease and well preserved left ventricular global function.

In 113 patients demonstrating the clinical syndrome of unstable angina, acute-stage coronary angiography revealed multivessel disease. Acute PTCA of the ischaemia-related coronary artery or bypass grafting was performed depending on angiographic criteria. Of the total of 68 patients in whom PTCA was performed, 45 had two-vessel disease (2 vd) and 23 three-vessel disease (3 vd). 12 of the 45 patients with bypass operation had a left main stem stenosis, whereas 33 had three-vessel disease. The primary success rate of PTCA was 81%, 89% in patients with 2 vd and 70% in patients with 3 vd. Acute post-PTCA bypass grafting was necessary in 2 patients having 2 vd and in 5 patients suffering from 3 vd. 5 of the 68 patients treated with PTCA developed a transmural myocardial infarct and one patient died after PTCA and emergency bypass surgery. 8 of the 45 operated patients had a perioperative or postoperative myocardial infarct and 5 patients died intraoperatively or postoperatively. The overall morbidity was 11.5%, and the mortality of hospitalised patients was 5.3% (6/113). Combination of PTCA with emergency bypass grafting offers a new and effective treatment with an acceptable risk even in multivessel disease patients and in those having unstable angina pectoris. The additional use of PTCA definitely improves therapeutic management in this high-risk population.

To evaluate the feasibility of 201Tl single photon emission computed tomography (SPECT) for quantitative detection of myocardial infarction and ischemia, scintigraphic studies were related to angiographic findings. In study A infarct sizes with SPECT were compared with the angiographic infarct sizes of 30 patients. A linear correlation was found for the % infarct of the left ventricular circumference between both methods (r = 0.73; P less than 0.001; mean infarct size 20.7% +/- 10.5% (angio) vs 19.8% +/- 12.9% (SPECT), mean +/- SD). Furthermore, a significant inverse correlation between scintigraphic infarct size and left ventricular ejection fraction (r = -0.87, P less than 0.001) was obtained. In study B exercise/rest 201Tl SPECT was used for quantification of myocardial ischemia. Forty-three patients underwent both stress 201Tl SPECT and biplane exercise left ventriculography. Ischemia was expressed as % defect size of the left ventricular circumference. Sensitivity and specificity for detection of ischemia were 96% and 100% respectively with stress SPECT. Extent of myocardial ischemia correlated significantly with both methods (r = 0.63; SPECT defect = 1.0 angiographic ischemia +2%; P less than 0.001). The regression followed the line of identity and the mean sizes of ischemia were identical (SPECT 12.2 +/- 7.6% vs 14.6 +/- 12.4% ventriculography, mean +/- SD) demonstrating the agreement of both methods. However, there was some intraindividual variance between the scintigraphic and the angiographic study. The sensitivity and specificity in single regions with SPECT were lower compared to the global test results.(ABSTRACT TRUNCATED AT 250 WORDS)

The accuracy of radionuclide techniques for detection of exercise-induced myocardial ischemia was analyzed with TL-201 single-photon emission computer tomography (SPECT) and gated blood pool ventriculography in 31 patients. Reversible and persistent perfusion defects in the biphasic SPECT studies, parametric phase and amplitude images and global indices of left ventricular function were evaluated and compared to the results of exercise cineventriculography. Out of 25 patients with coronary heart disease, 20 had exercise-induced ischemia and 17 patients had a prior myocardial infarction. SPECT detected ischemia with a sensitivity of 85% and a specificity of 100%, gated blood pool ventriculography had a sensitivity of 60% and a specificity of 91%. Both scintigraphic methods were comparable in the detection of myocardial infarcts (SPECT/gated blood pool ventriculography: sensitivity 88%/82%; specificity 100%/93%; positive predictive value 100%/93%). A difference in detection of ischemia between both methods was found in patients with myocardial infarct and additional ischemia: all patients with additional ischemia were detected by SPECT, whereas gated blood pool ventriculography failed to identify the additional ischemia in 1/4 of these patients (p less than 0.05).

Using the exponential downslope of the thermodilution curve right ventricular ejection fraction and volumes can be calculated. To evaluate the accuracy of this method for clinical application thermodilution measurements were compared to the results of biplane cineventriculography in 40 patients. Mean right ventricular ejection fraction was 52 +/- 9% determined by thermodilution (Th), and 53 +/- 8% determined by angiography (A). Mean enddiastolic volume was 189 +/- 74 ml (Th) and 162 +/- 42 ml (A) and mean endsystolic volume 92 +/- 42 ml (Th) and 75 +/- 20 ml (A). Ejection fraction of thermodilution measurements correlated with the results of angiography (r = 0.59; SEE = 7%; % SEE = 13 rel. %; p less than 0.001). The correlation for endsystolic volume was: r = 0.50; SEE = 36 ml; % SEE = 48%; p less than 0.001, and for enddiastolic volume: r = 0.36; SEE = 70 ml; % SEE = 43%; p less than 0.05. The differences in ejection fraction calculated by the two different methods were especially high (up to 25%) in patients (n = 10) with low (less than 110 ml) or high (greater than or equal to 200 ml) enddiastolic volume. For the other 30 patients the correlation for right ventricular ejection fraction was: r = 0.82; SEE = 5%; % SEE = 9 rel. %; p less than 0.001. Thus, the thermodilution method allows an approximative assessment of right ventricular ejection fraction only in patients with a normal right ventricle. Since right ventricular ejection fraction cannot be determined with sufficient accuracy in patients with right ventricular dilatation, the clinical application of this method is limited.

The haemodynamic effects of a combined intravenous treatment of nifedipine and propranolol in ten patients with coronary artery disease compared to a single treatment with nifedipine or placebo were investigated. Nifedipine infusion resulted in a reduction of left ventricular (LV) afterload and LV volumes with an increase in heart rate and EF and no change of the double product, coronary sinus flow, LV diastolic parameters and dp/dtmax. Addition of propranolol lowers myocardial oxygen demand by reducing heart rate and dp/dtmax together with a sustained afterload reduction with no change in LV volumes and EF. The vasodilatatory action of nifedipine pretreatment balanced the negative effects of acute beta-receptor blockade on LV function and allows the reduction of myocardial oxygen demand without a deterioration of LV function.

A novel 1.3 mm diameter laser catheter, consisting of 20 concentric 100 microns quartz fibres around a central lumen for a 0.35 mm flexible guide wire, was used to ablate atherosclerotic tissue in thirty patients with coronary artery disease. The laser catheter was coupled to an excimer laser delivering energy at a wavelength of 308 nm and a pulsewidth of 60 ns. The primary success rate was 90% (27 of 30 lesions). The mean (SD) percentage stenosis fell from 85 (15)% to 41 (19)% after laser ablation. In ten patients the lumen diameter after laser angioplasty was considered sufficient, but subsequent balloon angioplasty was carried out for the other twenty patients. Failure to pass the lesion was caused by vessel kinking in two patients and a total occlusion in one patient. No complications directly attributable to laser ablation, such as vessel wall perforation, occurred; one dissection occurred but had no clinical sequelae. There was one early reocclusion and death in a patient with triple vessel disease and unstable angina, probably as a result of plaque rupture after balloon angioplasty. These results are encouraging and justify further clinical investigations.