The prospective clinical and scintigraphic assessment of patients with preserved left ventricular systolic function after transmyocardial laser revascularisation.

Aim: To analyse the clinical outcome and myocardial perfusion and function after transmyocardial revascularisation (TMR) in patients with normal left ventricular function and multivessel coronary artery disease non-amenable for standard revascularisation.

Method And Results: Twenty three severely symptomatic patients (CCS score median 4) with normal left ventricular systolic function but coronaries non-amenable for either PTCA or CABG were subjected to TMR. The angina score, left ventricular systolic and diastolic function in radionuclide ventriculography at rest, exercise tolerance and myocardial perfusion--Thallium-201 SPECT (adenosine stress 74 and 37 MBq under nitrate cover) were evaluated before and 3, 6, 12 months post-operatively.

Paraprosthetic leak unmasked by thrombolysis for thrombosed mitral valve.

Prosthetic valve thrombosis (PVT) is classically a cardiothoracic surgical emergency. Case series, however, report thrombolysis as first line management for PVT. A case of mitral PVT treated successfully with thrombolysis is described.

Platelet IIb/IIIa antagonists followed by delayed stent implantation. A new treatment for vein graft lesions containing massive thrombus.

The percutaneous treatment of saphenous vein graft lesions containing angiographically massive thrombus is associated with a high risk of distal embolisation and no-reflow. The optimal management for these lesions remains unclear and a challenge to the interventional cardiologist. Five cases are described in whom the risks of percutaneous angioplasty were felt to be excessive owing to a high thrombus load.

Instantaneous lead entrapment: successful percutaneous removal using the cook workstation.

An unusual complication of transvenous endocardial lead placement is reported in which an electrode became entrapped within the vicinity of the tricuspid valve apparatus, resisting all initial attempts at removal. The lead was subsequently successfully removed percutaneously via the right femoral vein.

Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease.

Background: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease.

Methods: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group.

Results: Sixty patients underwent CABG and 49 patients PTCA.

Objective assessment of "cardioprotective" efficacy as a prognostic guide to management of mildly symptomatic revascularizable coronary artery disease.

Objectives: The concept of "cardioprotection" based on ejection fraction was tested to see whether patients with coronary artery disease in whom medical treatment fails to be cardioprotective can be distinguished from those in whom it is safe to continue such treatment.

Background: Ejection fraction is of fundamental prognostic importance. Its modification by anti-ischemic medication may allow assessment of cardioprotection from adverse outcome.

Exercise testing without interruption of medication for refining the selection of mildly symptomatic patients for prognostic coronary angiography.

Objective: To examine how exercise testing on background medical treatment affects the ability of the test to predict prognostically important patterns of coronary anatomy in patients with a high clinical probability of coronary artery disease but who are well controlled on medication.

Design: Prospective study.

Setting: Regional cardiothoracic centre and referring district general hospital.

Suppression of inducible painless myocardial ischemia by conventional medical therapy: effect on short-term outcome and left ventricular systolic function.

To test the hypothesis that abolition of exercise-induced painless myocardial ischemia by anti-ischemic medication improves prognosis in patients with medically treated coronary artery disease, we studied such patients with painless ischemia during exercise radionuclide ventriculography performed after temporary discontinuation of medication. The test was repeated while patients received conventional medical therapy that rendered angina no worse than New York Heart Association class I. The relative risk of adverse cardiac events was reduced by > 5-fold when painless ischemia was abolished by symptom-dictated therapy.

Long-term effect of inducible silent ischaemia on left ventricular systolic function.

Silent myocardial ischaemia is readily detected by exercise radionuclide ventriculography in patients with coronary artery disease. In those who remain asymptomatic and event-free, it is not known whether silent ischaemia which is inducible despite anti-ischaemic medication exerts an insidious detrimental effect on left ventricular function. To study this, 34 medically treated patients (mean age 57; 26 men) underwent prospective measurement of left ventricular ejection fraction (LVEF) during rest and exercise radionuclide ventriculography without interruption of anti-ischaemic medication at baseline and 12 months later.

Novel approach to the interpretation of long-term "deterioration" in ejection fraction in individual patients with coronary artery disease.

Objective: The long-term predictability of left ventricular ejection fraction (LVEF) measurements was evaluated with particular emphasis on the assessment of deterioration in individual patients whose coronary artery disease was initially treated medically.

Design: Prospective pilot study.

Setting: Regional cardiac centre.

Left ventricular volume calculation using a count-based ratio method applied to first-pass radionuclide angiography.

Most count-based radionuclide methods for calculating left ventricular volume rely on measurement of radioactivity in a peripheral blood sample and a measurement of ventricle to collimator distance. We have developed a method which requires neither a blood sample nor a distance measurement and which is applicable to first-pass radionuclide angiography. The parameters used to calculate volume are the area of pixel, the total counts in the left ventricle and the maximum pixel count.

High-risk coronary angioplasty with elective intra-aortic balloon pump support.

Percutaneous transluminal coronary angioplasty was attempted with elective percutaneous intra-aortic balloon pump support in 21 patients (mean age 60 years, range 40-82; 18 males) with unstable angina (n = 2), multivessel coronary disease requiring multivessel angioplasty (n = 2), severe left ventricular dysfunction (ejection fraction 10-30%; n = 16) or ventricular fibrillation at diagnostic angiography (n = 1). Fourteen patients had 3-vessel disease (1 with vein grafts also diseased), 6 had 2-vessel disease and 1 had isolated left anterior descending disease. Twenty-five procedures were performed (one in 18 patients, two in 2 patients and three in one patient) on 42 lesions in 34 vessels/grafts.

Effect on prognosis of abolition of exercise-induced painless myocardial ischemia by medical therapy.

During exercise radionuclide ventriculography, many patients with coronary artery disease exhibit painless myocardial ischemia defined as an abnormal left ventricular ejection fraction response without accompanying angina. To see if complete suppression of such exercise-induced painless ischemia by anti-ischemic medication implies a better prognosis in medically treated coronary artery disease, 34 patients underwent repeat testing at 4 weeks receiving regular conventional therapy that rendered angina no worse than class I. With such therapy, painless ischemia was abolished in 12 patients (group I) and persisted in 22 (65%, group II).