Search

Objective: To conduct a pilot study to evaluate and compare the 24-hour habitual intraocular pressure (IOP) and ocular perfusion pressure (OPP) fluctuation in glaucoma patients treated with medical therapy, selective laser trabeculoplasty (SLT) or trabeculectomy., Design: Pilot study., Participants: Criteria for inclusion were patients aged 18 years or older with well-controlled IOP with either maximum tolerated medical therapy, previous SLT, or previous trabeculectomy., Methods: Recruited patients were admitted to the sleep lab for 24-hour serial habitual IOP and blood pressure measurements. IOP and OPP fluctuation among the 3 treatment groups were compared., Results: Thirty three (33) eyes from 33 patients were recruited in this study, including 11 patients in the medical therapy group, 11 patients in the SLT group, and 11 patients in the trabeculectomy group. The medical therapy group was found to have significantly higher 24-hour IOP fluctuation (8.3 ± 1.6 mmHg) than the SLT (3.5 ± 1.9 mmHg) and trabeculectomy (4.3 ± 1.3 mmHg) groups (P < 0.001). Mean 24-hour OPP fluctuation was also significantly higher in the medical therapy group (18.5 ± 4.0 mmHg) than the SLT (11.9 ± 7.3 mmHg) and trabeculectomy (14.1 ± 3.9 mmHg) groups (P < 0.05). No difference in IOP or OPP fluctuation was found between SLT and trabeculectomy groups (P > 0.05)., Conclusions: Both SLT and trabeculectomy may be more effective in reducing 24-hour IOP and OPP fluctuation than medical therapy alone. IOP and OPP fluctuation was comparable between SLT and trabeculectomy cohorts. Future studies are warranted to investigate this further., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To compare the agreement and repeatability of intraocular pressure (IOP) measured with the slit lamp-mounted ST500 rebound tonometer (iCare Finland Oy), the hand-held IC200 rebound tonometer (iCare Finland Oy), and Goldmann applanation tonometry (GAT)., Design: Cross-sectional study., Participants: Glaucoma patients and staff of the Eye Care Centre, Nova Scotia Health., Methods: Intraocular pressure was measured twice each with the IC200, ST500, and GAT. Bland-Altman analysis was used to compare each pair of tonometers and whether the difference between tonometers depended on mean IOP. Intraclass correlation coefficients were also computed. Repeatability of the measurements with each tonometer was assessed by calculating the mean and variance of the difference between the first and second measurements. The relationship between IOP and central corneal thickness was also evaluated., Main Outcome Measures: Agreement and repeatability of IOP measurements with the IC200, ST500, and GAT., Results: One eye of 157 participants (64 men and 93 women) with a median (interquartile range) age and central corneal thickness of 62 (45-72) years and 553 (533-572) μm, respectively, were enrolled. Median IOP with the IC200, ST500, and GAT was 17.1 (14.3-21.0), 16.5 (14.0-20.8), and 17.0 (14.0-20.5) mmHg, respectively, while the range of IOP (measured with GAT) was 8.5 to 53.0 mmHg. Measurements with the 3 tonometers were not statistically different from each other, and in neither of the 3 paired comparisons was the difference in IOP between 2 tonometers dependent on mean IOP. The intraclass correlation coefficient values (0.97-0.98) showed excellent agreement between the tonometers. The variance of the difference between the first and second measurements of the ST500 was significantly lower than that of GAT (P = 0.04) and IC200 (P < 0.01). Intraclass correlation coefficients for intratonometer repeatability were also excellent (0.97-0.99)., Conclusions: The ST500 shows good agreement with GAT over a large range of IOP and significantly higher repeatability compared to the IC200 and GAT, suggesting it may be advantageous in clinical settings where topical anesthesia or skilled staff are unavailable., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Brilliant blue 0.05% and trypan blue 0.1% were mixed in a proportion of 1:1 in a 1-mL syringe. This combination produced a waterfall effect with the fast sinking of the dye to the posterior pole and little diffusion through the vitreous cavity. Therefore, it can effectively stain the internal limiting membrane and the epiretinal membrane with a good contrast during surgeries for a macular hole, myopic foveoschisis, and macular pucker., Competing Interests: None., (Copyright © 2024 Ferreira et al.)

Purpose: To describe a unique case of unilateral open angle glaucoma secondary to heterotopic bone formation in the anterior chamber angle., Observations: A 57 year-old male with an unremarkable history presented with right eye pain. Anterior segment examination demonstrated a solid, white deposit overlying the trabecular meshwork and peripheral iris associated with an intraocular pressure of 44 mmHg. The left eye examination was unremarkable. Biopsy of the material surprisingly showed heterotopic bone. Removal of the material and medical treatment were unable to adequately control the intraocular pressure and a trabeculectomy was successfully performed., Conclusions and Importance: This case demonstrates a unique cause of secondary open angle glaucoma: heterotopic bone formation in the anterior chamber angle., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023 Published by Elsevier Inc.)

Many aerial robotic applications require the ability to land on moving platforms, such as delivery trucks and marine research boats. We present a method to autonomously land an Unmanned Aerial Vehicle on a moving vehicle. A visual servoing controller approaches the ground vehicle using velocity commands calculated directly in image space. The control laws generate velocity commands in all three dimensions, eliminating the need for a separate height controller. The method has shown the ability to approach and land on the moving deck in simulation, indoor and outdoor environments, and compared to the other available methods, it has provided the fastest landing approach. Unlike many existing methods for landing on fast-moving platforms, this method does not rely on additional external setups, such as RTK, motion capture system, ground station, offboard processing, or communication with the vehicle, and it requires only the minimal set of hardware and localization sensors. The videos and source codes are also provided.

Purpose: To describe four cases of ocular adverse events resembling intraocular inflammatory and non-inflammatory conditions following yellow fever vaccination (YFV) during a recent yellow fever (YF) outbreak in Brazil., Methods: Charts of patients diagnosed with ocular adverse events after YFV between January 2017 and January 2019 at two tertiary referral centers in Brazil., Results: Four patients (two adults and two children) are reported. Case 1 presented with typical findings of central serous chorioretinopathy which resolved spontaneously; case 2 was diagnosed with acute Vogt-Koyanagi-Harada disease; cases 3 and 4 had bilateral diffuse retinal vasculitis. In the absence of infectious and noninfectious disorders, the temporal association between stand-alone YFV and onset of ocular symptoms within 15 days was interpreted as evidence of causation., Conclusions: Clinicians should be aware of the wide spectrum of possible ocular adverse reactions to stand-alone YFV.

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes and its evaluation remains challenging. The proportion of patients presenting to the emergency department because of acute chest pain appears to be increasing. Nowadays, the essential chest pain-related issues are the missed diagnoses of acute coronary syndromes with a poor short-term prognosis and the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs, but chest pain is never low risk and appropriate diagnosis is always mandatory. The correct diagnosis will guide the treatment strategy. The implementation of networks between hospitals (hub and spoke) with various levels of technology, provide optimal care while minimizing delays, thereby improving clinical outcomes. Cardiologists should actively collaborate with all stakeholders, particularly emergency physicians, in establishing such networks.

Introduction: We examined the effects of the selective late INa inhibitor eleclazine on the 50% probability of successful defibrillation (DFT50) before and after administration of amiodarone to determine its suitability for use in patients with implantable cardioverter defibrillators (ICDs)., Methods and Results: In 20 anesthetized pigs, transvenous active-fixation cardiac defibrillation leads were fluoroscopically positioned into right ventricular apex through jugular vein. ICDs were implanted subcutaneously. Dominant frequency of ventricular fibrillation was analyzed by fast Fourier transform. The measurements were made before drug administration (control), and at 40 minutes after vehicle, eleclazine (2 mg/kg, i.v., bolus over 15 minutes), or subsequent/single amiodarone administration (10 mg/kg, i.v., bolus over 10 minutes). Eleclazine did not alter DFT50, dominant frequency, heart rate, or mean arterial pressure (MAP). Subsequent amiodarone increased DFT50 (P = 0.006), decreased dominant frequency (P = 0.022), and reduced heart rate (P = 0.031) with no change in MAP. Amiodarone alone increased DFT50 (P = 0.005; NS compared to following eleclazine) and decreased dominant frequency (P = 0.003; NS compared to following eleclazine)., Conclusion: Selective late INa inhibition with eleclazine does not alter DFT50 or dominant frequency of ventricular fibrillation when administered alone or in combination with amiodarone. Accordingly, eleclazine would not be anticipated to affect the margin of defibrillation safety in patients with ICDs.

Background: Air pollution is one of the most environmental health concerns in the world and has serious impact on human health, particularly in the mucous membranes of the respiratory tract and eyes. However, ocular hazardous effects to air pollutants are scarcely found in the literature., Design: Panel study to evaluate the effect of different levels of ambient air pollution on lacrimal film cytokine levels of outdoor workers from a large metropolitan area., Methods: Thirty healthy male workers, among them nineteen professionals who work on streets (taxi drivers and traffic controllers, high pollutants exposure, Group 1) and eleven workers of a Forest Institute (Group 2, lower pollutants exposure compared to group 1) were evaluated twice, 15 days apart. Exposure to ambient PM2.5 (particulate matter equal or smaller than 2.5 μm) was 24 hour individually collected and the collection of tears was performed to measure interleukins (IL) 2, 4, 5 and 10 and interferon gamma (IFN-γ) levels. Data from both groups were compared using Student's t test or Mann- Whitney test for cytokines. Individual PM2.5 levels were categorized in tertiles (lower, middle and upper) and compared using one-way ANOVA. Relationship between PM2.5 and cytokine levels was evaluated using generalized estimating equations (GEE)., Results: PM2.5 levels in the three categories differed significantly (lower: ≤22 μg/m3; middle: 23-37.5 μg/m3; upper: >37.5 μg/m3; p<0.001). The subjects from the two groups were distributed unevenly in the lower category (Group 1 = 8%; Group 2 = 92%), the middle category (Group 1 = 89%; Group 2 = 11%) and the upper category (Group 1 = 100%). A significant relationship was found between IL-5 and IL-10 and PM2.5 levels of the group 1, with an average decrease of 1.65 pg/mL of IL-5 level and of 0.78 pg/mL of IL-10 level in tear samples for each increment of 50 μg/m3 of PM2.5 (p = 0.01 and p = 0.003, respectively)., Conclusion: High levels of PM2.5 exposure is associated with decrease of IL-5 and IL-10 levels suggesting a possible modulatory action of ambient air pollution on ocular surface immune response.

Introduction: Ventricular rate during atrial fibrillation (AF) can be reduced by slowing atrioventricular (AV) node conduction and/or by decreasing dominant frequency of AF. We investigated whether combined administration of ivabradine and ranolazine reduces ventricular rate during AF., Methods and Results: Ivabradine (maximum clinical dose, 0.25 mg/kg, and 0.10 mg/kg, i.v.) and ranolazine (2.4 mg/kg, i.v., bolus followed by 0.135 mg/kg/min) were studied in an anesthetized pig (N = 16) model of AF. Combined administration of 0.25 mg/kg ivabradine with ranolazine reduced ventricular rate during AF by 51.9 ± 9.7 beats/min (23%, P = 0.017) and dominant frequency of AF by 2.8 ± 0.5 Hz (32%, P = 0.005). It increased PR (P = 0.0002, P = 0.0007) and A-H intervals (P = 0.047, P = 0.002) during pacing at 130 and 180 beats/min, respectively, to a greater degree than additive effects of single agents. Combined administration of 0.1 mg/kg ivabradine with ranolazine exceeded additive effects of single agents on A-H intervals and dominant frequency of AF. Moreover, ranolazine potentiated low-dose ivabradine's reduction in ventricular rate, as combined administration more than doubled effects of the higher ivabradine dose alone and was similar to the combination with the higher dose. Neither drug nor their combination affected contractility (left ventricular [LV] dP/dt), QT or His-ventricular (H-V) intervals, or mean arterial pressure during sinus rhythm or AF., Conclusion: Combined administration of ivabradine and ranolazine at clinically safe levels decreases ventricular rate during AF by reducing AV node conduction and AF dominant frequency without QT prolongation or depression in contractility. Targeting these actions offers intrinsic advantages over conventional nodal agents, which can reduce contractility., (© 2014 Wiley Periodicals, Inc.)

Background: If channels are functionally expressed in atrioventricular (AV) nodal tissue., Objective: The purpose of this study was to address whether the prototypical If inhibitor, ivabradine, at clinically safe concentrations can slow AV node conduction to reduce ventricular rate (VR) during atrial fibrillation (AF)., Methods: Effects of ivabradine (0.1 mg/kg i.v. bolus) were studied in an anesthetized Yorkshire pig (N = 7) model of AF and in isolated guinea pig hearts (N = 7)., Results: Ivabradine reduced heart rate (P = .0001) without affecting mean arterial pressure during sinus rhythm. The agent lengthened PR intervals in a rate-dependent manner (P = .0009) by 14 ± 2.7 ms (P = .003) and 25 ± 3.0 ms (P = .0004) and increased atrial-His (A-H) intervals in a rate-dependent manner (P = .020) by 10 ± 1.7 ms and 17 ± 2.8 ms during pacing at 130 and 180 bpm, respectively (both P = .0008). Similar rate-dependent effects were observed in isolated guinea pig hearts. Ivabradine slowed VR during AF from 240 ± 21 bpm to 211 ± 25 bpm (P = .041). The ivabradine-induced increase in A-H interval was inversely correlated with VR (r = -0.85, P = .03, at 130 bpm; r = -0.95, P = .003, at 180 bpm). QT and HV intervals, AF dominant frequency (8.5 ± 0.9 to 8.7 ± 1.1 Hz, P = NS), mean arterial pressure, and left ventricular dP/dt (1672 ± 222 to 1889 ± 229 mm Hg/s, P = NS) during AF were unaffected., Conclusion: Ivabradine's rate-dependent increase in A-H interval is highly correlated with VR during AF. As dominant frequency was unaltered, AV node conduction slowing during high nodal activation rates appears to be the main mechanism of ivabradine's VR reduction. If inhibition in the AV node may provide a promising target to slow VR during AF without depression in contractility., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Ischemic heart disease is associated with dual risk for atrial and ventricular arrhythmias., Objective: We examined whether selectively targeting late sodium channel current (INa) with GS-458967 (hereafter GS967) can reduce cardiac electrical instability and compared its effects to a clinically relevant dose of flecainide., Methods: Electrode catheters were positioned on the left atrial appendage and left ventricle of anesthetized pigs to monitor repolarization alternans and electrocardiographic heterogeneity before and during left circumflex coronary artery stenosis (75% flow reduction) before and after GS967 (0.4 mg/kg, intravenously [IV]) or flecainide (1 mg/kg, IV, bolus over 2 minutes followed by 1 mg/(kg·h), IV, for 1 hour) administration., Results: Left circumflex coronary artery stenosis increased atrial repolarization alternans by 520% (from 9.4 ± 1.2 to 58.3 ± 11.3 μV; P = .029) and T-wave alternans by 1038% (from 30.7 ± 8.2 to 349.3 ± 103.8 μV; P = .049). GS967 prevented ischemia-induced increases in alternans in the left atrium (19.3 ± 5.6 μV vs 58.3 ± 11.3 μV; P = .023) and left ventricle (217.9 ± 95.8 μV vs 349.3 ± 103.8 μV; P < .001) (n = 7). GS967 reduced ischemia-induced increases in depolarization heterogeneity (atrium: from 45% to 28%; ventricle: from 92% to 51%) and repolarization heterogeneity (atrium: 43% to 23%; ventricle: 137% to 91%). GS967 did not alter heart rate, arterial blood pressure, PR and QT intervals, or QRS duration, but it mildly decreased contractility (left ventricular dP/dt) during ischemia, which was consistent with late INa inhibition. Flecainide (n = 7) amplified ischemia-induced increase in atrial and ventricular repolarization alternans, electrocardiographic heterogeneity, and ventricular fibrillation incidence., Conclusion: Selective late INa inhibition with GS967 exerts potent protective effects against ischemia-induced depolarization and repolarization abnormalities in both atria and ventricles., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Two-millimeter punch biopsy is a swift and practical diagnostic tool in the outpatient setting. However, few studies have evaluated the efficacy of the method for diagnosis of malignant eyelid tumors., Methods: This was an observational study of patients with suspicion of malignant eyelid tumor attending the Ocular Plastic Surgery Center at Hospital das Clínicas, University of São Paulo School of Medicine. Following standard procedures, preoperative biopsies were taken with a 2-mm trephine and surgical excision was performed with safety margins, followed by reconstruction. Anatomopathologic analysis of the surgical specimen was used as gold standard to evaluate the accuracy of diagnosis by punch biopsy., Results: The study included 50 periocular tumors with suspicion of malignancy. The indicators of efficacy in the identification of malignancy by 2-mm punch biopsy were: sensitivity 88%, specificity 100%, positive predictive value 100%, and negative predictive value 64%. Accuracy was 90% for malignancy and 80% for histologic type. The κ index of agreement between the diagnostic methods was 0.722 (p < 0.001)., Conclusion: A positive result with 2-mm punch biopsy is a safe indication for surgical excision of the tumor, whereas a negative result does not necessarily imply benignity. In cases of high clinical suspicion, a second biopsy should be taken from a different part of the tumor to rule out malignancy.

Background: One of the biggest debates in modern cardiology regards the relative merit of primary percutaneous transluminal coronary angioplasty (PTCA) versus thrombolysis for the treatment of acute myocardial infarction with persistent ST-segment elevation. After the excellent results with primary PTCA in trials and meta-analyses, the next question is whether such results might be duplicated in "real world" conditions., Methods: Between January 1995 and April 2003, 1000 consecutive patients with acute myocardial infarction, out of 2272 (44%) with ST-segment elevation admitted to the coronary care unit at the Cardiology Department of the S. Anna Hospital, were treated with PTCA. Our Institution is a medium-high volume center, without on-site surgery. Usual clinical and interventional practice, adjunctive antithrombotic therapy and results are described in this paper., Results: Primary PTCA has been performed in 825 patients (75%) out of 1095 undergoing emergency angiography, "facilitated" in 140 (13%), rescue in 35 (3.2%). Eighty patients of the "facilitated" PTCA group had been pre-treated with tissue-type plasminogen activator 50 mg i.v. bolus, 50 with abciximab and 10 with reduced doses of fibrinolytic and abciximab. One hundred and seventy patients (16%) had been transferred to our Institution from community hospitals. Nine patients out of 1000 undergoing PTCA (0.9%) have been transferred immediately after the procedure (bail-out, failure) to perform urgent coronary artery bypass grafting. PTCA has been completed by stenting in 919 patients (92%). The median door-to-balloon time was 58 min (25th-75th percentile 49-71). The in-hospital total mortality rate was 4.9% (49 deaths): 5.3% (44 deaths) in the primary PTCA group, 2.1% (3 deaths) in the "facilitated" PTCA group (p = 0.042), and 5.7% (2 deaths) in the rescue PT-CA group. Early reinfarction rate was 1.5% (15 cases). The median time to hospital discharge was 10 days (25th-75th percentile 7-14)., Conclusions: Since 9 years, our practice in the treatment of acute myocardial infarction with persistent ST-segment elevation is going on extending the use of primary PTCA, integrating pharmacological and mechanical options in selected cases.

The aim of this pilot study was to evaluate the safety and efficacy of the BiodivYsio phosphorylcholine-coated stent in the primary treatment of acute myocardial infarction. The BiodivYsio stent (Biocompatible) is a balloon-expandable stent, laser etched from a 316 L stainless steel tube. This device is coated with phosphorylcholine, a synthetic, hemocompatible phospholipid polymer that has been shown in experimental studies to reduce platelet and protein adhesion to the surface of the metal. One hundred consecutive patients within 24 hr of symptoms of onset of acute MI, treated with primary PTCA, were enrolled. After PTCA, stenting was attempted in all eligible lesions (reference diameter > or = 2.5 mm; no bend lesion > 45 degrees ). Poststenting regimens contained ticlopidine (500 mg/day) and aspirin (325 mg/day) and 6-12 hr of heparin infusion. Procedural success (TIMI > or = II and residual stenosis < 30%) was obtained in 70/74 cases (95%). TIMI grade III was restored in 90% of cases. In the patient group with procedural success (70 cases), 70 BiodivYsio stents were placed. After stenting, diameter stenosis decreased from 96% +/- 11% to 22% +/- 12% (P < 0.01) and minimal luminal diameter increased from 0.13 +/- 0.29 to 2.47 +/- 0.43 (P < 0.01). Nominal stent diameter was between 3.0 and 4.0 mm (mean, 3.5 +/- 0.4 mm). Stent length was between 11 and 28 mm (mean, 17 +/- 4.5 mm). Clinical follow-up was obtained in all patients; angiographic follow-up was performed in 65/70 (93%). No acute or subacute thrombosis was reported. Two in-hospital major adverse cardiac events (MACE) were reported due to a nontreated left main disease that required coronary artery bypass graft (CABG) surgery. At follow-up, MACE were found in 9 of 68 patients (13%), target lesion revascularization (TLR) in 6%, and CABG in the remaining 6%. Primary stenting with phosphorylcholine-coated stent leads to excellent short- and mid-term clinical outcomes and is associated with a restenosis rate of 12%.

Background: Percutaneous transluminal myocardial revascularization (PTMR) is a new procedure to improve perfusion of the ventricular wall for patients with intractable angina and untreatable by surgery or conventional catheter-based intervention. Actually PTMR requires femoral approach to utilize 8F-9F system device. We now report the feasibility study of PTMR using a laser delivered through a novel Eclipse system and new 6F and 7F guiding catheters that allow to perform PTMR even in patients with peripheral vascular disease and particularly suitable for alternative small vascular access., Methods: Percutaneous vascular access for PTMR treatment was obtained via the femoral or radial artery. A 6F or 7F mono-directional catheter carrying flexible fiber optics was used with a Holmium laser (Eclipse system) and was placed across the aortic valve into the left ventricular cavity to create channels of 5 mm in depth from the endocardial surface into the myocardial tissue. From June 1999 to September 2000, 39 patients (28 males, 11 females, mean age 72 +/- 8 years, range 58-86 years) underwent PTMR with the Eclipse system. Preoperative mean Canadian Cardiovascular Society (CCS) angina class was 3.5 +/- 0.5 and previous myocardial procedures had been performed in 39 patients (18 coronary artery bypass graft and 31 coronary angioplasty)., Results: The procedure was well tolerated and a procedural success was obtained in all patients (100%). We performed a mean of 19 +/- 7 channels in a mean fluoroscopy time of 21 +/- 9 min. We report only one procedural complication: one embolic stroke (2.4%). No hospital major adverse cardiac events were observed. The average length of hospital stay was 3.1 days. The mean CCS angina class at entry was 3.5 and it declined from 3.5 +/- 0.5 to 1.25 +/- 0.8 at discharge. At the follow-up of 8.2 +/- 3.9 months the mean CCS was 1.5 +/- 0.7., Conclusions: This experience confirmed the safety and technical feasibility of PTMR with this mini-invasive approach with a reduction in operative and fluoroscopy time. The PTMR with the 6F or 7F guiding catheter is feasible in high risk patients even when the femoral approach is contraindicated. Immediate and short-term results confirm that a clinical improvement is obtained in most patients.

Currently, in-stent thrombosis is a rare but serious clinical event. The mechanical or pharmacological approach has not totally solved this problem. In this report we describe the treatment of in-stent thrombosis with a new device for mechanical thrombus aspiration. We used the Rescue catheter (Rescue Catheter System, Boston Scientific), a new 4.5F dual lumen monorail catheter that was able to break and aspirate thrombus without evidence of distal embolization. In this case the procedure was quickly performed with good angiographic results after mechanical aspiration and additional traditional coronary angioplasty. Moreover, the excellent clinical outcome confirmed the efficacy of the technique in the percutaneous treatment of this late complication of stent implantation.

Background: Percutaneous transluminal myocardial revascularization (PTMR) is a new procedure to improve perfusion of the ventricular wall for patients with intractable angina that is untreatable by surgery or conventional catheter-based intervention. PTMR allows the creation of myocardial channels through the controlled delivery of holmium laser energy from the ventricular chamber. Preliminary studies in animals and human subject have yielded promising results. We now report the feasibility study of PTMR using a laser delivered through a novel Eclipse system, and we present the results of this sole therapy in patients with severe coronary disease and angina refractory to maximal medical treatment angina (III-IV CCS)., Methods: Percutaneous vascular access for PTMR treatment was obtained via the femoral artery. A 9F directional catheter carrying flexible fiber optics was used with a holmium laser (Eclipse system) and was placed across the aortic valve into the left ventricle cavity to create channels with a depth of 5 mm from the endocardial surface into the myocardial tissue. From April to November 1998, 15 patients underwent PTMR with Eclipse system. Two patients were female; the mean age was 66 +/- 8 (range 59-74). Five patients had a severe LV dysfunction (FE < 30%). Preoperative angina class was III in 10 patients and IV in 5 and previous myocardial procedures had been performed in all patients., Results: The procedure was well tolerated and procedural success was obtained in 14 of 15 patients. There was one myocardial perforation because of guiding-catheter manipulation (pericardial drainage in fourth day). We performed a mean of 13 +/- 4 channels in a mean fluoro time of 23 +/- 11 min. Upon release and during follow-up (5.3 months +/- 4.2, range 2-10), angina class had significantly improved in 14 of 14 patients with complete PTMR treatment, with 4 asymptomatic patients, 6 patients in CCS I, 3 in CCS II, 2 in CCS III and only one patient hospitalized due to angina., Conclusion: This pilot study confirmed the safety and technical feasibility of PTMR. Immediate and short-term results confirm that a clinical improvement is obtained in most patients. Although these are early clinical benefits, the true efficacy of this approach will necessarily be defined by a randomized trials with prospectively-defined endpoints and with PTMR compared with medical therapy.

Background: Although it is superior to thrombolysis, primary PTCA does have some limitations, both in hospital (recurrent ischemia and reinfarction due to reocclusion of the infarct-related artery) and at the six-month follow-up (high rate of late restenosis). Coronary stenting is a promising way of solving some of these problems, even if its use in patients with acute myocardial infarction could prove to be controversial because of intracoronary thrombus. In this study, we propose two procedural strategies in the treatment of the infarct-related artery (IRA): the search for optimal angiographic results after PTCA ("stent-like result"--SLR--with residual stenosis < or = 20%--no dissection--TIMI III flow) or intracoronary stenting when SLR was not obtained after a second inflation., Methods and Results: From December 1995 to May 1998, 200 patients with AMI underwent direct PTCA or rescue PTCA because of failed thrombolysis. There were 143 men and 57 women, mean age 65 (range 36-84). Nineteen patients were in cardiogenic shock and 25 were in Killip class > II. Recanalization of the IRA was achieved in 196 patients (98%). In four patients, it was not possible to cross total occlusion with the guide-wire. SLR post-PTCA was achieved in 40 patients (20%). Stents were placed in 147 patients (75%), with "elective" implantation in 73 lesions because of suboptimal results after PTCA in 41, and early loss or coronary dissection with threatening occlusion in 33. In nine patients without SLR, stenting was not performed because of diffuse disease of the IRA. In-hospital complications included ten deaths (8 of 19 patients with cardiogenic shock at admission and 2 with multivessel disease and severe left ventricular dysfunction). None of the patients required emergency coronary bypass for procedural complications. One patient had a subacute thrombosis on the third day after bail-out stent implantation (re-PTCA). Five patients required elective bypass surgery to complete revascularization for multivessel disease with ten days after the surgical procedure. At the six-month follow-up, one patient had died of cardiogenic shock. Eleven (5%) patients with bail-out procedures underwent coronary bypass surgery or PTCA. Thirty-one patients (31/168) had recurrence of ischemia: 15 patients in the stent group, 11 in SLR group and 5 in the non-SLR group. Re-PTCA was performed in 20 patients, CABG in five and medical therapy in six. Other patients were angina-free at follow-up., Conclusions: Based on our experience, seeking optimal angiographic results with or without (SLR) stent implantation is a safe and effective operative approach to achieve the best procedural and clinical outcome and reduce complications in patients undergoing PTCA for AMI.

Background: Patients with end-stage cardiomyopathy frequently require acute or chronic infusional treatments and long hospitalization. Availability of a simple and safe vascular access is a true necessity for these patients, especially in case of inotropic or diuretic outpatient treatment. In this study we have evaluated the usefulness and the applicability of implantable vascular access in the management of end-stage cardiomyopathy. Technical problems and both short and long term complications have been analysed., Methods: Nineteen implantable vascular system (16 Port-A-Cath, Pharmacia; 3 Celsite, Bruneau) have been implanted in a group of 15 patients with end-stage cardiomyopathy. All patients had been previously hospitalized and needed prolonged infusional therapy. Implantation was performed in local anaesthesia with technique derived from pace-maker implantation., Results: All the interventions were well tolerated, average procedural time was 30 min (range 20-60 min). No procedural complications occurred. Re-implantation of the system was required in 2 patients due to catheter thrombosis, In 1 patient due to catheter rupture caused by wrong positioning of infusion needle, and in 1 patient due to inflammatory reaction. In 2 further cases catheter thrombosis was treated with local infusion of urokinase. In 1 patient the catheter was repositioned after dislocation. The average in situ permanence of the systems was 8 months (range 15 day-18 months)., Conclusions: Vascular implantable systems have proved useful and easily applf1p4e in the management of patients with end stage cardiomyopathy. After training some of the implied complications are easily avoidable. The use of this device has concurred to reduce duration and frequency of hospitalizations.

Myoglobin (Mb) is an intracardiac protein known to be rapidly released after onset of reperfusion. The new automated latex-enhanced nephelometric immunoassay is an interesting fast alternative to the other methods. Therefore we sought to assess the accuracy of rapid rise of Mb concentration to predict the success of reperfusion. Thirty consecutive patients, admitted to the coronary care unit for first acute Q-wave myocardial infarction, were prospectively studied. They underwent thrombolysis 126 +/- 45 min (range 30-180) after onset of symptoms. Mb determinations were obtained before starting therapy and, thereafter, hourly for 5 hours, and after 8 and 12 hours. The usual non invasive markers of reperfusion were considered, and coronary arteriography was performed in all patients at 5.5 +/- 0.9 days (range 1-6). In 23 patients (77%) patent infarct-related artery (IRA) (TIMI II-III) and in 7 (23%) occluded IRA (TIMI 0-I) was observed at coronary arteriography. We modified the judgment in 3 cases (10%) with occluded IRA. All reperfused patients (Group A) showed a rapid rise of Mb concentration with a mean time to peak occurring 133 +/- 80 min (range 60-180) after therapy. Mean value of unreperfused patients (Group B) was 330 +/- 173 min (range 180-420). We retrospectively stated a time to peak of Mb concentration within 180 min as diagnostic threshold for reperfusion. Sensitivity was 100%, specificity 50%, positive predictive value 93%, negative predictive value 100%. The results of this study confirm that Mb release kinetics may play an interesting role in the early prediction of patency of IRA in acute myocardial infarction after thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)