BACKGROUND: The safety of ergonovine provocation for coronary vasospasm (CVS) performed outside the catheterization laboratory has been questioned. We sought to address the issues of safety, feasibility and clinical impact of noninvasive diagnosis of CVS. METHOD AND RESULTS: We retrospectively analyzed the results of bedside ergonovine provocation testing with monitoring of left ventricular regional wall motion abnormalities (RWMAs) by 2-dimensional echocardiography (ergonovine echocardiography, Erg Echo). After confirmation of no significant fixed epicardial coronary artery disease, 1,504 Erg Echo were performed in 1,372 patients from July 1991 to December 1997. Erg Echo was prematurely terminated in 13 patients (0.9%) due to limiting side effects unrelated with myocardial ischemia. Among 1,491 completed tests, 32% (477) showed positive results with development of RWMAs in 467 tests (98%) or ST displacement in ECG in 10 tests (2%). During the test, transient arrhythmias developed in 1.7% (26/1491) including transient ventricular tachycardia (2) and atrioventricular block (4), which were promptly reversed with nitroglycerin. There were no procedure-related death or development of myocardial infarction. On the basis of angiographic criteria in 218 patients, who also underwent invasive spasm provocation test during coronary angiography, the sensitivity and specificity of Erg Echo for the diagnosis of CVS were 93% and 91% respectively. From 1990 to 1997, total 2,073 spasm provocation tests were performed either during invasive coronary angiography in the catheterization or in the echocardiography laboratory. Since 1994, noninvasive Erg Echo became a more popular diagnostic method and comprised more than 95% of all spasm provocation tests in recent 3 years. Erg Echo was also performed safely in outpatient clinic setting without hospital admission in 34% (500/1491). CONCLUSIONS: Erg Echo is highly feasible, accurate and safe for diagnosis of CVS and can replace the invasive spasm provocation test during coronary angiography in the catheterization laboratory.
Ambulatory Care Facilities ; Arrhythmias, Cardiac ; Atrioventricular Block ; Catheterization ; Catheters ; Coronary Angiography ; Coronary Artery Disease ; Coronary Vasospasm* ; Diagnosis* ; Echocardiography ; Echocardiography, Stress* ; Electrocardiography ; Ergonovine* ; Humans ; Myocardial Infarction ; Myocardial Ischemia ; Nitroglycerin ; Retrospective Studies ; Sensitivity and Specificity ; Spasm ; Tachycardia, Ventricular

BACKGROUND: The safety of ergonovine provocation for coronary vasospasm (CVS) performed outside the catheterization laboratory has been questioned. We sought to address the issues of safety, feasibility and clinical impact of noninvasive diagnosis of CVS. METHOD AND RESULTS: We retrospectively analyzed the results of bedside ergonovine provocation testing with monitoring of left ventricular regional wall motion abnormalities (RWMAs) by 2-dimensional echocardiography (ergonovine echocardiography, Erg Echo). After confirmation of no significant fixed epicardial coronary artery disease, 1,504 Erg Echo were performed in 1,372 patients from July 1991 to December 1997. Erg Echo was prematurely terminated in 13 patients (0.9%) due to limiting side effects unrelated with myocardial ischemia. Among 1,491 completed tests, 32% (477) showed positive results with development of RWMAs in 467 tests (98%) or ST displacement in ECG in 10 tests (2%). During the test, transient arrhythmias developed in 1.7% (26/1491) including transient ventricular tachycardia (2) and atrioventricular block (4), which were promptly reversed with nitroglycerin. There were no procedure-related death or development of myocardial infarction. On the basis of angiographic criteria in 218 patients, who also underwent invasive spasm provocation test during coronary angiography, the sensitivity and specificity of Erg Echo for the diagnosis of CVS were 93% and 91% respectively. From 1990 to 1997, total 2,073 spasm provocation tests were performed either during invasive coronary angiography in the catheterization or in the echocardiography laboratory. Since 1994, noninvasive Erg Echo became a more popular diagnostic method and comprised more than 95% of all spasm provocation tests in recent 3 years. Erg Echo was also performed safely in outpatient clinic setting without hospital admission in 34% (500/1491). CONCLUSIONS: Erg Echo is highly feasible, accurate and safe for diagnosis of CVS and can replace the invasive spasm provocation test during coronary angiography in the catheterization laboratory.
Ambulatory Care Facilities ; Arrhythmias, Cardiac ; Atrioventricular Block ; Catheterization ; Catheters ; Coronary Angiography ; Coronary Artery Disease ; Coronary Vasospasm* ; Diagnosis* ; Echocardiography ; Echocardiography, Stress* ; Electrocardiography ; Ergonovine* ; Humans ; Myocardial Infarction ; Myocardial Ischemia ; Nitroglycerin ; Retrospective Studies ; Sensitivity and Specificity ; Spasm ; Tachycardia, Ventricular

Since after first report of percutaneous transluminal coronary angioplasty in 1977, improved operator technique and advanced equipment designs have resulted in an increase in primary success rate from 67% to 92% in recent days. Despite these improvement, acute closure and restenosis remain as serious limitations to both the short and long-term success of PTCA. Coronary artery stents have been proposed as a method of treating acute closure and preventing restenosis. We implanted 21 balloon expandable Palmaz-Schatz Stent in selected 21 Patients(mean age 62+/-8 years, M/F : 16/5) with atherosclerotic coronary artery disease. The indications were elective stenting in 17, acute dissection postangioplasty in 2 and restenosis following angioplasty in 2. The clinical diagnosis of the subjects was unstable angina in 12 pts(57%), stable angina in 1, and post infarction angina in 8 including 6 acute myocardial infarction. The target vessel was right coronary artery In 12(57%), left anterior descending artery in 6(29%) and left circumflex in 3(14%). The size of implanted stent was 3mm in 15, 3.5mm in 5 and 4.0mm in 1. The morphology of attempted lesion was AHA/ACC classification type A in 1, type B in 17(B1 ; 1, B2 ; 16) and type C in 3. Angiographic findings were 1-vessel disease in 16 patients, 2-vessel disease in 4 and 3-vessel disease in 1. Coronary artery stenting wast technically successful in 21 all patients(100%) and complications included subacute total occlusion 1 week after stenting in 1, which was recanalized successfully by repeat PTCA without myocardial infarction, prolonged sinus arrest after stenting due to microembolism in 1 and puncture site bleeding requiring transfusion in 1. CONCLUSION: Coronary artery stenting was a safe and effective procedure to obtain adequate coronary blood flow in selected patients but long-term efficacy of primary elective coronary stenting should be evaluated prospectively.
Angina, Stable ; Angina, Unstable ; Angioplasty ; Angioplasty, Balloon, Coronary ; Arteries ; Classification ; Coronary Artery Disease ; Coronary Vessels* ; Diagnosis ; Equipment Design ; Hemorrhage ; Humans ; Infarction ; Myocardial Infarction ; Punctures ; Stents

Since after first report of percutaneous transluminal coronary angioplasty in 1977, improved operator technique and advanced equipment designs have resulted in an increase in primary success rate from 67% to 92% in recent days. Despite these improvement, acute closure and restenosis remain as serious limitations to both the short and long-term success of PTCA. Coronary artery stents have been proposed as a method of treating acute closure and preventing restenosis. We implanted 21 balloon expandable Palmaz-Schatz Stent in selected 21 Patients(mean age 62+/-8 years, M/F : 16/5) with atherosclerotic coronary artery disease. The indications were elective stenting in 17, acute dissection postangioplasty in 2 and restenosis following angioplasty in 2. The clinical diagnosis of the subjects was unstable angina in 12 pts(57%), stable angina in 1, and post infarction angina in 8 including 6 acute myocardial infarction. The target vessel was right coronary artery In 12(57%), left anterior descending artery in 6(29%) and left circumflex in 3(14%). The size of implanted stent was 3mm in 15, 3.5mm in 5 and 4.0mm in 1. The morphology of attempted lesion was AHA/ACC classification type A in 1, type B in 17(B1 ; 1, B2 ; 16) and type C in 3. Angiographic findings were 1-vessel disease in 16 patients, 2-vessel disease in 4 and 3-vessel disease in 1. Coronary artery stenting wast technically successful in 21 all patients(100%) and complications included subacute total occlusion 1 week after stenting in 1, which was recanalized successfully by repeat PTCA without myocardial infarction, prolonged sinus arrest after stenting due to microembolism in 1 and puncture site bleeding requiring transfusion in 1. CONCLUSION: Coronary artery stenting was a safe and effective procedure to obtain adequate coronary blood flow in selected patients but long-term efficacy of primary elective coronary stenting should be evaluated prospectively.
Angina, Stable ; Angina, Unstable ; Angioplasty ; Angioplasty, Balloon, Coronary ; Arteries ; Classification ; Coronary Artery Disease ; Coronary Vessels* ; Diagnosis ; Equipment Design ; Hemorrhage ; Humans ; Infarction ; Myocardial Infarction ; Punctures ; Stents

A clinical trial was done to evaluate the antihypertensive efficacy and side effects of manidipine, a new calcium antagonist, in 30 patients with mild to moderate essential hypertension. 1) The study patients consisted of 19 men and 11 women, and the mean age was 51.8 years. 2) Blood pressure dropped significantly in 2 weeks and in 4 weeks, and well maintained throughout the study period. The mean-pressure drop was 26.2/14.9mmHg after 10 weeks. 3) Heart rate did not change significantly with manidipine therpy. 4) Optimal dose for effective pressure-drop was between 10 and 20 mg in 86% of patients. Overall good antihypertensive effect was achieved in 83% of patients. 5) All of the laboratory parameters including blood chemistry, glucose, lipid and electrolytes did not change, but serum calcium increased from 9.2% mg/dl (p=0.001) in 10 weeks. 6) Side effects were mild in nature(palpitation in 3, dry mouth in 1, weakness in 1 and impotence in 1 patient). In conclusion, manidipine monotherapy with 10 to 20 mg once a day regimen is effective and well tolerated in the patients with mild to moderate essential hypertension.
Blood Pressure ; Calcium ; Chemistry ; Electrolytes ; Erectile Dysfunction ; Female ; Glucose ; Heart Rate ; Humans ; Hypertension* ; Male ; Mouth

BACKGROUND: Coronary artery bypass grafts obtained from internal mammary artery(IMA) have a greater patency rate than do saphenous vein grafts(SVG). The release or production of endothelium-derived relaxing factor(EDRF), which regulates blood flow and inhibits platelets function, may contribute to the higher patency rate of IMA. In order to evaluate the difference between endothelium dependent relaxation in IMA and in grafted saphenous veins, we observed acetylcholine responses of IMAs and SVGs in humans. METHOD: Incremental dose if acetylcholine(Ach:A1-20, A2-50, A3-100microg) or single dose if acetylcholine(A3) were infused into the non-grafted IMA in 16 patients with different clinical presentation of coronary artery disease(3 with stable angina, 2 with acute myocardial infarction 4 with variant angina and atypical chest pain syndrome in 7). After the dose-response to Ach was completed nitroglycerine 200microg was injected into the IMA. Graded dose of Ach (A1, A2, A3) was also infused in 13 grafted saphenous veins(SVG). RESULTS: The overall vascular effects of Ach into the IMA were dilatory responses regardless of different clinical presentation. Two or 3 minutes after Ach injection, the diameter of IMA increased by 9.2%(A1) and 16. 7%(A3) respectively(p<0.01). Maximal dilatory response after A3 was comparable to that after nitroglycerin injection. Angiographically normal segements of SVGs also increased its diameter 2 minutes after Ach injection (7.2% with A1, 6.9% with A2 and 8.5% with A3). Thus the degree of relaxation of IMA was more prominent than that of SVGs. Angiographically dicreased segments of SVGs had no response after Ach injection. The overall responses of native coronary artery to Ach was dose dependant constriction. CONCLUSION: Injection of Ach to IMA and angiographically normal segments of SVGs caused vascular dilatation probably due to EDRF response. However the degree of relaxation was more prominent in IMA than in SVG. Angiographically diseased segments of SVGs had no response to Ach injection, suggesting that diseased SVG does not produce EDRF. However the finding of a consistent Ach-induced EDRF relaxation in the SVGs despite of constrictive response in the majority of native coronary arteries might suggest that the regenerated endothelial cell in the SVGs were probably of saphenous vein origin rather than derived from the coronary arterial endothelium.
Acetylcholine ; Angina, Stable ; Chest Pain ; Constriction ; Coronary Artery Bypass ; Coronary Vessels ; Dilatation ; Endothelial Cells ; Endothelium ; Humans ; Mammary Arteries* ; Myocardial Infarction ; Nitroglycerin ; Relaxation ; Saphenous Vein* ; Transplants*

BACKGROUND: Intimal tear or dissection is a serious complication after coronary angioplasty,sometimes which may develop an acute ischemic event. We evaluate the factor that may predict the development of dissection after angioplasty. METHODS: To identify the factors that development of dissection after angioplasty, the data of 52 patients identified as having dissection with or without immediate vessel closure were examined. Follow-up coronary angiogram was obtained in 22 out of 58 lesions at mean 5.6 month after angioplasty. RESULTS: Intimal dissection developed 58 lesion(31%) out of 177 lesions in 122 patients after PTCA. Ischemic complications, defined as ischemic chest pain, myocardial infarction, the need for coronary bypass surgery occured in 5 patients(9.6%) out of 52 patients with dissections. Significant correlates of a development of dissection were the lesion morphology of type C(P<0.01), more tight diameter stenosis before PTCA(P<0.01), and right coronary artery(P<0.02), especially in the proximal portion (P<0.05). There were no significant correlations of clinical pictures, whether complex or simple angioplasty and PTCA in single vessel disease or in multivessel disease. Morphologic feature of dissection was type A(radiolucency) in 22(38%), B(filling defect)in 14(24%), C(extra-luminal "cap")in 8(14%), D(spiral dissection)in 5(9%), E(filling defect with delayded antegrade flow)in 7(12%) and F(total occlusion) in 2(3%). Twenty-two(38%) dissection out of 58 were obtained follow-up angiogram at mean 5.6 month. Angiographic restenosis occured in 9(41%) lesions, which included more type A dissections (7/9,78%) compared to lesions with dissection healing (3/13, 23%)(P<0.001) at follow-up. Thirteen lesions with dissection healing at follow-up included more B and C dissection(B;54%,C;15%)and E dissection in 1. Furthermoremore restenosis occurred more prevalent in the infarct-related artery(P<0.001) and left anterior decending coronary artery lesion(P<0.01). There was somewhat higher diameter residual stenosis after angioplasty (32+/-11% vs 26+/-10%) in the lesions with restenosis, but there was no statistical significance. CONCLUSION: Intimal dissection after angioplasty occurred in 58(31%) leisions out of 122(177leisions) consecutive patients underwent PTCA developments if intimal dissection after PTCA significantly correlated with the lesions if type C, more tight diameter stenois before PTCA and right coronary artery. At mean 5.6months follow-up,angiographic restenosis occured in 41% of dissections, which had more included type A(radiolucency)dissections, infarct-related artery and left anterior descending coronary artery leision.
Angioplasty* ; Arteries ; Chest Pain ; Constriction, Pathologic ; Coronary Vessels ; Follow-Up Studies* ; Humans ; Myocardial Infarction

BACKGROUND: Large series of patients with symptomatic mitral stenosis have undergone percutaneous mitral balloon valvuloplasty(PMV) with use of the Inoue or double balloon technique. But to date the result of the two procedure have not been compared with a single series prospectively. METHODS: In order to assess the immediate hemodynamic results and the longterm efficacy of two different PMV technique, a prospective, randomized trial of PMV was performed using the Inoue balloon(Toray, I group) in 59 patients and the double balloons(a pair of Mansfield balloon. D group) in 61 patients with moderate to severe mitral stenosis. Before valvuloplasty, the patients series were comparable with regard to average age. gender, most clinical and echocardiographic variables. All the patients(120 patients, M/F 38/82, mean age 41+/-11 year) were preselected with good echoscore> or =9. RESULTS: The success rate was 83% in the I group and 89% in the D group when the success defined as mitral valve area(MVA)> or =1.5cm2 with 25% gain in MVA and mitral regurgitation> or =2+ at the end of procedure. The magnitude of increase of mitral valve area and decrease of mitral gradient, left atrial pressure and pulmonary arterial pressure were not significantly different in the Inoue and double balloon series(1.0+/-0.4 and 1.1+/-0.4cm2 for mitral vale area, 10.2+/-6.6 and 11.7+/-6.4mmHg for mitral gradient, 10.5+/-6,4 and 12.9 +/-7,3mmHg for left atrial pressure, and 8.7+/-7.3 and 10.1+/-9.4 mmHg for pulmonary artrial pressure respectively). Immediatly after dilation, the long diameter changes of the mitral orifice was more prominent in the D group(from 1.0+/-0.2 to 2.6+/-0.4cm p<0.01) than those in I series(from 1.1+/-0.4 to 2.3+/-0.3cm) Moreover, the magnitude of increase in the EF slop was significantly larger in the D group(31.9+/-17.0 vs 21.8+/-14.2mm/sec, p<0.001). The duration of total procedure(56+/-20 vs 84+/-24 min, p<0.002) and the fluoroscopic time (15+/-6 vs 25+/-11min, p<0.002) was significantly shorter in group I. The incidence of left to right shunt at the atrial level(Qp/Qs>1.5) was 3.4% in group I and 4.9% in group D. Severe mitral regurgitation> or =3+ occurred in 2 patients in each I(3.4%) and D(3.3%) group respectively. At follow-up, the mitral valve area was significantly decreased(1.6 in group I vs 1.8cm2 in group D, P<0.001 vs immediate after MVA) at 6 months and well maintained at 1 year follow-up in both groups. Until 6 months after valvuloplasty, the long diameter of orifice was greater in group D, however the difference was not apparent at 1 year follow-up. CONCLUSION: The Inoue and double balloon techniques obtained equivalent results of the success rate and the frequently of complications. However, the Inoue balloon technique reduced significantly fluoroscope time and total procedure duration. Double balloon technique afforded a longer longitudinal splitting of the commissure immediatly and 6 months after valvuloplasty. However the differences was not apparent at 1 year follow-up. Increased MVA was well maintained at 1 year in both groups. The severity of the newly developed mitral regurgitation immediately after valvuloplasty reduced significantly in 53% of the Inoue and 43% in the double balloon group at 6 months follow-up. In the view point of similiar immediate and late results of the two methods, the stepwise dilation with Doppler echocardiographic monitoring during the Inoue procedure appeared to be cumbersome.
Arterial Pressure ; Atrial Pressure ; Balloon Valvuloplasty* ; Echocardiography ; Follow-Up Studies* ; Hemodynamics ; Humans ; Incidence ; Mitral Valve ; Mitral Valve Insufficiency ; Mitral Valve Stenosis ; Prospective Studies

BACKGROUND: The value of coronary reperfusion resulting from Thrombolysis and/or coronary angioplasty in patients with evolving myocardial infarction has been rigorously evaluated and improved left venticular function and short-term survival rates have been demonstrated consistently in controlled studies. Benefits from delayed coronary angioplasty at 7-10 days after onset of acute myocardial infarction (AMI) without thrombolysis remains unclear. In order to assess the effect of delayed reperfusion in infarct-related artery(IRA), we analyzed the restenosis rate of IRA after successful coronary angioplasty and the change of left ventricular function at late follow-up angiogram. METHOD: Coronary angioplasty in 69 lesions of 55 patients(M/F:48/7, mean age 53 years) with acute myocardial infarction(AMI) were performed at 7-10 days after onset of AMI and follow-up coronary angiogram (25 lesions of 20 pts) with left ventriculogram were obtained at means 5.1 months(range 4-6 months) after angioplasty. Restenosis rate of dilated infaret-related arteries and the changes of left ventricular function after angioplasty were evaluated. RESULTS: The overall procedural success rate of delayed elective coronary angioplasty in patients with AMI was 86% with a higher success rate in subtotally occluded vessel(98%) than in the occluded IRA(64%). Complications included acute closure after large dissection in 1(1.6%) and on -hospital mortality due to cardiogenic shock in 1(1.8%). Angiographically restenosis rate of IRA was 65% at mean 5.1 months follow-up, which was relatively higher than that after non-IRA angioplasty in AMI(25%) and in patients with angina(24%). Left ventricular ejection fraction improved significantly from 47.2+/-12.7% to 58.8+/-8.6%(P<0.05) at follow-up. Patients who had a patent IRA at follow-up had a restenotic IRA at follow-up had no statistically significant improvement in EF(table 3). Patients with a left anterior descending artery(LAD) lesion had lower mean immediate EFs than patients with right coronary artery lesion, however the degree of improvement in EF at follow-up was more significant in patients with LAD lesion. CONCLUSIONS: Delayed elective angioplasty of IRA at 7-10 days after onset of AMI was relatively safe and had comparable procedural success rate. Higher restenosis rate(65%) of IRA at follow-up appeared to be related, at least on part, to the endothelial dysfunction after ischemic-reperfusion injury and clinically unstable status. Left ventricular function improved significantly after angioplasty at follow-up. Recovery of left ventricular function might be reated to whether or not the IRA had an angiographically restenosis at follow-up.
Angioplasty* ; Arteries ; Coronary Vessels ; Follow-Up Studies* ; Humans ; Mortality ; Myocardial Infarction* ; Myocardial Reperfusion ; Reperfusion ; Shock, Cardiogenic ; Stroke Volume ; Survival Rate ; Ventricular Function, Left

Percutenous transluminal coronary angioplasty(PTCA) for total coronary occlusion was performed in 20 patients(mean age 51+11years, male 16, female 4) including 12 patients with recent myocardial infaction. Primary success rate of procedure was 71%(15 out of 21 lesions). The success rate with occlusion<3 months duration was 11 out of 13(85%) lesions vs 4 out of 8(50%) with occlusion>3 months duration(P=NS). There was no difference in success rate according to vessel dilated(left anterior descending and intermediate branch 70%, right coronary artery 83%, left circumflex 67%). All patients had well developled(>grade 2 in 15 patients) collateral flow to the occluded vessel. The leng of occluded lesion more than 1.5cm was in 4 out of 21, and 3 of them had procedural failure because of inability to cross with a guide wire. Six procedsural failures included inability to cross the lesion with a guide wire in 5 and one in inability to dilate the lesion due to recoiling. Complications included intimal dissection in 3(1.5%), prolonged chest pain in 1 1 and one death due to cardiogenic shock. Although the primary success rate is relatively lower than that associated with conventional stenotic lesions, coronary angioplasty could be performed safely and successfully in the majority of patients with coronary occlusion.
Angioplasty* ; Chest Pain ; Coronary Occlusion ; Coronary Vessels* ; Female ; Humans ; Male ; Shock, Cardiogenic