"Rescue" thrombolysis with intracoronary tissue plasminogen activator for failed intravenous thrombolysis with streptokinase for acute myocardial infarction.
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Female↗
Biomedical subjects
J A Ormiston
Publications and source records attributed to J A Ormiston.
Simultaneous inflation of tandem (sequential) angioplasty balloons: a means of simultaneously treating multiple lesions in one coronary artery.
We report a novel approach to dilating multiple lesions in a coronary artery. Through the same guide and over different wires, a 3.5 mm diameter, 20 mm length, and a 3.0 mm diameter, 90 mm length balloon were simultaneously inflated in a right coronary artery. This approach, which simultaneously treats sequential (tandem) lesions of different diameter and length, allows reduction of both the total duration of ischemia and procedural time and may improve early angiographic outcome.
Angina Pectoris↗
Frequent reocclusion of patent infarct-related arteries between 4 weeks and 1 year: effects of antiplatelet therapy.
OBJECTIVES: This study assessed the effect of the combination of aspirin and dipyridamole on patency of the infarct-related artery between 4 weeks and 1 year after myocardial infarction. BACKGROUND: Patency of the infarct-related artery is an important determinant of prognosis after myocardial infarction. The incidence of late reocclusion and the effects of antiplatelet therapy are unknown. METHODS: To investigate the importance of antiplatelet therapy for the prevention of late reocclusion, 215 patients who had a patent infarct-related artery 4 weeks after myocardial infarction were randomized in a double-blind manner to receive either a combination of 25 mg of aspirin and 200 mg of dipyridamole twice daily or placebo. One hundred fifty-four patients underwent further coronary arteriography 1 year later. RESULTS: At 1 year, 38 (25%) of 154 patients had reocclusion of the infarct-related artery; 18 (23%) of 79 patients receiving aspirin and dipyridamole had late reocclusion versus 20 (27%) of 75 who received placebo (p = NS). The rate of reocclusion was related to the severity of the residual coronary artery stenosis at 4 weeks (< 50% stenosis 9.2%; 50% to 69% stenosis 11.6%; 70% to 89% stenosis 30.4%; > or = 90% stenosis 70%, p < 0.01). The majority of reocclusions were silent, and only 17 (45%) of 38 were clinically associated with further infarction. There were no differences for a hierarchic end point of cardiac death, myocardial infarction or revascularization (14.8% aspirin and dipyridamole vs. 17.8% placebo). CONCLUSIONS: Late reocclusion of the patent infarct-related artery is a frequent event, occurring in 25% of patients. Antiplatelet therapy with the combination of aspirin and dipyridamole does not alter the overall rate of late reocclusion. Other strategies are required to reduce late reocclusion.
Aspirin↗
Directional coronary atherectomy in lesions unfavourable for balloon angioplasty: initial Green Lane and Mercy Hospitals experience.
AIMS: directional coronary atherectomy is a new percutaneous interventional technique in which coronary arterial stenotic material is shaved off to alleviate stenosis. This study presents the initial outcome of coronary atherectomy at Green Lane and Mercy hospitals where the major indications for atherectomy are lesions with angiographic appearances unfavourable for balloon angioplasty or where balloon angioplasty had been unsuccessful. METHODS: data on patients undergoing coronary atherectomy between February 1990 and December 1991 were analysed. No patient or procedure was excluded. RESULTS: for the first 28 lesions in 25 patients, procedural success, improvement in lumen diameter to less than 50% diameter loss stenosis, but freedom from myocardial infarction, death or emergency bypass surgery, was achieved in 27 of 28 lesions. In one patient there was acute thrombotic coronary arterial closure treated successfully by balloon angioplasty. Another patient developed an asymptomatic fistulous connection with an adjacent coronary vein which resolved spontaneously. CONCLUSIONS: although technically more difficult than balloon angioplasty, directional coronary atherectomy can be carried out in selected patients with a high initial success rate and low complication rate. The technique has allowed percutaneous treatment of a number of selected patients unsuitable for balloon angioplasty, and has turned an unsuccessful angioplasty into an initial procedural success in others.
Adult↗
Doppler echocardiography in the assessment of the homograft aortic valve.
To determine the utility of Doppler echocardiography in the evaluation of the homograft valve in the aortic position, 27 patients with normally functioning valves (group 1) and 30 patients with suspected malfunctioning valves (group 2) were examined. Simultaneous cardiac catheterization and Doppler echocardiography were performed in 23 group 2 patients. Doppler and surgical findings were compared in 7 patients too ill for invasive studies. In group 1 patients, the maximal velocity (+/- standard deviation) was 1.8 +/- 0.37 m/s, the mean pressure gradient was 7.1 +/- 3.07 mm Hg and the mean aortic valve area was 2.2 +/- 0.79 cm2. The maximal velocity in group 2 patients with aortic regurgitation (AR) classified as moderate or greater was 2.5 +/- 0.55 m/s, compared with 1.8 +/- 0.44 m/s in patients with mild AR or less (p less than 0.01). In the quantitation of AR, pulsed-wave mapping and angiographic grades were identical in 18 patients and differed by 1 grade in 5. Seven patients too ill for catheterization had severe destruction of valve leaflets at cardiac surgery. In 6 patients, both Doppler grading methods suggested severe AR. In a seventh patient, who had an obstructed Starr-Edwards valve in the mitral position, AR was graded as mild by pulsed-wave mapping. Only 1 patient had homograft valve stenosis, with a withdrawal gradient at catheterization of 34 mm Hg and a Doppler maximal gradient of 36 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Effect of intravenous streptokinase as compared with that of tissue plasminogen activator on left ventricular function after first myocardial infarction.
In a double-blind trial comparing two thrombolytic agents as treatment for acute myocardial infarction, we randomized 270 consecutive patients an average (+/- SD) of 2.5 +/- 0.6 hours after the onset of chest pain from a first myocardial infarction--135 to receive intravenous streptokinase (1.5 million units over 30 minutes) and 135 to receive intravenous recombinant tissue plasminogen activator (rt-PA) (100 mg over three hours). The primary end point was left ventricular function as assessed by cineangiography performed three weeks after infarction. The effects of the two agents on left ventricular function were similar. The ejection fraction was identical (58 +/- 12 percent) in both groups. The end-systolic volume was 61 +/- 29 ml in the streptokinase group and 66 +/- 31 ml in the rt-PA group (P not significant). Patency rates at three weeks for the infarct-related artery were also similar (75 percent in the streptokinase group and 76 percent in the rt-PA group). Reinfarction rates at 30 days were the same (5 percent) in both groups. One patient had a fatal intracerebral hemorrhage 13 hours after receiving rt-PA, and another had a fatal cerebellar hemorrhage 21 hours after receiving rt-PA for reinfarction nine days after treatment with streptokinase. An intention-to-treat analysis revealed that mortality at 30 days was 3.7 percent in the rt-PA group as compared with 7.4 percent in the streptokinase group (P greater than 0.2). Follow-up for a mean of 9.0 months revealed no significant difference in survival; we observed 12 deaths (8.9 percent) in the streptokinase group and 8 deaths (5.9 percent) in the rt-PA group (P = 0.34). We conclude that rt-PA and streptokinase, in the doses given, have similar effects on left ventricular function after a first myocardial infarction. Because of the small number of deaths, it is not possible to determine whether their effects on mortality are similar.
Double-Blind Method↗
Clinical evaluation versus Doppler echocardiography in the quantitative assessment of valvular heart disease.
We tested the hypotheses that Doppler echocardiography has a higher accuracy than clinical evaluation in the detection of significant aortic and mitral valvular heart disease and that Doppler echocardiography is highly accurate as compared with cardiac catheterization for the assessment of valvular disease severity. Thus, cardiac catheterization for the assessment of valve lesion severity may be unnecessary in selected patients. We prospectively evaluated 75 consecutive patients, ages 20-74 years (mean, 52 years), with clinically suspected valvular heart disease. Specific clinical and Doppler echocardiographic criteria were used to categorize each valve lesion as absent, insignificant, or significant. Criteria for a significant lesion at cardiac catheterization was an aortic or mitral valve area less than 1.1 or 1.5 cm2, respectively, or equal to or greater than 3+ cm2 aortic or mitral regurgitation at angiography. In all valve lesions, Doppler echocardiography had a higher overall accuracy than clinical evaluation. Increases in accuracies of 28%, 19%, 15%, and 7% occurred for mitral stenosis, aortic stenosis, aortic regurgitation, and mitral regurgitation, respectively, resulting in overall accuracies of 97%, 100%, 95%, and 96%. Clinical evaluation alone made 28 errors (37% of patients and 19% of valve lesions assessed), and 17 of these errors (23% of patients and 12% of valve lesions) would have resulted in inappropriate management. In only four (24%) of these 17 patients, the attending cardiologist would not have proceeded to assess the valve at cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Effect of intravenous streptokinase on left ventricular function and early survival after acute myocardial infarction.
In a double-blind trial of streptokinase for acute myocardial infarction, 219 consecutive patients presenting with infarction within four hours (mean, 3.0 +/- 0.8) of the onset of chest pain were randomly assigned to treatment with streptokinase (1.5 million units) or placebo, given intravenously over 30 minutes. The primary end point of the study was left ventricular function in patients with first infarctions. Patients who could undergo beta-blockade also received intravenous propranolol. Heparin (for 48 hours) and a combination of low-dose aspirin and dipyridamole were administered to both groups until cineangiography was performed at three weeks. In the patients with first infarctions treated with streptokinase, the left ventricular ejection fraction was 6 percentage points higher (streptokinase vs. placebo, 59 +/- 10.5 vs. 53 +/- 13.5 percent; P less than 0.005), with benefit to patients with either anterior infarction (57 +/- 11.9 vs. 49 +/- 15.9 percent; P less than 0.05) or inferior infarction (60 +/- 9.1 vs. 55 +/- 11.3 percent; P less than 0.05). Left ventricular function was improved regardless of whether concomitant propranolol was given. Survival (at 30 days) was improved with streptokinase: 2 deaths occurred among 79 patients who received this drug, as compared with 12 deaths among 93 patients who received placebo (2.5 vs. 12.9 percent, P = 0.012). Rates of reinfarction (streptokinase vs. placebo, 3 vs. 1 percent) and requirements for surgery or angioplasty (7 vs. 5 percent) were similar in the two groups. We conclude that administration of intravenous streptokinase (1.5 million units) to patients with a first myocardial infarction results in improved left ventricular function and short-term survival.
Adrenergic beta-Antagonists↗
Echocardiographic evaluation of normal and prolapsed tricuspid valve leaflets.
The tricuspid valve was examined by 2-dimensional (2-D) echocardiography in 14 patients with tricuspid valve prolapse (TVP) and in 16 normal subjects. Individual leaflets were identified anatomically and for frequency of prolapse. Maximal and minimal anular sizes were measured. Multiple tomograms of the tricuspid anulus were recorded at 30 degrees intervals around the tricuspid anulus with the transducer placed at the right ventricular apex. Anuli were reconstructed from the 6 planes and corrected for body surface area. Three leaflets of the tricuspid valve could be anatomically identified in all patients. Prolapse of all 3 leaflets was observed in 6 patients, 2 leaflets in 5 and 1 in 3. Frequency of individual leaflet prolapse was 93% for the septal cusp, 86% for the anterior and 43% for the posterior. Maximal anular circumference and area in TVP were 7.9 +/- 0.6 and 8.9 +/- 1.3 cm2/m2, respectively--significantly larger than values in normal subjects (6.4 +/- 0.5 cm/m2 and 6.1 +/- 0.9 cm2/m2, respectively) (p less than 0.001). Percent reductions in circumference and area in TVP were 14 +/- 3 and 25 +/- 5%, respectively--significantly smaller values than in normal subjects (19 +/- 4 and 33 +/- 4%, respectively). Tricuspid regurgitation (TR) was detected by contrast echocardiography in 7 of 14 patients with TVP. The severity of TR appeared to be minimal in 6 of the 7 patients, and was not associated with an increase in anular size. Thus, TVP is associated with anular dilatation irrespective of associated TR, probably as a primary pathologic characteristic.
Adult↗
The correlates of an abnormal first heart sound in mitral-valve-prolapse syndromes.
In 52 patients with mitral-valve prolapse we studied the intensity of the first heart sound (S1) in relation to the timing of the prolapse and to the presence of leaflet tip coaptation. Sixteen normal subjects served as controls. With two-dimensional echocardiography, three distinct groups were identified. Sixteen patients had early systolic mitral prolapse coincident with initial mitral-leaflet coaptation at the S wave on electrocardiography. Twenty-one had middle to late systolic mitral prolapse. Fifteen had flail mitral leaflet without normal leaflet coaptation at the free margins. The intensity of S1 was expressed as the ratio of the S1 amplitude to that of the aortic component of the second heart sound. This ratio was greater in the patients with early prolapse (6.2 +/- 3.1, mean +/- S.D.) than in the controls (1.4 +/- 0.7) (P less than 0.01). The ratio was reduced in patients with flail valves (0.3 +/- 0.5) (P less than 0.01) and did not differ between patients with middle to late prolapse (1.3 +/- 0.6) and controls. We conclude that the amplitude of S1 may provide a clue to the type and timing of mitral-valve prolapse.
Adolescent↗
Patterns of exercise response in patients with severe left ventricular dysfunction: radionuclide ejection fraction and hemodynamic cardiac performance evaluations.
To evaluate the exercise response of the severely diseased left ventricle, 13 patients with chronic congestive cardiomyopathy with mean resting ejection fraction (EF) of 18.8 +/- 9.6% underwent maximal supine bicycle exercise with hemodynamic and radionuclide monitoring. Two patterns of exercise response were noted. Group I (n = 7) was characterized by significant (p less than 0.001) increases in stroke work index (SWI) (+52%), stroke volume index (SVI) (+34%), mean arterial pressure (AP) (+23%), and cardiac index (CI) (+119%) and by a decrease in systemic vascular resistance (SVR) (-45% p less than 0.001). In group II (n = 6) there were no significant changes in SWI (-15%), AP (+11%), and SVR (-17%)(; SVI decreased significantly (-14%, p less than 0.05), and the increase in CI, although significant (+27%, p less than 0.01), did not achieve the level of Group I. EF did not change with exercise in either group. There were no significant differences at rest in any of the above variables, and the pulmonary capillary wedge pressures at maximal exercise were similar. We conclude that there are two patterns of exercise response in patients with severe congestive heart failure (CHF) and that these patterns may have important therapeutic and prognostic implications.
Adult↗
Assessment of tricuspid regurgitation by directional analysis of right atrial systolic linear reflux echoes with contrast M-mode echocardiography.
Twenty-seven individuals were studied for diagnostic assessment of tricuspid regurgitation (TR) using directional analysis of echo contrast lines on M-mode echocardiograms (MME). Group I consisted of 12 patients with physical findings, as well as phonocardiogram and jugular venous pulse tracings, compatible with TR. Group II consisted of five normal volunteers and 10 control patients without any evidence of congestive heart failure or TR. Following peripheral venous injection of contrast material, all 12 patients in group I demonstrated linear reflux contrast echoes in the right atrium (RA) on MME consisting of multiple posteriorly directed echo lines throughout systole behind the tricuspid valve. In addition, linear reflux contrast echoes in the hepatic vein directed away from its entry into the inferior vena cava were noted in 8 of the 12 patients by a cursor-placed MME. The remaining 15 patients in group II showed none of the above findings on contrast echocardiography. These observations indicate that linear systolic reflux contrast echoes in the RA behind the tricuspid valve on MME may be a specific and sensitive sign of TR.
Diastole↗
Improvement in supine bicycle exercise performance in refractory congestive heart failure after isosorbide dinitrate: radionuclide and hemodynamic evaluation of acute effects.
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Aged↗
Size and motion of the mitral valve annulus in man. II. Abnormalities in mitral valve prolapse.
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Adult↗
The tricuspid valve annulus: study of size and motion in normal subjects and in patients with tricuspid regurgitation.
The tricuspid valve leaflets and their annular attachments were recorded by two-dimensional echocardiography from a view of the right ventricular inflow tract obtained by placing the transducer at an intermediate position between the left ventricular apex and the left lower sternal border. The transducer was rotated, and recordings were made at 30 degrees rotational intervals around the circumference of the tricuspid valve annulus. The cyclical pattern of variations in tricuspid annular size was studied with 12 measurements made during the cardiac cycle in five normal subjects. Annular areas and circumferences were measured. The overall motion pattern was similar to that reported in normal mitral valve annular study. Subsequently, in 16 normal subjects and 18 patients with tricuspid regurgitation, the maximum and minimum tricuspid annular sizes and their percent reduction were measured. The mean maximum annular circumference and area were 11.9 +/- 0.9 cm (mean +/- SD) and 11.3 +/- 1.8 cm2 in normal subjects. They were significantly greater in tricuspid regurgitation (14.0 +/- 0.7 cm and 15.8 +/- 1.8 cm2, respectively). The mean minimum annular sizes were much larger in tricuspid regurgitation (12.5 +/- 0.6 cm and 13.0 +/- 1.4 cm2) than in normal subjects (9.6 +/- 0.9 cm, 7.6 +/- 1.4 cm2). Thus, the percent reduction of annular circumference and area were significantly decreased in tricuspid regurgitation. For anatomic correlations, measurements of the tricuspid annular circumference were made at autopsy in 18 hearts without underlying valvular disease. The annular circumference was measured in the fresh and fixed states. The measurement in the fresh state was 13.5 +/- 0.8 cm and in the fixed state was 12.0 +/- 0.8 cm. The values measured in the fixed hearts were more similar to measurements obtained by echocardiography in a group of normal subjects. Thus, tricuspid annular reconstruction by the new two-dimensional echocardiographic method provides additional information about normal and abnormal size and function of the tricuspid valve annulus.
Adult↗
Infective endocarditis: a lethal disease.
One-hundred-and-eighty-nine episodes of infective Endocarditis were seen in 177 patients in the Green Lane Cardiology Unit over a 18-year period. Hospital survival was 79% and 13-year actuarial survival was 47%. A number of factors including the underlying cardiac lesion, infecting organism, clinical features and surgical intervention were related to outcome. No patient with extreme heart failure survived without operation. Hospital survival in patients with severe heart failure was 69% (9/13 patients) where surgery was carried out before completion of antibiotic treatment, and 40% (6/15 patients) where the antibiotic course was completed. Survival was 53% in patients who still had a fever after one week of antibiotic treatment and 96% if the temperature was normal. In 61% of patients with a fever at one week, extended infected pannus was present compared with 6--10% where the temperature was normal. In patients undergoing operation before completion of antibiotics, the surgical mortality was higher but neither the incidence of recurrence of endocarditis nor the need for re-operation was increased. We believe that better results will be achieved with a policy of surgical intervention when signs of infection and heart failure have not settled within one week of treatment.
Actuarial Analysis↗
Size and motion of the mitral valve annulus in man. I. A two-dimensional echocardiographic method and findings in normal subjects.
Using wide-angle, phased-array, two-dimensional echocardiography, mitral leaflets and their annular attachments were recorded from a view close to the standard apical four-chamber view. The transducer was rotated and recordings were made at 30 degrees rotational intervals around the circumference of the mitral valve annulus. To reconstruct the annulus, the diameters (chords) from each rotational interval were arranged around a reference point. This was done for 12 times during the cardiac cycle. Annular areas were planimetered and circumferences measured. Correlation was good for areas reconstructed and measured by the same observer on separate occasions (r = 0.963) and by two different observers (r = 0.987). In 11 normal subjects the annular area index (area divided by body surface area) increased during diastole to a maximum of 3.8 +/- 0.7 cm2/m2 (mean +/- SD) in late diastole. There was presystolic followed by systolic narrowing to a minimum in midsystole. The mean reduction in area was 26 +/- 3%. The maximal annular circumference was 9.3 +/- 0.9 cm and the mean reduction in circumference was 13 +/- 3%. The overall motion pattern was similar to that reported in experimental studies in the dog. Mitral annular reconstruction may provide new information about normal and abnormal function of the mitral valve apparatus.
Diastole↗