Complications of cardiac catheterization versus coronary angiography.
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Cardiac Catheterization↗
Biomedical subjects
G S Reeder
Publications and source records attributed to G S Reeder.
Modern management of acute myocardial infarction.
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Angioplasty↗
Effect of Doppler echocardiography on utilization of hemodynamic cardiac catheterization in the preoperative evaluation of aortic stenosis.
OBJECTIVE: To examine the use of Doppler echocardiography in preoperative assessment of aortic stenosis and to determine its effect on subsequent use of hemodynamic cardiac catheterization. MATERIAL AND METHODS: We retrospectively reviewed a consecutive series of 574 adult patients who underwent aortic valve replacement for aortic stenosis between 1990 and 1992 at our institution. The use of Doppler echocardiography and cardiac catheterization and the predictive factors for use of hemodynamic catheterization were analyzed. RESULTS: After Doppler echocardiography in 423 patients, invasive hemodynamic assessment of the severity of aortic stenosis was performed in only 42% (179 patients). The use of cardiac catheterization declined over time (54% in 1990, 40% in 1991, and 35% in 1992) (P = 0.003), whereas no significant change in the baseline clinical characteristics of the population or in severity of stenosis as determined by Doppler echocardiography occurred during that time. Multivariate analysis identified the following variables as independent predictors of use of cardiac catheterization after Doppler echocardiography: clinically not severe aortic stenosis, mean gradient of less than 50 mm Hg determined by Doppler echocardiography, Doppler-determined aortic valve area of more than 0.8 cm2 or not calculated, attending cardiologist not specialized in echocardiography, and earlier year of assessment. CONCLUSION: After Doppler echocardiography, less than 50% of our patients undergoing aortic valve replacement for aortic stenosis have cardiac catheterization preoperatively. The use of cardiac catheterization after Doppler echocardiography--thus, duplication of hemodynamic assessment--declined significantly over time during the study period. Decline in the use of catheterization is related to the degree of diagnostic certainty provided by Doppler echocardiography and to the level of familiarity of the attending cardiologist with the technique.
Adult↗
Natural history of hypertrophic cardiomyopathy. A population-based study, 1976 through 1990.
BACKGROUND: Hypertrophic cardiomyopathy is a disease entity characterized by marked heterogeneity in morphology and natural history. Most of our knowledge of the natural history of this disorder derives from the study of hospital-based populations and is influenced by referral bias. Therefore, this population-based study was undertaken to examine the natural history of hypertrophic cardiomyopathy among unselected residents of Olmsted County, Minnesota. METHODS AND RESULTS: Patients with hypertrophic cardiomyopathy, confirmed by echocardiography, were identified by use of the resources of the Rochester Epidemiology Project. Patients with the echocardiographic features of hypertrophic cardiomyopathy but with long-standing hypertension requiring drug therapy were categorized as having hypertensive hypertrophic cardiomyopathy. Baseline clinical details and follow-up events were obtained by retrospective chart review. Thirty-seven patients were diagnosed with hypertrophic cardiomyopathy and 24 with hypertensive hypertrophic cardiomyopathy. Eight additional patients were first diagnosed at autopsy. The mean age of the 37 patients with hypertrophic cardiomyopathy was 59 +/- 20 years (range, 1 week to 92 years); the mean ventricular septal thickness was 17.5 +/- 3 mm. Follow-up was obtained for a median of 7.7 years (range, 45 days to 17.2 years). The 1- and 5-year survival rates were 95% and 92%, respectively; these rates did not differ from those of an age- and sex-matched population (P = NS). The annual risk of cardiac death was 0.7%. The mean age of patients with hypertensive hypertrophic cardiomyopathy was 79 +/- 8 years (range, 62 to 91 years), and the mean ventricular septal thickness was 19 +/- 2.5 mm. Follow-up was obtained for a median of 2.8 years (range, 4 days to 16.7 years). The 1- and 5-year survival rates were 75% and 43%, respectively, which differed sharply from the expected rates of 94% and 70% (P = .0028). The annual risk of cardiac death was 5%. Atrial fibrillation and evidence for myocardial infarction on ECG, use of digoxin and diuretics, and a high New York Heart Association functional class at presentation were all associated with decreased survival by multivariate analysis for both groups combined. A history of myocardial infarction, atrial fibrillation, and mitral annual calcification at presentation were associated with cardiac death. CONCLUSIONS: Hypertrophic cardiomyopathy is a more benign disease than previously reported from tertiary referral centers. Patients assessed as having hypertensive hypertrophic cardiomyopathy represent a subset at higher risk for cardiac and noncardiac death, with an overall decreased survival rate.
Adolescent↗
Intracoronary thrombus: still a risk factor for PTCA failure?
Pre-existing intracoronary thrombus has been associated with an increased risk of percutaneous transluminal coronary angioplasty (PTCA) failure. Whether intracoronary thrombus is an independent risk factor for failure is uncertain, as conflicting data exist in the literature. Additionally, given advances in patient selection and angioplasty balloon design, it is uncertain whether the current risk posed by intracoronary thrombus is as substantial as that in the early angioplasty experience. The primary objective of this study was to first assess whether pre-existing coronary thrombus was an independent predictor of angioplasty failure and if so, whether the risk due to thrombus had changed from the early angioplasty experience to the present time. Our prospectively collected angioplasty data base was used to identify individuals undergoing single-vessel angioplasty of a thrombus-containing segment from January 1, 1984 through December 1, 1991. Univariate and multivariate stepwise logistic regression techniques were utilized to analyze clinical, angiographic, and procedural characteristics associated with angioplasty failure. The study period was divided into three separate time periods and these used as variables in our multivariate analysis. In the study population that consisted of 2,699 patients with single-vessel angioplasty, univariate analysis demonstrated that among many factors, thrombus was importantly associated with angioplasty failure (P < 0.0001). A multivariate logistic model of angioplasty failure was developed and thrombus achieved independent predictive significance in this model.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Long-term outcome of patients with biopsy-proved myocarditis: comparison with idiopathic dilated cardiomyopathy.
OBJECTIVES: The study objectives were 1) to assess the long-term outcome of patients with biopsy-proved lymphocytic myocarditis (Dallas criteria), and 2) to compare the outcome of these patients with that of patients with idiopathic dilated cardiomyopathy. BACKGROUND: Endomyocardial biopsy is frequently performed in patients presenting with dilated cardiomyopathy to identify lymphocytic myocarditis. Most previous studies of the natural history of myocarditis were performed before the establishment of the Dallas criteria. Thus, it is important to evaluate the prognostic value of positive endomyocardial biopsy findings in patients presenting with dilated cardiomyopathy, using standardized criteria for lymphocytic myocarditis. METHODS: All endomyocardial biopsy results from the Mayo Clinic (October 1979 to April 1988) with a diagnosis of myocarditis were reclassified according to the Dallas criteria. Patients whose biopsy specimens showed borderline or lymphocytic myocarditis were included in the study group; those with systemic inflammatory diseases known to be associated with myocardial involvement were excluded. Study group survival was compared with that for a cohort of patients with idiopathic dilated cardiomyopathy seen at the Mayo Clinic from 1976 to 1987 who had endomyocardial biopsy findings negative for myocarditis. RESULTS: Biopsy specimens from 41 patients met the Dallas criteria for a diagnosis of myocarditis (n = 28) or borderline myocarditis (n = 13). Of these 41 patients, 9 were excluded because of the presence of systemic diseases known to be associated with myocarditis, and 5 patients were excluded because of lack of available follow-up data. The myocarditis study group therefore included 27 patients (10 with borderline myocarditis, 17 with myocarditis). Fifty-eight patients with a diagnosis of idiopathic dilated cardiomyopathy who underwent endomyocardial biopsy served as the comparison cohort. Ejection fraction was lower in patients with idiopathic dilated cardiomyopathy ([mean +/- SD] 25 +/- 11%) than in those with myocarditis (38 +/- 19%, p = 0.001), even though a higher proportion of myocarditis group patients were in New York Heart Association functional class III or IV (63%) than patients in the dilated cardiomyopathy group (30%, p = 0.005). There was no difference in 5-year survival rate between the myocarditis and idiopathic dilated cardiomyopathy groups (56% vs. 54%, respectively). CONCLUSIONS: This study demonstrates that the long-term outcome of patients with biopsy-proved myocarditis seen in a referral setting is poor, although no different from that of patients with idiopathic dilated cardiomyopathy. With the current lack of proved effective treatment for lymphocytic myocarditis and no demonstration of survival benefit for patients with myocarditis, these data suggest that endomyocardial biopsy performed to exclude myocarditis is of limited prognostic value in the routine evaluation of dilated cardiomyopathy.
Adult↗
Identification and treatment of complications of myocardial infarction.
Mechanical complications of acute myocardial infarction include papillary muscle rupture with severe mitral regurgitation, ventricular septal rupture with acute ventricular septal defect, acute and subacute free-wall rupture, and hemodynamically significant right ventricular infarction. Although such complications are infrequent, their importance is underscored because of the potential ability to correct them with early diagnosis and appropriate treatment. The diagnosis necessitates a high degree of suspicion based on clinical clues and rapid diagnostic testing. Beside two-dimensional echocardiography, sometimes with transesophageal echocardiography, is most commonly used to diagnose or exclude these complications. Patients suspected of having a mechanical complication of myocardial infarction should be urgently transferred to a medical center experienced in the management of these problems. For deteriorating patients without identifiable mechanical complications, coronary angiography and reperfusion with direct angioplasty should be considered.
Heart Diseases↗
Acute myocardial infarction: risk stratification in the thrombolytic era.
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Clinical Trials as Topic↗
Acute myocardial infarction: enhancing the results of reperfusion therapy.
Reperfusion therapy (by either administration of thrombolytic agents or immediate angioplasty) is the mainstay of treatment of acute myocardial infarction, yet it remains underutilized. Additionally, many patients do not experience optimal reperfusion because of suboptimal flow rate in the infarct-related artery, abnormal microvascular flow, and intermittent or complete reocclusion of the infarct-related artery. Strategies to enhance the results of reperfusion therapy include expanding the population of patients considered as candidates, earlier treatment, newer methods to improve infarct-related artery flow rates, and ancillary treatments currently being studied to reduce reperfusion injury, which may be one cause of decreased microvascular flow. Although aspirin, heparin, and warfarin sodium have been the conventionally used agents for inhibiting thrombin and platelet function, newer agents such as hirudin and inhibitors of the platelet glycoprotein IIb-IIIa receptor are becoming available, and their clinical application will increase in the future.
Angioplasty, Balloon, Coronary↗
Adjunctive therapy in the management of patients with acute myocardial infarction.
Adjunctive therapy for acute myocardial infarction should include aspirin, beta-adrenergic blocking agents, and, in most patients, consideration of the use of angiotensin-converting enzyme inhibitors, especially if left ventricular function is reduced. Heparin has an important adjunctive role in enhancing early vessel patency in patients who receive tissue-type plasminogen activator and in decreasing the frequency of reocclusion of an infarct-related artery during any thrombolytic therapy. Heparin must also be administered to all patients who undergo primary angioplasty. Intravenously administered nitroglycerin and orally administered nitrates are probably most effective in patients with symptomatic ischemia. Calcium channel blockers and prophylactic antiarrhythmic agents are not indicated for most patients with acute myocardial infarction. Currently, insufficient evidence is available to recommend the widespread use of intravenously administered magnesium sulfate in the setting of acute myocardial infarction. In patients with ischemic pain, judicious intravenous administration of morphine can provide relief. Use of warfarin sodium should be reserved for patients at risk for left ventricular mural thrombus. Although the use of lipid-lowering agents after myocardial infarction has been controversial, recent studies have demonstrated the importance of such therapy for secondary prevention of death and morbidity.
Acute Disease↗
Angioplasty or thrombolysis for acute infarction?
The benefit of thrombolytic therapy for acute myocardial infarction has been conclusively established by many trials. Direct angioplasty (without thrombolytic therapy) is often utilized urgently for patients with acute infarction based on observational studies. Recently, three randomized trials compared outcomes of patients undergoing thrombolysis versus direct angioplasty. The results of these trials indicate that either strategy, if applied early, can benefit patients with acute infarction. Specific advantages of angioplasty include slightly higher patency and flow rates in the infarct-related artery. However, thrombolysis is more readily available to large segments of the population. Either therapy must be applied early to be effective.
Angioplasty, Balloon, Coronary↗
Coronary perforation after excimer laser coronary angioplasty: the Excimer Laser Coronary Angioplasty Registry experience.
OBJECTIVES: This study assessed the frequency of perforation with excimer coronary angioplasty. BACKGROUND: Coronary artery perforation after conventional percutaneous transluminal coronary angioplasty is extremely rare. Because laser coronary angioplasty involves actual tissue ablation, it has an increased potential for perforation. METHODS: All patients in the Excimer Laser Coronary Angioplasty Registry were included in this prospective study. Those who had a perforation related to the procedure were compared with those who did not have this complication. RESULTS: Of 2,759 consecutive patients in the Excimer Laser Coronary Angioplasty Registry, 36 (1.3%) had perforation. In these patients, the left anterior descending coronary artery was the most frequently treated vessel (53%). There were no differences in fiber sizes between patients with and those without perforation. Among the patients with perforation, 36.1% required coronary artery bypass surgery, 16.7% experienced an infarction and 5.6% had a fatal outcome. Among the patients without perforation, the rates were 3.1%, 3.8% and 0.6%, respectively. However, 41.7% of the patients with documented coronary artery perforation did not need coronary artery bypass surgery or experience myocardial infarction or death. No angiographic characteristics distinguished lesions with from those without perforation. The frequency of coronary artery perforation declined over time with increasing operator experience, from 1.6% in the first 1,888 patients to only 0.4% in the last 1,000 patients (p = 0.002). CONCLUSIONS: With increasing operator experience, the rate of perforation with excimer laser coronary angioplasty has decreased. When perforation occurs, subsequent event rates increase.
Angioplasty, Balloon, Coronary↗
Diagnostic role of Doppler echocardiography in constrictive pericarditis.
OBJECTIVES: This study was conducted to assess the diagnostic role of Doppler echocardiography in constrictive pericarditis. BACKGROUND: It has been observed that patients with constrictive pericarditis have a characteristic Doppler pattern of respiratory variation in ventricular filling and central venous flow velocities. However, the observation was based on a small number of patients with known diagnosis. METHODS: We reviewed the echocardiographic features of 28 patients (21 men and 7 women; mean age +/- SD 55 +/- 15 years) with suspected constrictive pericarditis who underwent exploratory thoracotomy or pericardiectomy. RESULTS: At operation, constrictive pericarditis was diagnosed in 25 patients, restriction in 1 and normal pericardium in 2. Of the 25 patients with constriction, correct preoperative Doppler diagnosis was made in 22 (88%) and Doppler echocardiography showed restriction in 3. In two patients with a normal pericardium, Doppler features were consistent with constriction in one patient and were normal in the other. In the one patient with restriction, Doppler echocardiography showed restriction. In 19 patients with surgically proved constriction, repeat Doppler study after pericardiectomy showed normal findings in 14 and restriction in 5. Twelve of the 14 patients with normalized Doppler findings became asymptomatic, whereas all 5 with restrictive Doppler features remained symptomatic. CONCLUSIONS: Doppler echocardiography performed simultaneously with respiratory recording is highly sensitive for diagnosing constrictive pericarditis, and it appears to predict functional response to pericardiectomy.
Adult↗
Restrictive cardiomyopathy associated with the eosinophilia-myalgia syndrome.
OBJECTIVE: We report the first case of restrictive cardiomyopathy occurring in a patient with the eosinophilia-myalgia syndrome. DESIGN: In this article, we discuss the various clinical manifestations of the eosinophilia-myalgia syndrome. MATERIAL AND METHODS: In a 46-year-old woman with the eosinophilia-myalgia syndrome, orthopnea, chronic persistent edema, and severe dyspnea on exertion developed 2 years after she had discontinued use of L-tryptophan. Doppler echocardiography showed ventricular filling confined to early diastole and no atrial filling during ventricular systole--the Doppler hallmarks of restrictive disease. Right-sided cardiac catheterization revealed that the pulmonary wedge pressure equaled the pulmonary artery diastolic pressure and the mean right atrial pressure. A myocardial biopsy specimen showed dense endocardial fibrosis. Special immunofluorescent stains for eosinophilic granule major basic protein showed substantial deposition along the endocardial myocardial interface, an indication that eosinophils were present some time in the past. RESULTS: A follow-up telephone call 14 months after the patient's initial assessment at the Mayo Clinic revealed that she had class III symptoms of congestive heart failure. She was receiving high doses of three diuretics daily, and her condition had improved considerably since her first examination at our institution. CONCLUSION: Restrictive cardiomyopathy may occur in the setting of the eosinophilia-myalgia syndrome and should be considered in patients with this disease in whom exertional dyspnea and peripheral edema occur.
Cardiomyopathy, Restrictive↗
Thrombolysis in acute myocardial infarction: t-PA for everyone?
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Clinical Trials as Topic↗
Cost comparison of immediate angioplasty versus thrombolysis followed by conservative therapy for acute myocardial infarction: a randomized prospective trial. Mayo Coronary Care Unit and Catheterization Laboratory Groups.
OBJECTIVE: Immediate angioplasty and thrombolysis followed by conservative therapy are treatment strategies for acute myocardial infarction. The objective of this study was to compare the costs of these two strategies during a 12-month period. METHODS: Of 103 patients with acute myocardial infarction who sought medical assistance within 12 hours after onset of symptoms, 4 were excluded from analysis for various reasons, 51 received tissue plasminogen activator, and 48 underwent immediate angioplasty as the initial revascularization strategy. The main outcome determinants were direct monetary costs and indirect measures of costs, including duration of hospital stay and return to work. RESULTS: No significant difference in monetary costs between the two initial treatment strategies could be demonstrated. A trend was noted toward a briefer hospital stay and fewer late in-hospital procedures for patients treated initially with immediate angioplasty. Other measures of indirect costs were not statistically different. CONCLUSION: The hypothesis that thrombolysis followed by conservative therapy would be more cost-effective than immediate angioplasty in the treatment of patients with acute myocardial infarction could not be substantiated. The two strategies seem to have similar cost-effectiveness.
Adult↗
Late outcome after percutaneous transluminal coronary angioplasty during acute myocardial infarction.
Early reperfusion for acute myocardial infarction (AMI) results in improved ventricular function and survival. There is a dearth of data on long-term survival (> 5 years) after percutaneous transluminal coronary angioplasty (PTCA) performed either as a primary procedure or in conjunction with thrombolytic therapy. We studied 160 patients who underwent PTCA during AMI between 1981 and 1987 either with (n = 101) or without (n = 59) streptokinase therapy. Mean time to reperfusion was 4.6 hours, and patency was achieved in 134 patients (84%). Mean discharge ejection fraction was 46 +/- 14%. Coronary artery bypass grafting was performed before dismissal in 34 patients (21%), including 21 of 130 patients (16%) with 1- or 2-vessel disease and 13 of 30 patients (43%) with 3-vessel disease (p < 0.05). Eleven patients (7%) died in the hospital. The 149 hospital survivors were followed for a mean of 69 +/- 21 months (median 72). During follow-up, 22 patients (15%) died, 21 (14%) had reinfarction, 23 (15%) underwent coronary artery bypass grafting, and 21 (14%) underwent repeat PTCA of the infarct-related artery. On univariate analysis, age > or = 62 years, multivessel disease, ejection fraction < or = 40%, previous AMI, and being a nonsmoker at the time of AMI were predictive of late mortality (p < 0.05 each variable). On multivariate analysis, only ejection fraction < or = 40% and prior AMI were predictive of late death. In patients treated with PTCA for AMI, late survival is excellent. Early surgical revascularization of high-risk patients may contribute to these encouraging results.
Adult↗
Predictors of major ischemic complications after coronary dissection following angioplasty.
Coronary dissection is a major cause of abrupt arterial closure after coronary angioplasty but may also be associated with no discernible event. Deciding which dissections should receive further treatment is often a dilemma if the artery remains patent. This case-control study examined predictors of major ischemic complications after coronary dissections. Fifty-eight patients with coronary dissections, but a patent artery at the completion of the angioplasty procedure, subsequently had in-hospital abrupt arterial closure, acute myocardial infarction, emergency coronary bypass surgery, or died; they were matched to 58 control subjects with dissection but no event. Analysis of each angiogram was performed with the examiner unaware of patient's history. Baseline angiographic and clinical characteristics of cases and controls were similar except for an excess of current smokers among the cases (31 vs 16%; p = 0.048). Residual luminal diameter at the dissection site was 1.2 +/- 0.6 mm (cases) versus 1.6 +/- 0.6 mm (controls; p = 0.001) with relative stenosis of 59 +/- 21% vs 43 +/- 21%, respectively (p = 0.0001). Dissections among cases were longer than among controls (11 +/- 7 mm vs 7 +/- 4 mm; p = 0.001). No significant difference was found in dissection morphology using 2 classification schemes or in final Thrombolysis in Myocardial Infarction study flow grade. Transient occlusion during the procedure, however, occurred in 47% of cases versus 5% of controls (p = 0.0001). Transient occlusion, residual percent stenosis > or = 70%, and dissections > or = 6 mm were independently predictive of major ischemic events.
Acute Disease↗