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Treatment of bifurcation lesions by percutaneous coronary interventions is one of the challenging issues for the interventional cardiologists. The overall complication rate is higher than nonbifurcation lesions. We describe a new stenting technique for the so-called true bifurcation lesions.
BACKGROUND: E-Selectin is expressed only on activated endothelial cells, and may be used as a marker of endothelial activation. The relationship between soluble form of E-selectin (sE-selectin) and development of restenosis after balloon angioplasty (PTCA) is controversial, and there are no data for after stent implantation. We evaluated the role of serially measured sE-selectin levels in predicting the development of restenosis after PTCA and stent implantation. METHODS: In sixty-one patients with stable angina pectoris who underwent PTCA (n=20) or stent implantation (n=41), peripheral blood samples were taken just before (baseline), at 3 and at 24 h after the intervention. sE-Selectin levels were measured by ELISA. Coronary angiography was repeated at 4-6 months after the intervention, and > or =50% stenosis at the site of the intervention was regarded as restenosis. Levels and time course of sE-selectin after the intervention were compared in patients with and those without restenosis. RESULTS: sE-Selectin levels of the patients with and those without restenosis were similar at each of the three measurements, and significantly increased after the intervention both in the PTCA and stent groups (P<0.001 for both groups). Posthoc analysis showed that sE-selectin levels increased significantly at 3 h after PTCA (P=0.024) and stent implantation (P=0.018), and did not change thereafter in patients with restenosis. In the nonrestenotic group, sE-selectin did not change significantly in the 24 h following PTCA, however, a significant difference was observed only by comparing the values at baseline with those at 24 h after stent implantation (P=0.021). CONCLUSIONS: A substantial increase in sE-selectin levels early (at 3 h) after PTCA and stent implantation may predict development of restenosis.
BACKGROUND: Active relaxation develops as a result of sequestration of calcium into the sarcoplasmic reticulum, and is controlled mainly by sarcoplasmic reticulum calcium ATPase (SERCA) and phospholamban.Tumour necrosis factor-alpha (TNF-alpha) downregulates both of these proteins, so it may play a role in the development of abnormal relaxation. However, a possible relationship between TNF-alpha and diastolic dysfunction has not been sufficiently evaluated in vivo. We investigated whether circulating levels of TNF-alpha increased in patients with relaxation abnormality. METHODS: Forty hypertensive patients with normal left ventricular systolic function were enrolled in the study. Age-adjusted values of echocardiographically measured mitral inflow velocities, E-wave deceleration time and isovolemic relaxation time were used to define normal and abnormal relaxation. Twenty of the patients (mean age 59.2 +/- 10.6) had a relaxation abnormality (group I), and the twenty other patients (mean age 45.9 +/- 7.9) had a normal diastolic function (group II). TNF-alpha levels were measured by ELISA. RESULTS: There were no significant differences between the two groups in terms of interventricular septal thickness, posterior wall thickness, left ventricular mass, ejection fraction, plasma creatinin level, and medication. Patients with a relaxation abnormality were older than those with a normal diastolic function (p < 0.001). TNF-alpha levels were similar in both groups (62.1 +/- 46.0 pg/ml for group I, and 48.7 +/- 51.4 pg/ml for group II, p = 0.089). CONCLUSION: In this preliminary study, we demonstrated that TNF-alpha levels did not increase in patients with a relaxation abnormality. However, we think that a possible relationship between TNF-alpha and diastolic dysfunction should be clarified by further studies involving a larger number of patients with a wider spectrum of diastolic dysfunction.
BACKGROUND: Experimental data suggest that tissue factor (TF) may induce neointimal hyperplasia after arterial injury. In this study, we investigated the hypothesis that elevated levels of TF in the circulation contribute to the development of restenosis after percutaneous transluminal coronary angioplasty (PTCA) or stent implantation. METHODS AND RESULTS: Whole-blood TF procoagulant activity (TF-PCA) was measured using a previously described assay before, at 3 hours after, and at 24 hours after the intervention in 61 patients with stable angina undergoing PTCA (n=20) or stent implantation (n=41). Coronary angiography was performed 4 to 6 months after the intervention, and luminal narrowing > or =50% was defined as restenosis. Whole-blood TF-PCA levels did not correlate with intracellular monocyte tumor necrosis factor-alpha expression, a marker of activation of these cells. Baseline levels and time course of whole-blood TF-PCA after the intervention were compared in patients who did or did not subsequently develop restenosis. Whole-blood TF-PCA levels did not change significantly in the 24 hours after either intervention. However, in both the PTCA and stent groups, initial TF-PCA was significantly higher in patients who subsequently developed restenosis (P=0.018 and 0.039 compared with those who did not develop restenosis for PTCA and stent groups, respectively). CONCLUSIONS: Higher baseline values of whole-blood TF-PCA may be a predictor of restenosis after PTCA and stent implantation.
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The aim of the study was to determine whether ticlopidine treatment prior the coronary stenting would be associated with lower rates of procedure-related minor myocardial injury (MMI) in patients undergoing elective coronary stenting. In this retrospective, nonrandomized, uncontrolled study, a total of 153 consecutive patients with a mean age of 63.4+/-8.9 years were divided into two groups based on the duration of ticlopidine treatment: group I (n=81), ticlopidine >/=3 days before the procedure, group II (n=72), on the same day as stent placement. Cardiac troponin T (cTnT) was measured immediately before and 12 h after the procedures. All patients were followed-up during the hospital stay with respect to MMI and major clinical events (MCE). The increase frequency and the amount of cTnT level in group I was found to be significantly lower compared with group II (4 vs. 13; P<0.01, and 0.35+/-0.06 vs. 0.52+/-0.11 ng/ml; P<0.01, respectively). In general, patients with elevated cTnT levels are more likely to have C type lesion and multivessel procedure than those of normal cTnT level (41 vs.10%; P<0.002 and 47 vs. 17%; P<0.009, respectively). Though there was a trend toward increased MCE rates in group II than that of group I, this did not reached statistical significance (3 vs.1; P=NS). The present study shows that an anti-platelet treatment with ticlopidine prior the coronary stenting of adequate duration to allow for the development of maximal inhibition is associated with a markedly decreased incidence of procedure-related MMI. Therefore, ticlopidine pretreatment may be a cost alternative for the prevention of platelet-rich microembolism in patients undergoing elective coronary stenting.
We searched a randomized, double-blinded, prospective study that compared the effectiveness of clopidogrel versus ticlopidine for prevention of minor myocardial injury (MMI) and major clinical events (MCEs) after elective coronary stenting. A total of 158 consecutive patients (98 male, 60 female patients with a mean age of 59.3+/-5.4 years) were divided into two arms based on treatment with thienopyridines: group I, clopidogrel 1 x 300 mg as a loading dose, and 1 x 75 mg per day thereafter, group II, ticlopidine 2 x 250 mg daily. Both thienopyridines were started on the same day as stent placement. Cardiac troponin T (cTnT) was measured immediately before and 12 h after the procedures. All patients were followed-up during the hospital stay (6+/-2 days) with respect to MMI and MCEs. The increase frequency and the amount of cTnT level in group I was found significantly lower compared with group II (5 vs.15; P<0.01; 0.38+/-0.11 vs. 0.44+/-0.12 ng/ml; P<0.001, respectively). Patients with elevated cTnT levels more likely to have C type lesion (P<0.004). Though there was a trend toward increased major clinical events rate in group II than those of group I, the statistical difference was not different (4 vs. 1.3%; P>0.05). The present study showed that the combination of clopidogrel and aspirin was more effective than the combination of ticlopidine and aspirin in decreasing the rate of MMI.
Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 +/- 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E', A') from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p < 0.001, p = 0.007, p < 0.001, respectively) after hemodialysis. Mitral annulus E' wave velocities and E'/A' ratios obtained from five different sides of the annulus also changed significantly (p < 0.001 for all); however, there was no change in the A' wave velocity (p > 0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E' velocities and E'/A' ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E', r = 0.329, p = 0.009 and E'/A' ratio, r = 0.286, p = 0.04; for septal side E', r = 0.376, p = 0.003 and E'/A' ratio, r = 0.297, p = 0.019; for anterior side E', r = 0.342, p = 0.007 and E'/A' ratio, r = 0.268, p = 0.035; for posterolateral side E', r = 0.423, p = 0.001 and E'/A' ratio, r = 0.343, p = 0.007; and for inferior side E', r = 0.326, p = 0.01 and E'/A' ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.
OBJECTIVE: To evaluate the feasibility and safety of direct stenting and to compare it with conventional implantation techniques in patients with acute coronary syndrome (ACS). METHODS: A total of 145 patients were divided into two arms based on the stenting technique used: group I (n = 71) = direct stenting without predilatation group that included only single-vessel procedures and group II (n = 74) = stenting with predilatation group that included only single-vessel conventional stent implantations. The primary endpoint of the study was the major adverse clinical event (MACE) rate in-hospital, at 1 month, and at 6 months and the secondary endpoint was the balloon inflation time (BIT), the number of balloon inflations (NBI), the radiation exposure time (RET), the amount of contrast dye used (ACD) and the no-reflow phenomenon. RESULTS: Primary success rate was 89% in group I and 95% in group II; overall procedural success rate was 94% in group I and 100% in group II. The rate of MACE was not different during the follow-up period between the two groups. The RET, BIT and NBI were significantly lower in group I than in group II (p < 0.001 for all). The ACD used was also significantly lower in group I than in group II (125 60 ml versus 155 71 ml; p = 0.006). Furthermore, the rate of no-reflow was significantly lower in group I than in group II (2.8% versus 13.5%; p = 0.03). CONCLUSION: Direct stenting is a feasible and safe technique. It is equivalent to single-vessel conventional stent implantation techniques with respect to MACE rate in-hospital, at 1 month, and at 6 month follow-up in selected patients with ACS.
UNLABELLED: This nonrandomized study evaluated the incidence of minor myocardial injury (MMI) in prospectively selected patients with simple lesion morphology and class II stable angina undergoing stenting with or without predilatation. METHODS: A total of 154 patients were divided into two arms based on the stenting technique used: direct stenting without predilatation (Group I; n = 78) and stenting with predilatation (Group II; n = 76). Cardiac troponin T (cTnT) was measured immediately before, at 12 hours and 24 hours postprocedure. The primary endpoint was the MMI in-hospital. The secondary endpoint of the study was the major clinical event (MCE) rate in-hospital and up to 6 months. RESULTS: The frequency increase in Group I was found to be significantly lower compared with Group II (5.1% vs. 21%, respectively; p < 0.007), as was the amount of cTnT release (0.28 0.04 vs. 0.51 0.12 ngr/ml at 12 hours, p < 0.001; 0.28 0.06 vs. 0.51 0.10 ngr/ml at 24 hours, p < 0.0004). No MCE was seen during the in-hospital period in both groups. Furthermore, no significant differences were found between the 2 groups with respect to MCE (12.8% vs. 18.4%, respectively; p > 0.05) at 6 months. The balloon inflation time (BIT) was significantly longer in patients with abnormal cTnT level than in those with normal cTnT level in Group II (120.3 4.7 seconds vs. 118.2 1.3 seconds; p < 0.002) but there wasn t any statistical difference in Group I (32.4 2.1 seconds vs. 30.6 2.4 seconds; p > 0.05). Furthermore, there was not any statistical difference with respect to the number of balloon inflations in patients with normal and abnormal cTnT levels in either group (1.2 0.2 inflations vs. 1.3 0.4 inflations in Group I, p > 0.05; 3.2 0.9 inflations vs. 3.0 1.4 inflations in Group II, p > 0.05). CONCLUSION: This study showed that MMI probably occurs less frequently after direct stenting.
A single coronary artery (SCA) constitutes a rare congenital anomaly. The reported incidence of SCA ranges from 0.2 1.6% of the population undergoing coronary angiography. The congenital absence of the ostium of the right coronary artery (RCA) with the origin of the RCA as a continuation of the distal circumflex artery is an extremely rare variant of the SCA. Its real incidence is unknown. We report a case of a 38-year-old white female with non-obstructive hypertrophic cardiomyopathy associated with SCA, in which the RCA arises as an extension of the circumflex artery.
The aim of this study was to evaluate whether direct stenting is superior to conventional stent implantation technique with respect to QTc dispersion in prospectively selected patients with simple lesion morphology and class II stable angina undergoing elective coronary stenting. One hundred thirty-four consecutive patients were divided into 2 groups based on the stenting technique used: the direct stenting without predilation group, group I (n = 64), and the stenting with predilation group, group II (n = 70). All patients had single-vessel disease. The primary end point of the study was the QTc dispersion at the 24th hour and at the first month after the procedure and the secondary end point of the study was the major clinical events (MCEs) rate in the hospital period and up to 1 month. Baseline maximum QTc, minimum QTc, and QTc dispersion were not different between the 2 groups. QTc dispersion decreased from 47+/-8 msec before stent implantation to 41+/-11 msec at 24 hours and 37+/-7 msec 1 month after angioplasty in group I (p < 0.006 and p < 0.01, respectively), whereas QTc dispersion decreased from 49+/-9 msec before stent implantation to 46+/-8 msec at 24 hours and 42+/-10 msec 1 month after angioplasty in group II (p < 0.03 and p < 0.01, respectively). Compared with group II, the decrease in QTc dispersion was significantly greater at the 24th hour and at the first month after the procedure in group I (p < 0.003 and p < 0.001, respectively). There was a decreased trend toward MCE rate in group I in relation to that of group II, but the statistical difference was not significant. Direct stenting is a feasible and safe technique. It is superior to conventional stenting technique in decreasing the QTc dispersion at the 24th hour and at the first month after the procedure, whereas it is equivalent to single-vessel conventional stent implantation technique with respect to MCEs rate in the short-term period.