Excimer coronary laser angioplasty: it's time for a critical evaluation.
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Biomedical subjects
Publications and source records attributed to D T Mason.
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Both angiotensin II and the protein kinase C activator, phorbol 12-myristate 13-acetate (PMA), significantly depressed developed pressure, oxygen consumption, and coronary flow in isolated perfused rat hearts and caused a decrease in diastolic and systolic [Ca2+]i and [Ca2+]i transients. PMA and angiotensin II did not change the levels of cAMP but moderately decreased PCr/Cr. The decrease in systolic [Ca2+]i and amplitude of [Ca2+]i transients caused by PMA and angiotensin II resulted in depressed cardiac function. Hearts perfused with PMA and angiotensin II had a decreased sensitivity to extracellular calcium. Depressed developed pressure and oxygen consumption in the PMA- and angiotensin II-treated hearts may have been due to a decrease in amplitude of effective [Ca2+]i transients, because the [Ca2+]i threshold for cross-bridge interaction was presumably higher than the diastolic [Ca2+]i in these hearts.
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The risk-benefit relationship of open heart surgery in octogenarians is not well established. Eighty consecutive patients over the age of 80 who underwent cardiac operations under cardiopulmonary bypass were evaluated. Twenty-five patients were in functional class IV, 42 in class III, and 13 in class II. Forty-four patients had only coronary artery bypass grafts (CABG), 12 only aortic valve replacement (AVR), 6 only mitral valve replacement (MVR), 12 CABG and AVR, 4 CABG and MVR, 1 CABG and aneurysmectomy, and 1 had resection of left atrial myxoma. Operative mortality (within 30 days) was 12.5% for the group. Mortality was related to bleeding, left ventricular failure, primary ventricular fibrillation, pulmonary failure, and renal failure. Mortality was higher in patients with (1) advanced functional class, (2) mitral valve replacement, (3) postoperative hemorrhage, and (4) associated pulmonary disease. While a generally conservative approach is recommended for octogenarian patients, many with life-threatening cardiac disease, especially those free of major multisystem illnesses, should not be denied the benefit of surgical treatment.
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This study, which was designed to evaluate the effects of positive inotropic agents on intracellular calcium transients ([Ca2+]i), is the first to analyze calcium transients in the whole heart. The positive inotropic agents that augment intracellular cyclic adenosine monophosphate (cAMP) (dibutyryl cAMP, amrinone, and isoproterenol) caused an increase in developed pressure and [Ca2+]i transients and a decrease in diastolic [Ca2+]i. On the other hand, the glycoside digoxin and the alpha-adrenoceptor agents, phenylephrine and dobutamine, also caused an increase in [Ca2+]i transients and developed pressure. However, unlike the agents that increase [cAMP]i, they induced an elevation in diastolic [Ca2+]i. With all the positive inotropic agents, developed pressure increased commensurately with the percentage changes in amplitude of the [Ca2+]i transients.
To study the mechanism of dobutamine on end-stage heart failure, we assessed hemodynamic responses, high-energy phosphates (31P-NMR), and free intracellular calcium ([Ca2+]i) transients (surface fluorometry) during perfusion with 10(-6) mol/L dobutamine in Syrian cardiomyopathic hamsters with severe heart failure. These results were compared to perfusion of the heart with 10(-6) mol/L norepinephrine and 10(-6) mol/L isoproterenol. With the positive inotropic agents the rate-pressure product increased immediately (p less than 0.01 with dobutamine, norepinephrine; p less than 0.003 with isoproterenol); after 10 to 15 minutes of perfusion the rate-pressure product remained relatively stable with norepinephrine and isoproterenol but decreased with dobutamine (p = NS vs control values). [Ca2+]i-transients increased significantly in all groups. The end-diastolic [Ca2+]i decreased continuously with norepinephrine and isoproterenol (p less than 0.008; p less than 0.005) but increased during dobutamine by 19%. Alterations in coronary flow, pHi, high-energy phosphates, and the phosphorylation potential were not significantly different among the three catecholamines. In conclusion, in contrast to norepinephrine and isoproterenol, dobutamine depressed myocardial performance and increased end-diastolic [Ca2+]i in late heart failure.
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The fiberoptic scope is increasingly used in the coronary and peripheral arteries to quantitate the degree and type of arterial obstructive disease and to inspect the results of procedures such as bypass grafting and laser irradiation of obstructive lesions. Since little is known about this instrument's potential complications, we passed a variety of fiberoptic scopes (1.8 to 3.6 mm outer diameter) in fresh postmortem pig coronary arteries and live monkey and canine peripheral arteries, and observed the intraluminal anatomy through the angioscope. No perforations were created, but ridges rising from the vascular luminal surface, avulsion of the endothelial lining, and small flaps attached at one end to the vessel wall were observed. Histologically, subintimal and medial tears were evident. Inserting large diameter scopes or making frequent passes (10 to 100) in coronary arteries increased intravascular injury. The use of small diameter flexible scopes or infrequent passes (less than 10) in the larger iliac and femoral arteries of live monkeys and dogs resulted in a lower frequency of myointimal sloughing or flap formation. Current fiberoptic scopes are not ideal angioscopes; they have a rigid tip, cannot be steered adequately, and are relatively stiff, resulting in a high probability of intraluminal injury, especially when used in small tortuous arteries. To decrease the risk of such injury, we recommend gentle manipulations while passing the scope and use of the smallest diameter scope possible. We further suggest limited use of the fiberscope, or at least limiting the number of passes in small vessels such as coronary arteries.
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