Clinical characteristics, cardiac events and coronary angiographic findings in the prospective PREVEND cohort: an observational study

Background: The use of invasive procedures has mostly been studied in retrospective (multi)- national registries. Limited evidence exists on the association between microalbuminuria and coronary artery disease (CAD). Methods: The incidence of major adverse cardiac events (MACE) and invasive cardiac procedures was registered between 1997 and 2003 in 8139 subjects, without prior documented CAD, in the PREVEND cohort study (the Netherlands), in which the focus is on microalbuminuria and cardiovascular risk. Qualitative coronary angiographic analysis was performed. Results: During 5.5 years of follow-up, a first MACE occurred in 271 (3.3%) and a first coronary angiography (CAG) was performed in 264 (3.2%) subjects. Of these, 216 CAGs were available for qualitative angiographic analysis. Indications for CAG were stable angina in 129, acute coronary syndrome (ACS) in 55 and ST-elevation myocardial infarction (STEMI) in 32 subjects. Obstructive coronary artery disease was present in 61, 53 and 30 subjects, respectively. A revascularisation was performed in 50 (39%), 50 (91%) and 25 (78%) subjects, respectively. Microalbuminuria was associated with a first MACE, after adjustment for established risk factors. Microalbuminuria was present at baseline in 9% of subjects with normal coronary arteries, in 21% of subjects with one- and two-vessel CAD and in 39% of subjects with threevessel or left main CAD at CAG during follow-up (Ptrend=0.005). Conclusion: This large cohort study shows that two-thirds of diagnostic CAGs for stable angina were not followed by a revascularisation, in contrast to CAGs for STEMI or ACS. Furthermore, this study shows that microalbuminuria is associated with CAD. (Neth Heart J 2007;15:133-41.)     

Variations in use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality.

OBJECTIVE: To explore the relation between rates of coronary artery revascularisation and prevalence of angina to assess whether use of health services reflects need. DESIGN: Prevalence of angina symptoms determined by postal questionnaire on 16750 subjects (18 to 94 years). Comparison of data on use of coronary artery revascularisation with prevalence of symptoms and mortality from coronary heart disease. SETTING: Health authority with population of 530000. SUBJECTS: Patients admitted to hospital for coronary heart disease; patients who died; and patients undergoing angiography, angioplasty, or coronary artery bypass graft. Cohort of 491 people with symptoms from survey. MAIN OUTCOME MEASURES: Pearson''s product moment correlation coefficients for relation between variables. RESULTS: Overall, 4.0% (95% confidence interval 3.7% to 4.4%) of subjects had symptoms. Prevalences varied widely between electoral wards and were positively associated with Townsend score (r = 0.79; P < 0.001), as was mortality, but the correlation between admission rates and Townsend score was less clear (r = 0.47; P < 0.01). Revascularisation rate and Townsend score were not associated. The ratio of revascularisation to number experiencing symptoms was inversely related to Townsend score (r = 0.67; P < 0.001). The most deprived wards had only about half the number of revascularisations per head of population with angina than did the more affluent wards. In affluent wards 11% (13/116) of those with symptoms had coronary angiograms compared with only 4% (9/216) in poorer wards (chi 2 = 4.96; P = 0.026). Townsend score also inversely correlated with revascularisations per premature death from coronary heart disease (r = 0.55; P < 0.01) and revascularisations per admission for myocardial infarction (r = 0.47; P < 0.01). CONCLUSION: The use of interventional cardiology services is not commensurate with need, thus exhibiting the inverse care law.     

Prospective study of the role of cardiac troponin T in patients admitted with unstable angina.

OBJECTIVE--To examine the prognostic significance and role in risk stratification of the biochemical marker troponin T in patients admitted with unstable angina. DESIGN--Single centre, blinded, prospective study of patients admitted with chest pain. SETTING--Coronary care unit of a district general hospital. SUBJECTS--460 patients admitted with chest pain and followed up for a median of three years. 183 patients had a final diagnosis of unstable angina. MAIN OUTCOME MEASURES--Cardiac death, need for coronary revascularisation, or readmission with non-fatal myocardial infarction as first events. RESULTS--62 (34%) unstable angina patients were troponin T positive. This group had significantly increased incidence rates of subsequent cardiac death (12 cases (19%) v 14 (12%)), coronary revascularisation (22 (35%) v 26 (21%)), death or revascularisation (33 (53%) v 40 (33%)), and death or non-fatal myocardial infarction (18 (29%) v 21 (17%)) compared with the troponin T negative group. In multiple logistic regression troponin T status was a highly significant predictor for the end points coronary revascularisation and cardiac death or revascularisation as first events. CONCLUSION--Troponin T in the serum of patients with unstable angina identifies a subgroup at higher risk of subsequent cardiac events and its measurement aids in risk factor stratification. The increased risk extends to two years after admission. Prospective randomised trials are required to identify optimum therapeutic strategies for this subgroup.     

Long-term follow-up after bypass surgery or coronary stenting in elderly with multivessel disease

Background

We sought to compare long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in elderly patients with left main or multivessel disease, hypothesising that completeness of revascularisation and severity of coronary artery disease are predictors of adverse outcomes.

Methods

Patients aged ≥75 years with multivessel disease or left main disease who underwent PCI or CABG between 2012–2016 were included in this retrospective cohort study. Baseline characteristics from the index procedure were collected. Severity of coronary artery disease and completeness of revascularisation were assessed. Primary outcome was all-cause mortality, in addition we captured major adverse cardiac and cerebral events, bleedings, recurrent angina and new onset atrial fibrillation.

Results

A total of 597 patients were included. Median follow-up was 4 years (interquartile range 2.8–5.3 years). At baseline, patients in the PCI group more often had a previous medical history of CABG and more frequently underwent an urgent procedure compared with patients in the CABG group. Mortality at 5‑year follow-up was significantly higher in patients who underwent PCI compared with CABG (39.9% vs 25.4%, p < 0.001). Furthermore, acute coronary syndrome (ACS), repeat revascularisation and recurrent angina occurred more frequently after PCI, while occurrence of bleedings and new onset atrial fibrillation were more frequent after CABG. Neither completeness of revascularisation nor severity of coronary artery disease was a predictor for any of the outcomes.

Conclusion

Long-term mortality was higher in elderly patients with multivessel disease undergoing PCI compared with CABG. In addition, patients undergoing PCI had a higher risk of ACS, repeat revascularisation and recurrent angina.

     

Clinical trends in stent treatment of simple and complex coronary disease

This is a retrospective analysis of a consecutive group of patients from a single medical center who underwent stent implantation. It describes 316 patients who constituted 53% of the angioplasty procedures carried out in a single year. The authors describe the complications and their 1-year follow-up. We aimed to study the short and long-term results of stenting in our centre in relation to multiple clinical and angiographic variables. During 1996, 316 consecutive patients were treated with stent implantation for a total of 381 coronary lesions. The pharmacological protocol methods of stent implantation and patient characteristics were used. Clinical variables were: age 59.1 3 10.7 years, diabetes mellitus 25.3%, hypertension 33.0% and angina pectoris 88.7% (unstable in 44.1%). Previous coronary surgery had been undergone by 9.2%. Multivessel disease was present in 56% of the patients. The indications for stenting were: primary 58.5%, suboptimal results 33.0% and threatened or acute occlusion 8.5%. Angiographic success was 98.9% and clinical success 96.8%. The major in-hospital complications were acute myocardial infarction (2.2%), acute revascularization (0.3%) and major bleeding (0.6%). All occurred within 24 h of revascularization. Repeated angiography was performed in 115 cases (30.2%) at 160.3 3 109.4 days after stent procedure for unstable angina (38.7%), stable angina (26.1%) and other causes (35.2%). The restenosis rate in those catheterized was 38.1%, with an overall clinical restenosis rate of 11.3% during the follow-up period. Restenosis was more prevalent among diabetic patients (17.9 vs 9.15%, P 3 0.02) and patients with prior balloon angioplasty (18.6 vs 9.75%, P 3 0.046). Clinical follow-up was available in 90.8% of the patients for 291 3 112 days. The actuarial survival at the end of the follow-up period was 93.8%. Death/myocardial infarction was associated with unstable angina pectoris (P 3 0.006), hypertension (P 3 0.001), smoking (P 3 0.046) and threatened or acute occlusion (P < 0.001). In the first year of extensive stent use, stenting is associated with high technical and clinical success rates. Long-term results after stent implantation are associated with the occurrence of acute or threatened occlusion, and the in-hospital complications diabetes mellitus and hypertension.     

Catheter-based antegrade intracoronary viral gene delivery with coronary venous blockade

The purpose of this study is to evaluate the feasibility of percutaneous antegrade myocardial gene transfer (PAMGT). A consistent and safe technique for in vivo gene transfer is required for clinical application of myocardial gene therapy. PAMGT with concomitant coronary venous blockade was performed in 12 swine. The myocardium was preconditioned with 1 min of occlusion of the left anterior descending and left circumflex arteries. The anterior interventricular vein was occluded during left anterior descending artery delivery, and the great cardiac vein at the entrance of the middle cardiac vein was occluded during left circumflex artery delivery. With arterial and venous balloons inflated (3 min) and after adenosine (25 mug) injection, PAMGT was performed by antegrade injection of an adenoviral solution (1 ml of 10(11) plaque-forming units in each coronary artery) carrying beta-galactosidase or saline through the center lumen of the angioplasty balloon. In one set of animals, PAMGT was performed with selective coronary vein blockade (n = 9); in another set of animals, PAMGT was performed without coronary vein blockade (n = 5). At 1 wk after gene delivery, the animals were killed. Quantitative beta-galactosidase analysis was performed in the left and right ventricular walls. PAMGT was successfully performed in all animals with and without concomitant occlusion of the coronary veins. Quantitative beta-galactosidase analysis showed that PAMGT with coronary blockade was superior to PAMGT without coronary blockade. beta-Galactosidase activity increased significantly in the beta-galactosidase group compared with the saline group: 1.34 +/- 0.18 vs. 0.81 +/- 0.1 ng (P 相似文献   

Primary percutaneous coronary angioplasty in patients with acute coronary syndrome and concomitant cancer

The paper gives the results of X-ray surgical treatment in patients with acute coronary syndrome who have been ascertained to have concomitant cancer during their examination. Cancer was found in 11 patients in their medical history and diagnosed in 2 patients during examination after surgical treatment and 1 patient one year after his hospital discharge. The results of combination treatment showed the high efficiency of X-ray surgical treatment for acute coronary syndrome. Recovery of TIMI-III blood flow through the infarct-related coronary artery was achieved in 100% of cases; immediate clinical efficiency was 97.4%. In the concomitant cancer group, the therapeutic efficacy was 100%; there were no complications during X-ray surgery. All the patients from this group were discharged from hospital in a satisfactory state to be followed up by a cardiologist and oncologist for further treatment. The study performed suggests that concomitant cancer is not a contraindication to primary coronary angioplasty in patients with acute coronary syndrome. Primary coronary angioplasty with stenting is a safe effective treatment for acute coronary syndrome in this category of patients.     

Safety and efficacy of treatment with platelet GPIIb/IIIa receptor blockade in unstable angina patients awaiting PTCA at a referring clinic

BACKGROUND: Although balloon angioplasty has assumed an important role in the management of refractory unstable angina (UA), that is, UA that does not respond to conventional therapy, it is limited by complications related to thrombosis and acute coronary occlusion. The complication rate is higher in patients with UA than in those whose condition is stable. Preprocedural use of abciximab, a monoclonal platelet glycoprotein IIb/IIIa receptor blocker, has been used effectively in patients with UA, but its acceptance may be limited by safety concerns and economic constraints. The current trial investigated a protocol for abciximab pretreatment in patients with UA awaiting transfer from referring hospitals to a site of intervention (the 'drip and ship' protocol). AIMS: This observational study was conducted to evaluate whether a prophylactic, preprocedural regimen of abciximab can be safely and effectively administered to UA patients in referring hospitals while awaiting coronary angioplasty at the interventional clinic. METHODS: From April 1996 to December 1998, 168 consecutive patients with refractory UA (Braunwald class II or III) received abciximab prospectively at the referring clinic before undergoing PTCA or stent implantation at the interventional clinic. The following cost-conscious protocol was used: a 0.25 mg/kg bolus of abciximab followed by 10 micro g/min intravenously for 16 hours, in addition to intravenous nitrates, heparin and aspirin therapy. Patients were then transferred to a facility with PTCA capability via high-speed ambulance transport. No specific alterations of routine-transfer protocol were needed. Platelet aggregation studies were conducted during abciximab infusion. All interventions were performed while abciximab was given. Procedural and clinical success and long-term outcomes also were assessed. RESULTS: The primary angiographic success rate (patients with post-PTCA diameter stenosis < 50%) was 98%, and the in-hospital clinical success rate (angiographic success without major complications) was 98%. No major bleeding complications occurred during the abciximab pretreatment period. Platelet aggregation findings in the study patients showed a stable inhibition of >80% at the time of angioplasty. At 30-day follow-up, all patients were alive and 91% were free of major adverse events. Outcomes of balloon angioplasty and stenting were equally favorable, indicating no device-specific effect. Event-free survival at six months was 89% with a target vessel revascularization rate of 10%. CONCLUSION: Abciximab was administered safely and effectively to angioplasty patients with refractory UA awaiting transfer from a noninterventional setting to the site of angioplasty. These results extend the current knowledge base that has been established in randomized trials performed in interventional centers. The study protocol potentially could make abciximab therapy more feasible economically, and therefore more widely available to patients who are most likely to benefit from prophylactic administration.     

Evidence-based management of coronary artery disease in the elderly--current perspectives

Cardiovascular disease accounts for significant morbidity and mortality in the elderly. The clinical trial data available to guide therapy in this growing population subset are relatively limited. This review will focus on treatment approaches and recommendations obtained from subgroup analyses of elderly patients from major clinical trials for the management of chronic stable angina, acute coronary syndromes (unstable angina and non-ST-segment elevation myocardial infarction), and coronary revascularization. Recent advances in the treatment of stable angina have shown that use of angiotensin-converting enzyme inhibitors and lipid-lowering therapy as adjunctive measures show benefit in the elderly by reducing the occurrence of death, nonfatal myocardial infarction, and unstable angina. However, if patients experience disabling or unstable anginal symptoms despite effective medical therapy, coronary revascularization must be considered. Several clinical trials have shown a significant reduction in major adverse cardiac events when using intravenous glycoprotein receptor antagonists periprocedurally during percutaneous revascularization approaches in elderly patients with unstable angina or non-ST-segment elevation myocardial infarction, especially when these measures are performed as soon as possible. However, the success of myocardial revascularization by a percutaneous or surgical approach is highly dependent on the patient's associated comorbidities, especially in patients over age 80 years.     

Critical hand ischaemia after transradial cardiac catheterisation: an uncommon complication of a common procedure

We describe a case of critical hand ischaemia after transradial cardiac catheterisation. The patient presented with hand ischaemia 5 days after transradial coronary angiography. Urgent angiography demonstrated radial artery occlusion with embolisation to the palmar arch and digital arteries. The ischaemia was refractory to an extensive thrombolytic regimen, and subsequently, the patient was referred to the vascular surgeon for urgent thrombectomy and patch angioplasty. The patient recovered slowly and no amputation was necessary, but complaints of right hand numbness and paresthesia of all digits remained.     

STEMI or non-STEMI: that is the question

Acute coronary syndromes are usually classified on the basis of the presence or absence of ST elevation on the ECG: ST-elevation myocardial infarction or non-ST-elevation myocardial infarction (NSTEMI)patients with acute myocardial infarction (AMI) need immediate therapy, without unnecessary delay and primary percutaneous coronary intervention (PPCI) should preferably be performed within 90 min after first medical contact. However, in AMI patients without ST-segment elevation (pre) hospital triage for immediate transfer to the catheterisation laboratory may be difficult. Moreover, initial diagnosis and risk stratification take place at busy emergency departments and chest pain units with additional risk of ‘PPCI delay’. Optimal timing of angiography and revascularisation remains a challenge. We describe a patient with NSTEMI who was scheduled for early coronary angiography within 24 h but retrospectively should have been sent to the cath lab immediately because he had a significant amount of myocardium at risk, undetected by non-invasive parameters.     

Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study

Objective To investigate the relation between access to a cardiac catheterisation laboratory and clinical outcomes in patients admitted to hospital with suspected acute coronary syndrome.Design Prospective, multinational, observational registry.Setting Patients enrolled in 106 hospitals in 14 countries between April 1999 and March 2003.Participants 28 825 patients aged ≥ 18 years.Main outcome measures Use of percutaneous coronary intervention or coronary artery bypass graft surgery, death, infarction after discharge, stroke, or major bleeding.Results Most patients (77%) across all regions (United States, Europe, Argentina and Brazil, Australia, New Zealand, and Canada) were admitted to hospitals with catheterisation facilities. As expected, the availability of a catheterisation laboratory was associated with more frequent use of percutaneous coronary intervention (41% v 3.9%, P < 0.001) and coronary artery bypass graft (7.1% v 0.7%, P < 0.001). After adjustment for baseline characteristics, medical history, and geographical region there were no significant differences in the risk of early death between patients in hospitals with or without catheterisation facilities (odds ratio 1.13, 95% confidence interval 0.98 to 1.30, for death in hospital; hazard ratio 1.05, 0.93 to 1.18, for death at 30 days). The risk of death at six months was significantly higher in patients first admitted to hospitals with catheterisation facilities (hazard ratio 1.14, 1.03 to 1.26), as was the risk of bleeding complications in hospital (odds ratio 1.94, 1.57 to 2.39) and stroke (odds ratio 1.53, 1.10 to 2.14).Conclusions These findings support the current strategy of directing patients with suspected acute coronary syndrome to the nearest hospital with acute care facilities, irrespective of the availability of a catheterisation laboratory, and argue against early routine transfer of these patients to tertiary care hospitals with interventional facilities.     

Increase in plasma digitalis-like activity during percutaneous transluminal coronary angioplasty in patients with coronary stenosis

Despite the fact that numerous studies have been published regarding the possible presence in plasma of an endogenous Na-K pump inhibitor with a digitalis-like structure in essential hypertension, very little is known about this factor in heart disease in general, and in situations characterized by low cardiac output. We measured the ability of plasma obtained from the femoral vein to inhibit a human renal Na(+)-K+ ATPase before and immediately after percutaneous transluminal coronary angioplasty (PTCA) in 6 patients suffering from angina pectoris and severe coronary stenosis. Intraerythrocyte sodium and potassium concentrations were also measured simultaneously. Na(+)-K+ ATPase inhibition proved significantly greater after angioplasty as compared to basal activity (percentage inhibition: 31.5 +/- 7.8 vs 16.1 +/- 12.2). No significant changes in intraerythrocyte sodium and potassium were detected. Though we are not in a position to define the mechanism underlying the increase in the digitalis-like factor, a plausible hypothesis may be that the reduction in cardiac output during PTCA by raising cardiac pressures may stimulate the production of a factor of compensatory inotropic significance.     

Arterial end-to-side grafting in coronary artery bypass grafting: the Tector procedure

Background. The current treatment of choice in patients with three-vessel coronary disease is coronary artery bypass grafting. The use of the left internal mammary artery in bypass grafting has shown superior long-term outcomes compared with venous grafting. In our study we assess the safety and feasibility of all-arterial coronary artery bypass graft surgery using the procedure as described by Tector et al. in 2001.Methods. Between June 2001 and February 2007, we studied 133 patients eligible for non-emergency surgical revascularisation. Primary endpoints were death or re-infarction within a 30-day period. Secondary endpoints were the need for emergency coronary surgery, angioplasty and mediastinitis. Long-term follow-up had a mean duration of 33 months postoperatively.Results. All 133 patients were successfully revascularised, 98% with the off-pump technique. In 93% of the patients (n=124) full arterial grafting was achieved using both internal mammary arteries. Thirty-day mortality was 1.5% (n=2), ten re-thoracotomies were performed, one myocardial infarction and one case of mediastinitis were reported. In the next four years six additional patients died. Most of these deaths were due to non-cardiovascular causes. Two patients required angioplasty because of distal bypass graft failure and one for new native coronary artery disease. Conclusion. All-arterial bypass grafting using both internal mammary arteries with the technique as described by Tector is safe and feasible without excess deep sternal wound infections. Late major adverse cardiac events are rare and due to distal graft dysfunction, which can be treated by percutaneous coronary intervention. (Neth Heart J 2010;18:7-11.)     

Impact of the new generation coronary care unit.

A 30-bed coronary care unit with facilities for fluoroscopy, haemodynamic monitoring, mechanical heart assistance, and long-term electrocardiographic monitoring operated at a reasonable cost over five years. Much of the work was entrusted to trained nurses, and there was close consultation with cardiac surgeons over those patients who needed catheterisation or surgery. New procedures greatly reduced the numbers of early deaths from cardiac arrest and cardiac failure but had less influence on late mortality. Hospital mortality for all 3353 patients was 6-8%, and for patients under 65 with definite infarction, who were admitted direct it was 5-7%.     

Provisional stenting in the real world: results in 1058 consecutive patients undergoing percutaneous coronary angioplasty

OBJECTIVE: To study a strategy of aggressive coronary balloon angioplasty with provisional stenting in allcomers. In randomized trials, stenting has improved the outcome of patients undergoing coronary intervention. However, whether these results hold up in clinical practice is largely unknown. Furthermore, the results of balloon angioplasty have also improved dramatically. It is therefore essential to evaluate the current results of balloon angioplasty and to assess whether stents are required in all patients. METHODS: The authors prospectively studied the occurrence of death, myocardial infarction (MI) and target lesion revascularization (TLR) of a large consecutive group of patients undergoing aggressive balloon angioplasty with provisional stenting. None of the patients received a platelet glycoprotein IIb/IIIa receptor blocker. The results were compared with the outcome of routine stenting in recent randomized trials. RESULTS: Angioplasty was performed in 1058 patients of whom 369 (34.9%) received a stent. The angiographic success rate was 98.9%. During hospital stay, 4.8% of the patients suffered any cardiac event. At one-year follow-up, death occurred in 1.1%, MI in 3.3%, TLR in 12.4% and any event in 16.7% of the patients. Event-free survival at one-year was 82.3%. These results compare favorably with routine stenting in recent trials. CONCLUSIONS: Aggressive balloon angioplasty with provisional stenting yields excellent results in a general patient population.     

Recurrent myocardial infarction in a patient with Prinzmetal's angina and normal coronary arteries

A 55-year-old man was referred for the evaluation of frequent chest pain and syncope. While in the hospital, he experienced severe chest pain accompanied by transient ST segment elevation and a slight elevation of cardiac enzyme levels. Multiple coronary arteriograms were recorded at various times during an interval of 2 months. On one occasion, the results were normal; on another occasion, they showed total occlusion of the left anterior descending, diagonal, and circumflex coronary arteries. The occlusion was completely relieved with sublingual nitroglycerin. Because the patient's clinical condition deteriorated rapidly, double aortocoronary saphenous vein bypass was performed to the left anterior descending and circumflex coronary arteries. During the induction of anesthesia, ventricular fibrillation occurred, and the patient died from refractory recurrent fibrillation 4 hours after surgery. Postmortem examination revealed normal coronary arteries, patent vein grafts, and multiple focal areas of recent and old myocardial fibrosis. Thus, it appears that coronary spasm, in the presence of otherwise normal coronary arteries, can produce myocardial infarction with necrosis, and that medical management may provide a more successful method of treating such patients.     

Coronary stent implantation without balloon predilatation: a single-center experience

OBJECTIVE: Assessment of safety and efficacy of coronary stent deployment, without balloon predilatation. BACKGROUND: With newer high-performance balloon-premounted stents it has become more common to attempt coronary stent deployment without balloon pre- or postdilatation. METHODS: During 1998 524 coronary angioplasties were performed in the authors' institute, of which 279 resulted in coronary stenting. Of these 101 (36.2%) were stents without balloon predilatation (SWBP). PTCA was performed according to standard technique using mostly 7 F. guiding catheters, and 'rapid exchange' balloons and pre-mounted stents. RESULTS: Seventy-two patients had acute coronary syndromes (41 acute MI or post-MI angina, 28 unstable angina, 10 rescue PTCA after failed thrombolysis). Mean age was 56.4 3 11.1 years, 84.5% were males. Sixty per cent of the lesions were ACC-AHA type B2 or C. Target arteries were LAD 57.6%, LCX 21.2%, RCA 14.1% and SVG 7.1%. Procedure time was 18.2 3 17.3 minutes. Mean heparin dose was 3850 3 1570 units. Twenty-two patients received abciximab prior to stent deployment. Seven stents were not deployed without previous balloon dilatation and were retrieved safely via the guiding catheters and deployed after balloon dilatation. There was no stent embolization, ectopic suboptimal or partial stent deployment. Immediate angiographic success was obtained in 95 patients (94.1%). Minimal lumin diameter (MLD) increased from 0.27 3 0.15 to 3.23 3 2.1 mm. There were two in-hospital deaths (1.9%) due to cardiogenic shock. An intra-aortic balloon pump was required in eight patients. Two patients (1.9%) experienced subacute stent thrombosis. CONCLUSION: SWBP in selective groups of patients and lesions is feasible and safe. Larger randomized comparative trials are needed to assess the benefits and cost saving of this approach.     

Left main coronary artery stenosis undetected by 64-slice computed tomography: a word of caution

A 56-year-old man with a history of stent insertion in the circumflex artery two years before presented to the hospital with recurrent symptoms of angina. A 64-slice computed tomography scan was performed revealing mild in-stent and post-stent restenosis but no clear explanation for the symptoms. Coronary angiography demonstrated a severe localised stenosis of the left main coronary artery, not detected on multi-slice computed tomography, and subsequent angioplasty and placement of two stents obtained a good result. (Neth Heart J 2007;15:255-6.)