Acute & Interventional Cardiology 2004; Volume 11: pages AIC 1- AIC 104

Percutaneous treatment of bifurcation coronary lesions is less successful than treatment of non-bifurcation lesions, with a higher incidence of side branch occlusion and restenosis. The ‘crush technique’ was developed to ensure complete coverage of the ostium of the side branch, where restenosis frequently occurs. Drug-eluting stents are deployed in both side and main branches. The main branch stent crushes the side branch stent against the wall of the main vessel. The ‘reversed crush’ is used when the side branch result is unsatisfactory following stenting of the main branch, or when a 6F guiding catheter is needed. The ‘skirt technique’ was designed to treat pseudobifurcation lesions (lesions in the main branch which are immediately proximal to a bifurcation). It involves sandwiching two balloons in one stent. Preliminary results using the crush technique in 35 patients show angiographic success in all lesions....

In this issue of Acute and Interventional Cardiology there is a commissioned editorial about the release of cardiac enzymes after percutaneous coronary intervention (PCI). This remains a contentious area and attracts the views of two opposing schools of thought....

The measurement of biochemical markers of myocardial cell damage is a key component of modern cardiology practice. The use of these tests in the diagnosis of myocardial infarction (MI) has been routine for three decades, with the measurement of serum levels of creatine kinase (CK) and its myocardial band isofraction (CK-MB) emerging as the traditional standard in this respect....

Despite the availability of an array of medical therapies for the treatment of heart failure, quality of life is often poor for the majority of patients, and the mortality remains high. In addition, treatment is regularly not well tolerated and this results in frequent hospital admissions for some patients. This article reviews the management and medical treatment of acute heart failure, focusing on the emerging role of levosimendan. Levosimendan is currently licensed in 10 European countries (Simdax, Orion Pharma, Finland) for the treatment of acute heart failure. It is a new inotropic drug with a dual mechanism of action: sensitisation of the cardiac myofilament to calcium, thus enhancing cardiac contractility, and vasodilation of vascular smooth muscle. The published clinical studies so far have utilised intravenous levosimendan. However, the agent is also well absorbed orally, and phase two trials of its use in stable patients with less severe heart failure are underway.1...

Heart failure is an increasingly common condition for which device therapy, including the advanced pacing technique cardiac resynchronisation therapy, is becoming an accepted treatment. In this review we discuss the rationale, evidence base, indications, limitations and implant technique of this maturing treatment modality and speculate on expansion of its role in the near future....

Primary cardiac lymphomas (PCL) are rare neoplasms. They occur at any age and are rare in immunocompetent patients, accounting for 1.3% of all cardiac tumours and 0.5% of all extranodal lymphomas. PCL have been increasingly found in patients with acquired immune deficiency syndrome (AIDS).1 PCL are difficult to diagnose, especially during the early stages of the disease when their manifestations are non-specific.2 Discovery of a malignant cardiac tumour at operation would usually be managed by biopsy and closure without resection, and inevitably would result in early mortality. We report a patient who is alive 12 months after resection of a primary cardiac non-Hodgkin’s B cell lymphoma....

Ventricular tachycardia (VT) and sudden cardiac death are feared complications of severe heart failure, whatever the aetiology. VT has the propensity to become incessant, and this carries an adverse prognosis. In some cases incessant VT is refractory to a combination of electrical cardioversion and pharmacological therapy such that emergency catheter ablation is required. Even when the conventional endocardial approach fails, ablation can be performed safely and effectively via the epicardial route....

Isolated ventricular non-compaction is a rare cardiomyopathy, which is probably underdiagnosed. We describe a case manifested by chest pain, indistinguishable from acute myocardial infarction....

The pulmonary artery catheter (PAC) was introduced into critical care medicine without objective evidence of its efficacy. The direct risks from the PAC are around 1.5% for a serious complication and 0.2% for death. The Connors study on 5,735 intensive care patients used case-matching techniques, and demonstrated a worse outcome in the PAC cohort. However, in this study the need for inotropes and the response to treatment were excluded from the regression analysis. Three further studies have failed to show an association between PAC placement and outcome after case-mix adjustment. It has proved extremely difficult to recruit enough intensive care patients to exclude a clinically important mortality benefit of the PAC. New techniques such as the oesophageal Doppler, pulse contour continuous cardiac output and lithium dilution cardiac output machines offer simpler, and perhaps better, alternatives to the PAC. Nonetheless, even if future trials are negative, the PAC should remain available for treatment of patients with unusual conditions or combinations of conditions....

The use of coronary angiography as a diagnostic tool in modern hospital medicine continues to rise. With the increasing use of therapeutic coronary interventions, and the increases in procedure times and volumes of contrast media, incidence rates of contrast-induced nephropathy (CIN) have also been seen to climb over recent years. CIN has subsequently been shown to be a significant contributor to morbidity and mortality during hospitalisation. In this current clinical setting, it is incumbent on the modern cardiologist to be aware of this potentially serious complication of angiography, to be familiar with its presentation and treatment, and to be able to recognise at-risk groups and institute prophylactic measures where appropriate....

The success of the 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) in ameliorating atherothrombotic events is firmly established. Large randomised controlled clinical trials have consistently (and unequivocally) demonstrated a beneficial role in reducing coronary events and total mortality in patients with advanced coronary artery disease (CAD). ...

The benefits of transradial coronary intervention (TRI) over transfemoral (TFI) are becoming increasingly recognised. In the United Kingdom, an increasing number of interventions are being performed by the radial approach and courses supporting this approach are now well developed....

We report a case of unprotected, ostial left main coronary artery disease successfully treated with a rapamycin-coated ‘Cypher’ stent in an 81-year-old woman who was declined for coronary artery bypass surgery because of significant co-morbidity....

This study was set up to investigate the prognostic significance of different bands of troponin T in the diagnosis and management of patients presenting with suspected acute coronary syndrome without ST segment elevation. The study was a cohort study, set in a District General Hospital in the north west of England. The participants were 421 patients admitted with suspected acute coronary syndrome without ST segment elevation over a three-month period. Analysis was carried out depending on whether the level of troponin elevation was in a negative (< 0.03 µg/L), intermediate (0.03–0.1 µg/L) or positive (> 0.1 µg/L) band. The outcome was a composite of all-cause mortality or hospital admission due to non-fatal myocardial infarction at 30 days and 12 months. Both intermediate and positive levels of elevated troponin increased the risk of all-cause mortality and non-fatal myocardial infarction at least two-fold, both at 30 days and 12 months (p<0.01). People over 50 were found to have a worse prognosis than younger patients at 12 months (p<0.05) but gender had no significant effect. Patients with suspected acute coronary syndromes without ST segment elevation who have either intermediate or positive levels of troponin T show a substantial increase in adverse outcomes during short- and long-term follow-up. Further research is required on these bandings as new generations of troponin assays are developed with improved levels of precision....

Bivalirudin is a direct thrombin inhibitor that will be available in the UK in November 2004 as adjunctive anticoagulant therapy during percutaneous coronary intervention (PCI). Its mechanism of action offers potential advantages over heparin in terms of both efficacy and bleeding. Bivalirudin is convenient – ACT monitoring is unnecessary, infusion is only for the duration of the procedure, and half-life is short so that early sheath removal and ambulation are possible. Finally, bivalirudin may offer major cost savings over glycoprotein (GP) IIb/IIIa inhibitors. The REPLACE-2 trial demonstrated equivalent efficacy and reduced bleeding with bivalirudin alone versus heparin-plus-GP IIb/IIIa inhibition in 6,010 patients undergoing elective or urgent PCI (30-day MACE 7.6% vs. 7.1%, major bleeding 2.4% vs. 4.1%). Further trials are underway to evaluate the efficacy of bivalirudin during PCI for high-risk acute coronary syndromes (ACS) and acute myocardial infarction (AMI). This paper considers when bivalirudin should be used in contemporary PCI. The ISAR-REACT study provides firm evidence that heparin alone is safe and effective for elective PCI in low-to-moderate risk patients (30 day MACE 4% heparin-alone vs. 4% abciximab). Patients with AMI or unstable ACS were not included in the REPLACE-2 trial and should continue to receive GP IIb/IIIa inhibitors until further data are available. Bivalirudin could be considered in patients at intermediate risk in whom GP IIb/IIIa inhibitors are currently widely used, including during complex elective PCI, elective PCI in diabetics, and in patients with stabilised or low-risk ACS. Bivalirudin will also have a specific role in patients at increased risk of bleeding and with heparin-induced thrombocytopaenia. Further data are required before more widespread adoption of bivalirudin can be recommended....

There are many advantages to bioabsorbable stents, including the potential to inhibit intimal hyperplasia by avoiding prolonged foreign body reaction and/or releasing antiproliferative drugs during degradation. The bioabsorbable polymer poly-l-lactic acid (PLLA) is used as a biodegradable coating of permanent metallic stents but can also be used to manufacture complete stents, at the expense of a greater recoil. Clinical, angiographic and intravascular ultrasound results at four years with the first stent tested (Igaki Tamai, Igaki, Japan) show patency rates similar to the rates expected with stainless steel stents and full reabsorption. Magnesium stents are another, perhaps more encouraging, development because they retain mechanical properties similar to conventional metallic stents. Full degradation of the magnesium alloy used to manufacture the Biotronik Lekton Magic stent requires 6–8 weeks. In man, initial clinical experience with this stent has been gained in patients with critical lower limb ischaemia. An ongoing study is testing its safety and efficacy in human coronary arteries....

Recombinant factor VIIa (rFVIIa, Novoseven®, Novo Nordisk®, Denmark) is established for the management of bleeding episodes in haemophiliac patients with inhibitors. Interest has been growing in the use of this drug for the management of severe intractable bleeding following major trauma and surgery. ...