- Email: [email protected]
Doppler estimation of left ventricular filling pressures in patients with hypertrophic cardiomyopathy
LITERATURE REVIEW complications (TEC). In this prospective, multicenter trial, 82 patients with HIT were treated with one of four recombinant hirudin (r-hirudin) regimens, and the effects of r-hirudin on activated partial thromboplastin time (aPTT) and platelet recovery were determined and compared with historical controls. Major complications such as death, TEC, and limb amputation were also recorded. Eleven patients were excluded for not meeting the appropriate inclusion criteria. Study patients showed an enhancement of aPTT and an increase in platelet count compared with historical controls. These results imply that adequate anticoagulation and platelet recovery were present. Implication: r-Hirudin is a potent thrombin inhibitor that may be beneficial to patients with HIT who require anticoagulation. CORONARY ARTERY DISEASE
Takeuchi M, Himeno E: Does coronary stenting following balloon angioplasty improve myocardial flow reserve? Cardiovasc Intervent Radiol 21:459463, 1998 Clinical improvement of coronary artery blood flow does not always occur with successful angioplasty. Myocardial fractional flow reserve (FFRmyo) is the ratio of maximal hyperemic flow in the stenotic artery to the theoretical maximal hyperemic flow in the same artery (FFRmyo = Pd/Pa). The purpose of this study was to determine if FFRmyo would improve more with coronary stenting than with angioplasty alone in the same patient group. Eleven consecutive patients (10 men, 1 woman; mean age, 60 years; range, 36 to 76 years) scheduled for an elective coronary stenting procedure were evaluated. Measurements of FFRmyo were performed at baseline, after angioplasty, and after stent placement. FFRmyo after coronary stem placement (0.85 + 0.09) was significantly greater than at baseline (0.51 -+ 0.16; p < 0.001) and balloon angioplasty (0.77 _+ 0.11; p < 0.05). Implication: Stent placement may be used to maximize coronary blood flow after angioplasty.
Kosuga K, Tamai H, Ueda K, et ah Initial and long-term results of angioplasty in unprotected left main coronary artery. Am J Cardiol 83:32-37, 1999 Balloon angioplasty of unprotected left main coronary artery (LMCA) disease remains controversial because short- and long-term mortality remain high. With improvement in teclmiques, including coronary stents, the results of 175 procedures in unprotected LMCA disease in 107 patients were evaluated. Compared with elective procedures, patients presenting with acute myocardial infarction and those presenting emergently had a greater in-hospital mortality rate (3.6% v 35.7% and 40.0%, respectively). The 5-year survival of the elective group was also greater than the other groups. Moreover, repeat LMCA angioplasty had an overall mortality rate of 8.8%; 38.5% in acute and emergent procedmes and 1.8% in elective procedures. Implication: Elective angioplasty of unprotected LMCA may be efficacious in a select group of patients with closely scheduled angiographic folIow-up.
Jeremias A, Kutseher S, Haude M, et ah Nonischemic chest pain induced by coronary interventions: A prospective study comparing coronary angioplasty and stent implantation. Circulation 98:2656-2658, 1998 Chest pain after a percutaneous intracoronary procedure may be caused by abrupt vessel closure, coronary artery vasoconstriction,
503
peripheral embolization, or simply local trauma (stretch pain). Differentiating among these entities is crucial because ischemia and infarction may occur from the former two causes. This group performed a prospective study evaluating chest pain in patients after stent implantation, angioplasty, or diagnostic coronary angiography. Forty-one percent of the patients developed chest pain after stenting compared with only 9% to 12% of the patients undergoing angioplasty or angiography. Vessel diameter was significantly larger in the stent group compared with the angioplasty group (3.14 _+ 0.75 v 1.95 _+ 0.67 mm, respectively). In the group of patients who developed chest pain, only three developed elevations in creatine kinase enzyme levels and none had electrocardiogram changes or required repeat angiography. Implication: Nonischemic chest pain occurs frequently after coronary stent procedures and appears related to expansion of the diseased vessel.
ECHOCARDIOGRAPHY
Nagueh SF, Lakkis NM, Middleton K J, et ah Doppler estimation of left ventricular filling pressures in patients with hypertrophic cardiomyopathy. Circulation 99:254-261, 1999 Doppler estimates of left ventricular filling pressures are difficult to elicit in states of diastolic noncompliance. Echocardiographic parameters were evaluated in 35 patients with hypertrophic cardiomyopathy admitted for septat reduction therapy. Measured indices included isovolumic relaxation time, pulmonary venous flows, flow propagation velocity (color M-mode), transmittal velocity, and tissue Doppler early diastolic mitral annular velocity (Ea). The equations derived were then tested in a test population of 19 patients. Excellent correlations with filling pressures were obtained in the study group and test group. Test group correlation with filling pressures using E velocity/flow propagation velocity was r = 0.76 and E velocity/Ea was r = 0.82. Implication: Conventional mitral inflow velocities corrected for the effects of reduced left ventricular relaxation can provide a sensitive and specific measure of left ventricular filling pressures in patients with hypertrophic cardiomyopathy.
Cerisano G, Bolognese L, Carrabba N, et ah Doppler-derived mitral deceleration time. An early strong predictor of left ventricular remodeling after reperfused anterior acute myocardial infarction. Circulation 99:230-236, 1999 A short mitral valve deceleration time has been shown to predict adverse outcome after myocardial infarction. Patients successfully reperfused with angioplasty after anterior acute myocardial infarction (AMI) were followed up with serial echocardiograms (echo) at days 3, 7, and 30, and 6 months after infarction. Patients were divided into two groups based on the mitral deceleration time (-< 130 or > 130 milliseconds), measured at day 3. Diastolic volume indices were also measured. Volume indices were similar in the two groups at baseline. The group with short deceleration time had progressively larger end-diastolic and end-systolic left ventricular volumes over the 6-month period. A stepwise multivariate analysis, including demographic and clinical variables, showed mitral deceleration time was the most powerful predictor of ventricular dilation after AMI. Implication: An early assessment of mitral deceleration time can have prognostic value for diastolic function and ventricular remodeling after myocardial infarction.
Takeuchi M, Himeno E: Does coronary stenting following balloon angioplasty improve myocardial flow reserve? Cardiovasc Intervent Radiol 21:459463, 1998 Clinical improvement of coronary artery blood flow does not always occur with successful angioplasty. Myocardial fractional flow reserve (FFRmyo) is the ratio of maximal hyperemic flow in the stenotic artery to the theoretical maximal hyperemic flow in the same artery (FFRmyo = Pd/Pa). The purpose of this study was to determine if FFRmyo would improve more with coronary stenting than with angioplasty alone in the same patient group. Eleven consecutive patients (10 men, 1 woman; mean age, 60 years; range, 36 to 76 years) scheduled for an elective coronary stenting procedure were evaluated. Measurements of FFRmyo were performed at baseline, after angioplasty, and after stent placement. FFRmyo after coronary stem placement (0.85 + 0.09) was significantly greater than at baseline (0.51 -+ 0.16; p < 0.001) and balloon angioplasty (0.77 _+ 0.11; p < 0.05). Implication: Stent placement may be used to maximize coronary blood flow after angioplasty.
Kosuga K, Tamai H, Ueda K, et ah Initial and long-term results of angioplasty in unprotected left main coronary artery. Am J Cardiol 83:32-37, 1999 Balloon angioplasty of unprotected left main coronary artery (LMCA) disease remains controversial because short- and long-term mortality remain high. With improvement in teclmiques, including coronary stents, the results of 175 procedures in unprotected LMCA disease in 107 patients were evaluated. Compared with elective procedures, patients presenting with acute myocardial infarction and those presenting emergently had a greater in-hospital mortality rate (3.6% v 35.7% and 40.0%, respectively). The 5-year survival of the elective group was also greater than the other groups. Moreover, repeat LMCA angioplasty had an overall mortality rate of 8.8%; 38.5% in acute and emergent procedmes and 1.8% in elective procedures. Implication: Elective angioplasty of unprotected LMCA may be efficacious in a select group of patients with closely scheduled angiographic folIow-up.
Jeremias A, Kutseher S, Haude M, et ah Nonischemic chest pain induced by coronary interventions: A prospective study comparing coronary angioplasty and stent implantation. Circulation 98:2656-2658, 1998 Chest pain after a percutaneous intracoronary procedure may be caused by abrupt vessel closure, coronary artery vasoconstriction,
503
peripheral embolization, or simply local trauma (stretch pain). Differentiating among these entities is crucial because ischemia and infarction may occur from the former two causes. This group performed a prospective study evaluating chest pain in patients after stent implantation, angioplasty, or diagnostic coronary angiography. Forty-one percent of the patients developed chest pain after stenting compared with only 9% to 12% of the patients undergoing angioplasty or angiography. Vessel diameter was significantly larger in the stent group compared with the angioplasty group (3.14 _+ 0.75 v 1.95 _+ 0.67 mm, respectively). In the group of patients who developed chest pain, only three developed elevations in creatine kinase enzyme levels and none had electrocardiogram changes or required repeat angiography. Implication: Nonischemic chest pain occurs frequently after coronary stent procedures and appears related to expansion of the diseased vessel.
ECHOCARDIOGRAPHY
Nagueh SF, Lakkis NM, Middleton K J, et ah Doppler estimation of left ventricular filling pressures in patients with hypertrophic cardiomyopathy. Circulation 99:254-261, 1999 Doppler estimates of left ventricular filling pressures are difficult to elicit in states of diastolic noncompliance. Echocardiographic parameters were evaluated in 35 patients with hypertrophic cardiomyopathy admitted for septat reduction therapy. Measured indices included isovolumic relaxation time, pulmonary venous flows, flow propagation velocity (color M-mode), transmittal velocity, and tissue Doppler early diastolic mitral annular velocity (Ea). The equations derived were then tested in a test population of 19 patients. Excellent correlations with filling pressures were obtained in the study group and test group. Test group correlation with filling pressures using E velocity/flow propagation velocity was r = 0.76 and E velocity/Ea was r = 0.82. Implication: Conventional mitral inflow velocities corrected for the effects of reduced left ventricular relaxation can provide a sensitive and specific measure of left ventricular filling pressures in patients with hypertrophic cardiomyopathy.
Cerisano G, Bolognese L, Carrabba N, et ah Doppler-derived mitral deceleration time. An early strong predictor of left ventricular remodeling after reperfused anterior acute myocardial infarction. Circulation 99:230-236, 1999 A short mitral valve deceleration time has been shown to predict adverse outcome after myocardial infarction. Patients successfully reperfused with angioplasty after anterior acute myocardial infarction (AMI) were followed up with serial echocardiograms (echo) at days 3, 7, and 30, and 6 months after infarction. Patients were divided into two groups based on the mitral deceleration time (-< 130 or > 130 milliseconds), measured at day 3. Diastolic volume indices were also measured. Volume indices were similar in the two groups at baseline. The group with short deceleration time had progressively larger end-diastolic and end-systolic left ventricular volumes over the 6-month period. A stepwise multivariate analysis, including demographic and clinical variables, showed mitral deceleration time was the most powerful predictor of ventricular dilation after AMI. Implication: An early assessment of mitral deceleration time can have prognostic value for diastolic function and ventricular remodeling after myocardial infarction.