Faculty Bibliography

Coronary artery fistulae are rare anomalies in which a communication is present between a coronary artery and either a cardiac chamber or another vascular structure, such as the pulmonary artery or coronary sinus. Most fistulae are congenital in origin, but they can also occur as a result of chest trauma or endocardial biopsy. The presence of a fistula is a rare occurrence in itself, but the different origins and drainage sites of fistulae are what make them even more rare. We report the case of a 74-year-old woman with a history of progressive congestive heart failure who was found to have a large left main coronary fistula draining into a persistent left superior vena cava to a markedly dilated and aneurysmal coronary sinus

It is unknown whether the benefits of parenteral platelet glycoprotein (GP) IIb/IIIa inhibitors as an adjunct to percutaneous coronary intervention (PCI) demonstrated in randomized clinical trials extend to patients treated outside the setting of clinical trials. A contemporary registry of 10,847 consecutive PCI procedures was analyzed to determine the effect of GP IIb/IIIa inhibitor treatment on in-hospital major adverse coronary events ([MACEs] composite of death, urgent coronary artery bypass surgery, periprocedural myocardial infarction, abrupt closure, and stent thrombosis). In this registry, GP IIb/IIIa inhibitors were administered to 20.1% of patients. These patients were younger, more often men, and less often hypertensive than untreated patients. GP IIb/IIIa inhibitor-treated patients were more likely to present with acute myocardial infarction or unstable angina. Stents were placed in 79% of patients treated with GP IIb/IIIa inhibitors. MACEs occurred in 7.8% of GP IIb/IIIa inhibitor-treated patients compared with 3.8% of untreated patients (p <0.001). After multivariable adjustment for the propensity of GP IIb/IIIa inhibitor treatment as well as other possible confounders and interactions known to influence MACEs, GP IIb/IIIa inhibitor treatment was associated with a 57% increase in the risk of a MACE (odds ratio 1.57, 95% confidence interval 1.22 to 2.03; p = 0.0004). In a data set consisting of patients with a high degree of acuity predominantly treated with stent placement, GP IIb/IIIa inhibitor treatment is associated with an increase in thrombotic complications of PCI

Coronary heart disease is the leading cause of death among the elderly (> 65 years) and the very elderly (> 85 years). Little information is available regarding the outcome of very elderly patients referred for PCI in the current era of improved techniques, devices, and pharmacotherapy. The objective of the current study was to evaluate the clinical characteristics and outcomes of very elderly patients > or = 85 years of age in a large, contemporary, multi-institutional PCI database. Five hospitals in the New York City metropolitan area contributed these prospectively defined data elements on consecutive patients undergoing PCI from 1 January 1998 to 1 October 1999. Of 10,847 patients, 5,341 (49%) were younger than 65 years, 3,342 (31%) were 65-74 years, 1,885 (17%) were 75-84 years, and 279 (2.6%) were at least 85 years of age. Following PCI, the very elderly developed stroke (P < 0.001) and renal failure requiring dialysis (P = 0.002) more commonly than younger patients following PCI. The very elderly had a significantly increased in-hospital mortality rate at 2.5% (P < 0.001). However, on multivariate analysis, age > or = 85 years was not an independent predictor of in-hospital mortality (OR = 1.22; 95% CI = 0.37-4.07). The very elderly should not be refused PCI on the basis of advanced age alone

BACKGROUND: Compared with angioplasty, elective stent implantation has improved short-term and long-term outcome with a decrease in abrupt closure and a reduced 6-month restenosis rate. Although primary angioplasty during acute myocardial infarction has improved outcome, recurrent ischemic events and restenosis are still a problem. METHODS: Outcomes for 166 consecutively treated patients who underwent stent insertion procedures within 24 hours after the onset of acute myocardial infarction were compared with those for a similar group of patients (n = 212) who underwent consecutive balloon angioplasty procedures at one tertiary care institution. The objective of this study was to examine in-hospital and late clinical outcomes for the 2 groups. RESULTS: The procedural success rate for stenting in acute myocardial infarction was 100%; that for angioplasty was 98%. Mortality rates during hospitalization were similar for the stent group and the angioplasty group (4.0% vs 2.0%). The rate of in-hospital acute reocclusion necessitating urgent percutaneous reintervention was significantly lower for the stent group (0% vs 3%, P =.02). Six months after the procedure, the stent group had a significantly lower need for revascularization of the infarct-related artery (8% vs 20%, P =.001) and a significantly lower incidence of combined serious clinical events (death, acute occlusion, emergency bypass, target vessel revascularization, and nonfatal myocardial infarction; 12% vs 30%, P =.00003). CONCLUSION: Compared with balloon angioplasty, stent deployment in the setting of acute myocardial infarction was associated with significantly lower frequency of in-hospital acute occlusion and significantly less need for target-vessel revascularization 6 months after myocardial infarction

To gain insight into the altered kinetics of creatine kinase-MB (CK-MB) release after reperfusion, a physiologically based model with first-order CK-MB appearance and disappearance functions was postulated. This biexponential model is based on the assumption that reperfusion reestablishes nutritive blood flow, providing direct access of interstitial CK-MB to the bloodstream. This is in contrast to persistent coronary artery occlusion, in which no direct access to nutritive flow is present. The accuracy of this model was examined in 8 dogs reperfused after 2 hours of coronary artery occlusion. The fit to observed values was excellent, with a mean r2 of 0.97 +/- 0.05. In agreement with the biexponential model, the initial increase in CK-MB activity was abrupt and rapid. The same degree of accuracy was found in 21 patients with angiographic evidence of reperfusion after thrombolytic therapy (mean r2 0.97 +/- 0.02). The appearance characteristics were similar to the animal model, with an abrupt and rapid increase in CK-MB activity. When compared with 5 patients with persistent occlusion, ka, the rate constant of the appearance function, clearly distinguished patients with reperfusion (chi-square = 20.6, p less than 0.0001), whereas considerable overlap was present in the time to peak CK-MB (time to peak less than 12 hours, chi-square = 3.6, difference not significant). Alterations of CK-MB release in reperfusion can be accurately modeled with the biexponential model. The characteristics of this model suggest that early identification of reperfusion by serial CK-MB assay is possible

Ninety-six consecutive patients older than 40 years with severe mitral stenosis were retrospectively analyzed to determine the relation of angina pectoris (AP) and coexistent coronary artery disease (CAD). Of the 96 patients, 27 (28%) had angiographically significant CAD, 10 (37%) with AP and 17 (63%) without AP. Of the 96 patients, 21 had AP, 10 (48%) with angiographically significant CAD and 11 (52%) without (CAD). Of 75 patients without AP, 17 (23%) had angiographically significant CAD AP had a specificity of 84% and a sensitivity of 37% in its ability to detect significant CAD. The pulmonary artery systolic, diastolic and mean pressures and the pulmonary vascular resistance did not differ between patients with and those without AP (p greater than 0.05). It is concluded that coexistent CAD is commonly found in patients older than age 40 with severe MS, and is usually clinically silent

One hundred three patients with isolated, severe aortic stenosis (AS) were retrospectively analyzed to determine the relation of angina pectoris to angiographically significant coronary artery disease (CAD). All patients underwent coronary angiography regardless of the presence or absence of angina. Angina was significantly associated with CAD (p less than 0.002), with a sensitivity of 78% and a specificity of 53%. However, 25% of the patients without angina had angiographically significant CAD, and in these patients there was a 70% prevalence of 1-vessel disease. Patients with isolated, severe AS should undergo coronary angiography to identify coexistent CAD accurately. The absence of angina does not reliably exclude angiographically significant CAD