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Richard W Smalling

Publications and source records attributed to Richard W Smalling.

At least 19 recordsLinked to original sources
PubMed2006

Acute coronary syndrome may occur with in-stent restenosis and is associated with adverse outcomes (the PRESTO trial).

Patients with de novo acute coronary syndromes (ACSs) have a higher rate of adverse cardiac events and recurrent revascularization after percutaneous coronary interventions compared with patients who have stable angina. However, it is not known if an ACS presentation in patients with in-stent restenosis (ISR) is associated with a worse prognosis. Using the large PRESTO database of patients with ISR, we compared outcomes after successful percutaneous coronary intervention in 824 patients who presented with ACS with 617 patients who had stable angina. In-hospital and 9-month follow-up for myocardial infarction, target vessel revascularization, death, and a combined outcome of major adverse cardiac events (MACEs) were obtained. Follow-up angiographic results were also compared in those patients included in the angiographic substudy (140 patients with ACS and 99 with stable angina). Patients with ISR who presented with ACS were older and less often men, with higher incidences of diabetes, hypertension, tobacco use, previous coronary artery bypass graft surgery, and congestive heart failure. In-hospital complications were rare and similar in the 2 groups. At follow-up, patients with ACS had higher incidences of target vessel revascularization (33% vs 21%, p <0.001), MACEs (35% vs 22%, p <0.001), and angiographic restenosis (> or =50% narrowing, 56% vs 42%, p = 0.043). In multivariate analysis, after adjusting for baseline differences, an ACS presentation was associated with a higher incidence of long-term MACEs (odds ratio 1.66, 95% confidence interval 1.27 to 2.18, p <0.001). In conclusion, an ACS presentation in patients with ISR is associated with a higher incidence of recurrent adverse cardiovascular events and angiographic restenosis.

Angina Pectoris↗
PubMed2006

Analysis of emboli during carotid stenting with distal protection device.

BACKGROUND: The newly developed multi-frequency transcranial Doppler (TCD) is able to differentiate gaseous from solid emboli. Our goal was to apply this technology to initially characterize emboli detected during carotid stenting with distal protection. METHODS: Patients undergoing carotid angiography and stenting were monitored with 2-2.5 MHz TCD (Embo-Dop, DWL) over the middle cerebral artery unilateral to stent deployment. Sonographers insured optimal signal recordings during the procedures. Automated emboli detection and classification software (MultiXLab version 2.0) was applied for offline count and analysis. Monitoring using the Filter Wire EX (Boston Scientific) and ACCUNET system (Guidant Corporation) was performed. RESULTS: A total of 9,649 embolic signals were detected during 11 angiographic and 10 stenting procedures. An observer confirmed the signals using the International Consensus definition. Automated software classified these events into 5,900 gaseous and 3,749 solid emboli. During contrast injections without the protection device, 1,013 emboli were detected with 28% of these being solid. With deployment of the distal protection device, 8,636 emboli were found with 40% being solid (p < 0.001). During stenting and angioplasty with the protection device, 7,395 emboli with 42% solids were detected (p < 0.001). Finally injection of contrast after the procedure, with the protection device still deployed, yielded 1,241 emboli with 31% solids (NS). Only 1 patient developed transient hemiparesthesia during ballooning that reduced the flow velocity to zero for 14 s. Neither gaseous nor solid emboli resulted in a mean flow velocity decrease or clinical symptoms. CONCLUSIONS: Microembolization frequently occurs during stenting even with deployment of the distal protection device. More solid emboli are seen during manipulations associated with lesion crossing. Although novel TCD methods yield a high frequency of embolic signals, further validation of this technique to determine the true nature, size, and number of emboli is needed.

Aged↗
PubMed2006

Initial report of percutaneous right ventricular assist for right ventricular shock secondary to right ventricular infarction.

A 57-year-old female suffered an acute inferior ST segment elevation myocardial infarction. The patient failed thrombolysis and was urgently transferred for rescue percutaneous coronary intervention of the right coronary artery. She decompensated after reperfusion of the occluded RCA and developed cardiogenic shock from severe right heart failure refractory to IABP support and maximal pressors. A percutaneous right ventricular assist device was successfully implanted, which improved mean arterial pressure to a viable range and allowed withdrawal of inotropic medications. Right ventricular failure after infarction remains difficult to manage and has a high mortality. Intraaortic balloon pump and LVAD support have not proven beneficial in cardiogenic shock secondary to RV infarction. This is a report of the first insertion of a percutaneous right ventricular assist device for right ventricular support in a human. Further evaluation is warranted to evaluate the potential benefits of such a device as well as optimal timing of initiation of RV support.

Blood Pressure↗
PubMed2006

Cardioembolic stroke.

Cardiac sources of emboli account for over one quarter of all ischemic strokes. Strokes due to cardioembolism are in general severe and prone to early and long-term recurrence. Nonvalvular atrial fibrillation remains the most common cause of cardioembolic stroke. Despite the proven efficacy of oral anticoagulation, it is prescribed for less than half of the patients with risk factors for embolism and no contraindications for anticoagulation. The embolic risk of patent foramen ovale is low except when combined with an atrial septal aneurysm. Aortic arch atheroma as an independent risk factor for ischemic stroke is the subject of ongoing debate. As the risk of embolism is heterogeneous for the various potential cardioembolic conditions, accurate definition of stroke mechanism is very important to guide the most effective therapy.

Atrial Fibrillation↗
PubMed2006

Role of fibrinolytic therapy in the current era of ST-segment elevation myocardial infarction management.

In patients presenting with ST-elevation myocardial infarction, early, effective reperfusion of the culprit artery is needed to salvage myocardium, maintain left ventricular function, and reduce mortality. According to American College of Cardiology/American Heart Association guidelines for the treatment of these patients, the time from medical contact (i.e., firm ST-elevation myocardial infarction diagnosis) to initiation of fibrinolytic therapy (door-to-needle time) should be 30 minutes, and the time from medical contact to percutaneous coronary intervention (PCI) (door-to-balloon time) should be 90 minutes. Because many patients present to hospitals that are not equipped to administer PCI, door-to-balloon time often falls far short of the ideal. When PCI is not readily available, efficient prehospital treatment with t-PA-based fibrinolytic agent formulations that can be delivered in a bolus and do not require weight-based adjustment may reduce mortality rates and result in outcomes similar to PCI when administered promptly.

Emergency Medical Services↗
PubMed2005

Mechanical left ventricular unloading prior to reperfusion reduces infarct size in a canine infarction model.

We tested the hypothesis that unloading the left ventricle just prior to reperfusion provides infarct size reduction compared with left ventricular (LV) unloading postreperfusion and reperfusion alone. Twenty-four mongrel dogs were subjected to 2 hr of left anterior descending artery occlusion and 4 hr of reperfusion. A transvalvular (TV) left ventricular assist device (LVAD) was inserted just prior to reperfusion and maintained during the rest of the experiment (LV Assist Pre group). In the LV Assist Post group, the TV LVAD was inserted and activated just after reperfusion. A control group was subjected to reperfusion alone with a sham-TV LVAD. At baseline, the hemodynamic data were similar in the three groups. Myocardial infarct size expressed as percentage of area at risk was significantly reduced in the LV Assist Pre group compared to the control group (P = 0.011) and to the LV Assist Post group (P < 0.05). At 4 hr of reperfusion, transmural myocardial blood flow in the ischemic zone was slightly higher in the animals unloaded prior to reperfusion compared to controls and significantly higher than in the LV Assist Post group (P = 0.04). Postreperfusion end-diastolic wall thickness returned to baseline level in the TV LV Assist Pre group compared to both controls and TV LV Assist Post group. In these latter two groups, a significant increase in postreperfusion end-diastolic wall thickness and contraction band necrosis in the central ischemic zone correlated well with the degree of reperfusion injury. LV unloading prior to, but not after, reperfusion reduces the extent of myocardial necrosis in canine hearts subjected to 2 hr of left anterior descending artery occlusion and 4 hr of reperfusion compared to either reperfusion alone or LV unloading after reperfusion.

Analysis of Variance↗
PubMed2005

Superiority of endovascular grafts compared to bare metal stents with transstent coil embolization for endovascular abdominal aortic aneurysm repair in patients at high risk for surgery.

We sought to determine the effectiveness of uncovered stents with aneurysm transstent coil embolization compared with endografts for percutaneous abdominal aortic aneurysm (AAA) repair. Thirty-six patients with AAA considered inoperable underwent endovascular repair using the Ancure bifurcated endograft or overlapping uncovered stents with transstent coil embolization. Procedural success, outcomes, serial aneurysm size, aneurysm blood flow, and growth ratios were compared between groups. One patient in each group died due to the procedure and two patients in the endograft cohort required acute surgical repair. After 2.0 +/- 0.8 years of follow-up, three patients required endograft placement, four surgical repair, three had AAA rupture, with two AAA-related deaths in the uncovered stent group. No late deaths or surgical conversion occurred in the endograft group. The primary AAA flow exclusion and aneurysm expansion rate and growth were superior in the endograft group and during follow-up. In high-risk patients with AAA, the use of endografts was superior compared to uncovered stents with transstent coil embolization for endovascular repair.

Aged↗
PubMed2005

Endovascular repair of abdominal aneurysms: Is this the method of choice?

BACKGROUND: The prevalence of abdominal aneurysms has increased due to the aging population, and endovascular repair has developed into an effective, less invasive treatment. METHODS/RESULTS: Two recent cases at the University of Texas-Houston highlight a variety of clinical considerations that allow informed decision-making regarding optimal treatment of abdominal aneurysms. A thorough discussion of recent data summarizes the current understanding and techniques regarding abdominal aortic aneurysm repair. CONCLUSIONS: Endovascular repair of abdominal aortic aneurysms has emerged as a viable and a safe alternative to surgical repair and may offer important advantages in a majority of patients with this disease.

Aged↗
PubMed2005

Risk of bleeding complications is not increased in patients undergoing rescue versus primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: Concern for major bleeding complications (MBC) may lead to withholding of anticoagulation and fibrinolytic therapy in preparation for primary percutaneous coronary intervention (PCI), potentially resulting in unacceptable delays in achieving reperfusion. OBJECTIVES: The primary objective of this study was to evaluate MBC associated with primary and rescue PCI and how timing to revascularization affects this variable. METHODS: We evaluated 659 consecutive patients presenting within 24 hours of an acute ST elevation myocardial infarctions (MI). One hundred and eighty-three patients presented for rescue PCI and 476 for primary PCI. Eighty-seven rescue PCI patients were treated within 6 hours of their first dose of fibrinolytic. Demographics, procedural variables, outcomes, and major adverse cardiovascular events (MACE) were compared between the primary and rescue PCI groups and between early and late presenters in the rescue PCI group. RESULTS: We observed that the incidence of MBC was 8% in patients undergoing rescue PCI and 6% in primary PCI (P=0.35). There were no significant differences in bleeding associated with GP IIb/IIIa receptor antagonist use, procedural success, or MACE. Similarly, in patients presenting for early or late rescue PCI there was no significant difference in MBC, procedural success, or MACE. CONCLUSIONS: We concluded that early or late rescue PCI and primary PCI have similar rates of MBC and overall in-hospital outcomes for patients presenting within 24 hours of acute MI. Delaying the timing of a rapid reperfusion strategy in an effort to decrease the incidence of MBC complications is generally not justified.

Adult↗
PubMed2005

The use of brachytherapy to treat renal artery in-stent restenosis.

The percutaneous treatment of renal artery stenosis has become the accepted revascularization strategy by most physicians treating this disorder. Unfortunately, as renal artery angioplasty and stent implantation become increasingly prevalent the Achilles heel of angioplasty, in-stent restenosis, also rises. There are currently no data suggestive of the optimal treatment strategy for renal artery in-stent restenosis. However, given the similarities in the pathophysiology between renal artery and coronary artery in-stent restenosis, brachytherapy is considered a reasonable option. This is the strategy that has been suggested and used by a number of operators. This case report describes two examples of renal artery in-stent restenosis treated with angioplasty and brachytherapy.

Aged↗
PubMed2004

Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect.

Transcatheter closure of interatrial septal defects is guided by transesophageal echocardiography (TEE), which requires general anesthesia in most cases. Using a new intracardiac echocardiographic (ICE) catheter may avoid endotracheal and esophageal intubation while using only local anesthesia. Forty-two patients underwent transcatheter interatrial septal defect closure; half of them underwent TEE guidance with general anesthesia and the other half underwent ICE guidance with local anesthesia. Device deployment success rate, adequate 2-dimensional and Doppler visualization of the defect and deployment steps, interatrial communication closure at 24 hours, and at 3 and 6 months, procedure time length, complications, fluoroscopic time, and length of hospitalization were compared between both methods. All interventions were completed successfully with no complications, except for 1 patient in the TEE group who had a minor oral trauma. Echocardiographic visualization of the septal defect and deployment was adequate by both methods. Catheterization laboratory time (92 +/- 18 vs 50 +/- 12 minutes, p <0.001) and interventional procedure length (47 +/- 8 vs 35 +/- 6 minutes, p <0.001) were shortened using ICE. There was no difference in the rate of closure after 6-month follow-up by either method. ICE guidance offers equivalent echocardiographic views compared with TEE and similar rates of closure. ICE is associated with decreased procedure length while eliminating the risks of endotracheal or esophageal intubation and general anesthesia.

Balloon Occlusion↗
PubMed2004

Renal artery compromise treated percutaneously in a patient with chronic aortic dissection: a case report.

Organ malperfusion most commonly occurs in the acute stage of aortic dissection and is associated with a high mortality, but can occur with chronic dissection. We describe a case of a type 3 aortic dissection, which had a stenosed left renal artery originating from the false lumen and causing resistant hypertension. The left renal artery was successfully dilated and stented, with prompt resolution of the patient's hypertension.

Aortic Dissection↗
PubMed2004

Interatrial defect sizing by intracardiac and transesophageal echocardiography compared with fluoroscopic measurements in patients undergoing percutaneous transcatheter closure.

The purpose of this study was to evaluate prospectively the feasibility and accuracy of using echocardiographic measurements by transesophageal and intracardiac echocardiography (TEE and ICE, respectively) for interatrial septal defect sizing during percutaneous transcatheter closure. Forty-two patients underwent balloon sizing of interatrial septal defects using TEE in 21 of them and ICE in the other half. These measurements were correlated with quantitative fluoroscopic analysis and evaluated for bias and agreement between methods using a Bland-Altman analysis. Echocardiographic measurements were obtained by ICE and TEE in all patients. An excellent correlation was found between TEE and quantitative fluoroscopy (r = 0.898; P < 0.001) and between ICE and quantitative fluoroscopy (r = 0.876; P < 0.001), with a significant agreement (P < 0.001) and minimal positive bias toward the echocardiographic measurements. Both TEE and ICE are excellent methods of interatrial defect sizing when compared with quantitative fluoroscopic measurements.

Angioplasty, Balloon, Coronary↗
PubMed2004

Vascular access site complications with the use of closure devices in patients treated with platelet glycoprotein IIb/IIIa inhibitors during rescue angioplasty.

The objective of this study was to evaluate the effectiveness of two different closure devices in patients undergoing rescue percutaneous coronary intervention (PCI) using IIb/IIIa inhibitors and to compare it with patients undergoing elective PCI. One hundred sixty-two patients undergoing rescue PCI treated with IIb/IIIa inhibitors underwent vascular access site closure (6 Fr Perclose, n = 92, or 6 Fr Angioseal, n = 70). Vascular complications were compared with a sex- and age-matched group (n = 100) of patients undergoing manual compression after sheath removal and a similar group of patients undergoing elective PCI (n = 196). The incidence of access site complications was not significantly different between the three groups undergoing rescue PCI and was not higher than in patient receiving GP IIb/IIIa inhibitors without fibrinolysis (RR = 0.95; 95% CI = 0.88-1.01). In patients undergoing rescue PCI and receiving IIb/IIIa inhibitors, closure devices allow early sheath removal and are associated with similar outcomes compared with manual compression and elective PCI regardless of the type of closure device used.

Aged↗