Background: Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. Methods: All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. Results: Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004–2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure ( P <0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 ( P <0.001) after a median follow-up of 110 (7–452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) ( P <0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P =0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P =0.037), New York Heart Association class (HR, 2.00; P =0.015) at follow-up and baseline creatinine (HR, 8.19; P =0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P =0.002). Conclusion: Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery. # Clinical Perspectives {#article-title-21}

Introduction:The His-Purkinje system activates ventricular myocardium through Purkinje-Myocardial Junctions (PMJs).It has been suggested that most PMJs are normally non-functional at baseline due to source-sink mismatches at these junctions.We hypothesised that gap junctional uncoupling at the PMJs during acute ischaemia facilitates propagation across a greater number of functional PMJs, thereby leading to accelerated but more complex activation patterns.Methods: In aortic-perfused rabbit hearts (n ¼ 8), the right ventricles (RV) were exposed, preserving the Purkinje system (Figure ), and the endocardium optically mapped.Activation of the RV endocardium during atrial pacing was recorded during 40 minutes of global ischemia followed by 30 minutes reperfusion.A corresponding detailed 3D computer model of rabbit ventricles incorporating the Purkinje system was constructed to test the hypothesis.Results: Optical mapping studies revealed that the percentage of RV area activated within the first 5ms decreased from baseline 53 + 6% to 43 + 8% during early ischemia (,20 min), and paradoxically then increased to 59 + 8%, with more complex activation (p , 0.001).This coincided with more surface breakthroughs at more PMJs during late ischaemia (Figure).Activation normalised after reperfusion.In the computer model, a 6% reduction in conductivity was sufficient to render quiescent PMJs active.Increasing the fraction of functioning PMJs from 5% to 100% accelerated endocardial activation from 27.1 to 15.8 ms, compensating for reduced conduction velocity.Surface breakthroughs increased, as did the complexity of activation, matching the experiments.Conclusion: At baseline, most PMJs are quiescent.Ischaemia-induced closure of gap junction channels reduces conduction velocity, but as the uncoupling progresses, more PMJs become functional due to reduced source-load mismatch.The altered, more complex, activation patterns during ischaemia may be pro-arrhythmic as they increase the pathways for meandering wavefronts and the likelihood of wave collision.

Background: Altered metabolism is thought to play an important role in the pathogenesis of heart failure.Study of the metabolism may provide insights into the pathology of heart failure and may provide new diagnostic tools.Proton magnetic resonance spectroscopy (MRS) allows us to quantify total creatine, which plays an essential role in the transport of energy from the mitochondria to the myofibrils.Experimental autoimmune myocarditis (EAM) in rodents is an accepted model of myocarditis and dilated cardiomyopathy.As of yet, proton MRS has not been used to study the changes occurring in this model of heart failure.We aimed to study the metabolic changes occurring in an animal model of EAM, and compare these to the findings in healthy animals.Methods: Myocardial tissue of 10 male young Lewis rats with EAM (35 days after immunization with 0.25 mg porcine myocardial myosine) was analysed using 1H-MAS-MRS (Bruker 600 MHz).The metabolic profile was compared to fresh (n ¼ 7) and frozen (n ¼ 8) healthy controls and to the results from histology and immunohistochemistry (CD68).For fresh control samples the spectra were taken less than 10 min after death.Frozen control samples and myocarditis samples were shock-frozen in liquid nitrogen and stored for 4-6 months at -808C before measurements.Myocardial tissue from a basalcavity slice of the the left ventricle (30-40 mg) excluding epicardial tissue was placed in a 4 mm zirconium rotor, packed homogeneously using a spacer and spun at 4 kHz at 293 K.A water suppression pulse sequence was applied to obtain the proton spectrum (ns ¼ 128, t ¼ 7 min).Spectra were phased and baseline correction using polynomial fit to the region of interest was applied before integration of the peaks.Results: The metabolic ratio of taurine to creatine obtained by spectral analysis proved to be a significant biomarker for diagnosis of myocarditis compared to healthy controls (taurine/creatine ratio in myocarditis: 4.47(+0.83),fresh control: 2.59(+0.09),frozen control: 2.59(+0.28);P , 0.001).Myocarditis was confirmed histologically with an inflammatory cellular infiltrate and CD68 positive staining.Conclusions: Myocardial taurine/creatine ratio as detected by proton MRS is able to differentiate between healthy myocardium and myocardium from rats with EAM.This variation may occur due to creatine depletion as described in heart failure and/or an increase in taurine due to its antioxidant activity in inflammatory reactions.1237

Purpose: The AMPLATZER® Cardiac Plug (ACP) is a percutaneous transcatheter device intended to prevent thrombus embolizations from the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation (AF). The objective of this prospective, open-label study is to evaluate safety and performance of the ACP device in closure of the LAA and report the initial long-term follow-up results out to two years. Methods and results: We report safety results on a total of 40/161 (24.8%) patients who have been followed for two years post ACP implantation at ten investigative centers in Germany, Spain, United Kingdom, Ireland and the Czech Republic. Study follow-up included rigorous neurological and echocardiographic assessments at baseline, 1, 6, 12 months and 2 years post implant, as well as after a suspected stroke, TIA or systemic embolism. The study is being 100% monitored. An independent Data Monitoring Board is utilized and adjudicates seriousness and relatedness of all the safety events. In comparison to previously presented studies on ACP and other percutaneous LAA closure devices, this cohort was older and had a higher incidence of comorbidities. The majority of reconsented patients (50.9%) had a history of permanent AF, mean age was 70.48±12.54, mean CHA2DS2VASc score 3.27±1.55, and mean HAS-BLED score 2.857±1.15. Prior stroke or TIA was reported in 20.7% of reconsented patients. 100% of subjects with reported 2 year follow up TOE's reported closure of the LAA. Closure is defined as absence of flow or flow of < 3 mm jet into the LAA as assessed by transoesophageal echocardiography (TOE). From implant to six months, two ischemic strokes were adjudicated as unrelated to the device or procedure in a subject population of 204. With 40 subjects completing 6 months to 2 year follow-up, one new ischemic stroke occurred at 256 days post implant in a patient with a risk factor of prior ischemic stroke. Long term follow-up data revealed a total of 19 safety events occurring after the 6 month follow-up period in 9/40 (22.5%) patients. There have been no reported hemorrhagic strokes in any subjects post implant. There have been no reported thrombus on the device or device embolization after 6 months. Conclusion: The ACP device is a good alternative for high risk patients based on the reported excellent closure status. One out of five re-consented patients had a history of prior stroke/TIA and current long-term follow-up data revealed only one new stroke occurring after 6 months. The rate of safety events compares favorably with other LAA closure devices.

Introduction Patients presenting with chest pain, raised troponin but non-obstructive coronary arteries pose a clinical challenge in diagnosis, prognosis and management. We hypothesised that early cardiovascular magnetic resonance (CMR) imaging can provide a diagnosis and comprehensive characterisation for acute myocardial injury of indeterminate aetiology. Methods and results 120 patients presenting with chest pain, positive troponin (TnI>0.04 µg/l) and non-obstructive coronary arteries prospectively underwent early CMR (median 3 days, range 0–14 days) at 1.5 T, including cine imaging for function, T2-weighted imaging for oedema and late gadolinium enhancement (LGE) imaging for myocardial necrosis/scarring. The mean age=50±17 years (50% female); median TnI=3.99 ug/l (0.07–60 µg/l); mean left ventricular ejection fraction=64±12%. There was a high CMR diagnostic yield of 95%. Significant oedema was detected in 79% and LGE in 61%. The commonest diagnosis was myocarditis (37.5%), followed by Takotsubo cardiomyopathy (22.5%), myocardial infarction (17.5%), acute regional stunning (9.2%; wall motion abnormality with oedema but no LGE), dilated cardiomyopathy (4.2%), hypertrophic cardiomyopathy (3.3%), and missed pulmonary embolism (0.8%). Eleven of the 21 patients with MI (52%) had a patent foramen ovale (PFO) demonstrated on transthoracic echocardiography with agitated saline contrast and presumably suffered a paradoxical embolism to a coronary artery. The remaining 5.0% of patients had no clear diagnosis identified. Conclusions CMR has a high diagnostic yield (95%) in patients presenting with troponin-positive chest pain but non-obstructive coronary arteries when performed early (median 3 days). This study highlights the importance and usefulness of early access to CMR in this group of patients. When no apparent cause is identified, early conventional CMR was able to exclude myocardial infarction, wall motion abnormality, significant oedema or scarring.

Introduction More than 50% of renal transplant recipients will die as a consequence of cardiovascular disease (CVD). Type I diabetics undergoing simultaneous pancreas-kidney transplantation (SPK) are at an even greater risk of CVD. Optimising a patient′s cardiovascular status is necessary before SPK transplant surgery. Patients can remain on transplant waiting lists for years. There is little evidence as to how frequently repeat cardiovascular risk assessments are required in asymptomatic patients. Myocardial perfusion scintigraphy is used in SPK patients to detect any asymptomatic myocardial ischaemia or abnormal left ventricular function. This study analyses data from a SPK transplant centre with an annual surveillance programme to aim to establish the suitable frequency of MPS. Methods Potential SPK transplant recipients who had undergone two perfusion scans were included for analysis. An abnormal MPS was defined as either showing a regional wall motion abnormality, inducible ischaemia, or impaired left ventricular function. The scan results were both documented and compared. Angiography results from the study period were also recorded. Results 99 out of 130 patients on the SPK waiting list in November 2009 had undergone two perfusion scans as part of their pre-transplant assessment. The median age was 45 yrs (range 26–63), with 41% female and a median time between scans of 1.4 yrs (range 0.6–3.0). 59 patients (60%) had two consecutive normal scans. The remaining 40 patients had at least one abnormal scan. 16% of patients with a normal 1st scan developed an abnormal 2nd scan within a median period of 1.4 years. 28 (70%) of the patients with an abnormal MPS underwent angiography, of these 12 required revascularisation (either PCI or CABG). Of the remaining 16 patients; 1 died before angiography and the other 15 patients were treated with medical therapy. Of the 59 patients with two normal scans; 3 underwent angiography during the study period (for new symptoms), 1 of these patients required revascularisation after presenting with an ACS. 2 had minor plaque disease. Conclusions 40% of SPK patients on the waiting list have an abnormal MPS. Of the patients with normal scans 5% required an angiogram because of new symptoms with only 2% requiring revascularisation. Of the patients undergoing angiography driven by MPS 43% subsequently underwent revascularisation. The current screening interval is successfully monitoring changes in the patients9 cardiovascular status with only one patient requiring an intervention which was not predicted by MPS. Therefore a near annual MPS is a useful, non-invasive means by which to monitor patients at very high risk of asymptomatic cardiovascular disease while awaiting a SPK transplant.

Introduction Imaging to guide percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has traditionally required transoesophageal echocardiography (TOE) with general anaesthesia. The development of intracardiac echocardiography (ICE) allows these procedures to be performed under local anaesthesia, obviating the need for endotracheal intubation and general anaesthesia. We set out to evaluate prospectively the effect of ICE on the success and efficiency of PFO and ASD closure. Methods Data on all adult patients undergoing percutaneous PFO and ASD closure were collected prospectively between 2003 and 2008. Allocation to echocardiographic technique was non-random and determined by the availability of anaesthetic and cardiology staff, initial ICE probe availability and relative contraindication to general anaesthesia. Procedure time, fluoroscopy time, radiation dose, device deployment success rate, procedural complications, hospital stay length and interatrial communication closure at 3 months were compared between the two imaging modalities. Results 210 consecutive patients underwent percutaneous interatrial defect closure over the study period, 55 (26%) with TOE and 155 (74%) using ICE. Baseline characteristics of the TOE and ICE groups were similar (age 45.3 ± 15.5 vs 47.9 ± 13.6 years, p = 0.415; male 36% vs 42%, p = 0.524; body surface area 1.81 ± 0.27 vs 1.90 ± 0.26 m2, p = 0.110; interatrial defect size (for ASD) 19.8 ± 8.9 vs 18.2 ± 7.9 mm, p = 0.458). Procedural time (not including induction and recovery from general anaesthesia; 50 ± 21 vs 42 ± 18 minutes, p = 0.007), fluoroscopy time (8.0 ± 6.0 vs 5.4 ± 4.0 minutes, p Conclusions During percutaneous closure of interatrial defects, ICE avoids the risks and inconvenience of general anaesthesia and is associated with significantly reduced procedure times, radiation doses and inpatient stay compared with TOE, without compromising procedure success.

Since their introduction several years ago, the 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitorsthe statinshave been widely used for hyperlipidemia and for the primary/secondary prevention of cardiovascular diseases. They have been shown to be safe as well as efficacious in a number of different clinical trials; however, studies have suggested that they can interact with other co-administered therapies. More recently, the thienopyridines have been successfully integrated with the conventional medical treatment of coronary disease as they showed effectiveness in reducing platelet activity both in stable and unstable settings. They also improve the outcome of patients treated with percutaneous coronary intervention. The potential interaction of statins and thienopyridines is a matter of concern. Despite some preclinical data suggesting an interaction between statins metabolized by the liver cytochrome P3A4such as atorvastatin, lovastatin and simvastatinand clopidogrel, there is no compelling clinical evidence to stop their co-administration.

Background: Several devices are available for percutaneous PFO closure. Experience with the Gore-HELEX septal occluder device is relatively limited.

The safety and predictability of percutaneous coronary intervention (PCI) has improved dramatically in the last decade. The increased numbers of patients suitable for the procedures have placed pressure on existing health care systems. Treating patients with chronic stable angina on a day case basis without an overnight stay has several attractions,1 but there are some concerns over the safety of this approach. Troponin I is released rapidly following myocardial necrosis, it is highly sensitive, and may be more specific than other enzymatic markers of cardiac damage. Elevation of cardiac markers, mainly creatine kinase-MB, after both elective percutaneous and surgical revascularisation reflects myocardial necrosis and is associated with increased risk of in-hospital and long term adverse events.2 Glycoprotein (Gp) IIb/IIIa inhibitors appear to be particularly beneficial in reducing this complication,3 but day case intervention precludes overnight administration of Gp IIb/IIIa inhibitors. This audit determined the incidence of serum troponin I elevation after 6–8 hours in patients discharged the same day according to pre-specified clinical, angiographic, and procedural criteria. Two hundred and twenty nine consecutive patients were admitted for elective day case PCI from January to July 2002. This represents 30% of the total PCIs in our institution during this period (n = 762). Predetermined clinical and angiographic inclusion and exclusion criteria were …

The incidence of atrial septal defect associated with anomalous pulmonary venous drainage is low. This case illustrates the presence of partial anomalous pulmonary venous drainage into a midline atrial chamber with no interatrial communication, a situation not previously described in patients with the usual atrial arrangement. An incidental heart murmur in a 24-year-old woman led to discovery of an atrial septal defect with an apparent partition on echocardiogram. Transesophageal echocardiography and magnetic resonance imaging showed left pulmonary venous drainage into the left atrium (LA) and right pulmonary venous drainage into a midline atrial chamber that communicated with the right atrium (RA) but was completely partitioned from the LA (Figure 1, Figure 2). There were no other cardiac anomalies or visceral malformations. Cardiac catheterization confirmed absence of an interatrial communication and normal pulmonary artery pressure. There was a step up in oxygen saturation in the mid RA (94%) from the superior vena cava and high RA (78%). The main pulmonary artery saturation was 92%, whereas the right upper and lower pulmonary veins accessed through the RA into the midline chamber were 98% saturated. The left pulmonary venous drainage into the LA was visualized on the levo phase of the left pulmonary angiogram (Figure 2, B).Figure 2A, Transesophageal echocardiogram shows direction of blood flow (arrow) from midline chamber (MC) bounded by atrial septum (AS) and incomplete partition (IP) into RA and across tricuspid valve (TV) into right ventricle (RV). B, Cardiac catheterization shows occlusive nature (arrows) of atrial septum (AS) on levo phase of left pulmonary angiogram. LA and left ventricle (LV) are seen.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During the operation, the heart appeared normal externally. Right atriotomy showed a midline atrial chamber, formed by a right-sided incomplete partition and intact left-sided atrial septum, into which opened the orifices of the right upper and lower pulmonary veins. The free margin of the partition was suspended from the septal aspect of the atrioventricular junction and allowed venous return from the right pulmonary veins to flow to the tricuspid valve orifice. The atrial septum and the partition were excised, and the resulting common atrial chamber was reseptated with autologous pericardial patch to allow all pulmonary venous return to be directed into the LA. The eustachian valve and the valve of the coronary sinus were in the anatomically normal position. The patient recovered uneventfully and remains symptom free 7 years after the operation. Postoperative echocardiography confirmed drainage of all pulmonary veins into the LA. The incomplete midline accessory chamber in this case is intriguing, especially because the heart was otherwise normal, with the usual arrangement of the atrial appendages (situs solitus). It is well recognized that hearts with isomeric arrangement of the right atrial appendages (situs ambiguous) not infrequently have the pulmonary veins draining into an atrial pouch in the middle of the roof of the atrial mass.1Uemura H. Ho S.Y. Devine W.A. Kilpatrick L.L. Anderson R.H. Atrial appendages and venoatrial connections in hearts from patients with visceral heterotaxy.Ann Thorac Surg. 1995; 60: 561-569Abstract Full Text PDF PubMed Scopus (153) Google Scholar This is to be anticipated, because most of these hearts have grossly abnormal formation of the atrial septum and totally anomalous pulmonary venous connections according to morphologic criteria. To the best of our knowledge, our case exhibits a most unusual entity, one that has not been described previously. The diagnosis of the midline chamber was made with three imaging modalities. The differential diagnoses considered were partially anomalous pulmonary venous connections and cor triatriatum (also known as subdivided LA). In terms of flow, there is no doubt that the right pulmonary veins drained into the RA instead of the LA. Whether the right veins are also anomalously connected, however, cannot be determined. This is because the embryologic derivation of the intact septum to the left of the midline chamber is open to conjecture. We have considered this structure the atrial septum because in fetal life it must have been patent, at the oval fossa, to allow flow to the left side of the heart for normal development of the chambers on that side. Alternatively, this case is reminiscent of the case of subdivided LA described by Michaud and colleagues,2Michaud P. Dallaz C. Agé C. A propos d'un nouveau cas de coeur triatrial de l'adulte opéré avec succés.Arch Mal Coeur. 1970; 63: 291-300PubMed Google Scholar in which the left pulmonary veins drained into the distal chamber and the right pulmonary veins drained into the proximal chamber, the so-called type A2 of Thilenius and associates.3Thilenius O.G. Bharati S. Lev M. Subdivided left atrium an expanded concept of cor triatriatum sinistrum.Am J Cardiol. 1976; 37: 743-752Abstract Full Text PDF PubMed Scopus (83) Google Scholar The argument against our case being an example of subdivided LA is the configuration of the partition on the right side. The defect in the partition lies toward the atrioventricular junction, in a location comparable to an ostium primum, except that this heart lacks the hallmark of a common atrioventricular junction that is so characteristic of hearts with atrioventricular septal defects. It has discrete left and right atrioventricular junctions guarded by mitral and tricuspid valves, respectively. The embryologic derivation of this midline chamber is enigmatic, because the pulmonary venous incorporation into the atrium is closely timed with atrial septal development but the spatiotemporal sequence is an issue of controversy. Currently there are two schools of interpretation of the embryologic origin of the common pulmonary vein, which is the precursor of the definitive lateralized veins. The primary theory suggests the origin of common pulmonary vein within mediastinal tissues that remains distinct from the sinus venosus delineated by the right and the left venous valves.4Webb S. Kanani M. Anderson R.H. Richardson M.K. Brown N.A. Development of the human pulmonary vein and its incorporation into the morphologically left atrium.Cardiol Young. 2001; 11: 632-642Crossref PubMed Google Scholar The alternative theory supports its origin from sinus venosus, with eventual positioning of the common pulmonary vein into the LA.5Blom N.A. Gittenberger-de Groot A. Jongeneel T.H. DeRuiter M.C. Poelmann R.E. Ottenkamp J. Normal development of the pulmonary veins in human embryos and formulation of a morphogenetic concept for sinus venosus defects.Am J Cardiol. 2001; 87: 305-309Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar The septum primum grows into the common atrium and is separated from the left venous valve by the interseptovalvular space. Normally, the muscular septum secundum is formed within the interseptovalvular space and the left venous valve blends with the right side of septum secundum to obliterate this space. In this case, however, persistence of interseptovalvular space with the embryonic left venous valve remnant as the incomplete partition may explain the morphogenesis of the midline chamber. Because of marked asymmetry in the timing and sequence of events for pulmonary venous development, a process of differential pulmonary venous segregation, which supports the primary theory,4Webb S. Kanani M. Anderson R.H. Richardson M.K. Brown N.A. Development of the human pulmonary vein and its incorporation into the morphologically left atrium.Cardiol Young. 2001; 11: 632-642Crossref PubMed Google Scholar may explain right pulmonary vein malincorporation into the midline chamber. Although appreciation of the developmental basis would not have altered the surgical approach, recognition of precise anatomic disposition of this unusual anomaly is essential for effective planning of the appropriate corrective surgical strategy. Awareness of the exact nature of the pulmonary venous drainage is pivotal to the prevention of pulmonary venous obstruction and its ensuing adverse hemodynamic effects. Pillai, Balacumaraswami, Ho, Ormerod

Background Results of trials, comparing percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass grafting (CABG), indicate that rates of death or myocardial infarction are similar. with either treatment strategy. Management with PTCA is, however, associated with an increased requirement for subsequent, additional revascularisation. Coronary stents, used as an adjunct to PTCA, reduce restenosis and the need for repeat revascularisation. The aim of the Stent or Surgery (SoS) trial was to assess the effect of stent-assisted percutaneous coronary intervention (PCI) versus CABG in the management of patients with multivessel disease.Methods In 53 centres in Europe and Canada, symptomatic patients with multivessel coronary artery disease were randomised to CABG (n=500) or stent-assisted PCI (n=488). The primary outcome measure was a comparison of the rates of repeat revascularisation. Secondary outcomes included death or Q-wave myocardial infarction and all-cause mortality. Analysis was by intention to treat.Findings All patients were followed-up for a minimum of 1 year and the results are expressed for the median follow-up of 2 years. 21% (n=101) of patients in the PCI group required additional revascularisation procedures compared with 6% (n=30) in the CABG group (hazard ratio 3.85, 95% CI 2.56-5-79, p<0.0001). The incidence of death or Q-wave myocardial infarction was similar in both groups (PCI 9% [n=46], CABG 10% [n=49]; hazard ratio 0.95, 95% CI 0.63-1.42, p=0.80). There were fewer deaths in the CABG group than in the PCI group (PCI 5% [n=22], CABG 2% [n=8]; hazard ratio 2.91, 95% CI 1.29-6-53, p=0.01).Interpretation The use of coronary stents has reduced the need for repeat revascularisation when compared with previous studies that used balloon angioplasty, though the rate remains significantly higher than in patients managed with CABG. The apparent reduction in mortality with CABG requires further investigation.

Very elderly patients are excluded from most trials of percutaneous coronary intervention (PCI).1,2 There is little contemporary data to guide clinical decision making, particularly in elderly patients presenting with acute coronary syndromes. We have analysed the procedural outcomes of patients 80 years or older undergoing PCI in our centre. All patients over 80 years of age undergoing PCI between January 1996 and December 1999 were identified from the catheterisation laboratory computer database. Baseline clinical characteristics, indications for coronary intervention, and procedural outcomes were obtained by retrospective review of hospital records. All patients received a heparin bolus (5000–10 000 IU), administration of abciximab was at the operators' discretion, and postprocedural heparin was not used routinely. Routine antiplatelet treatment included long term aspirin, and ticlopidine or clopidogrel for four weeks, usually with preloading. Lesions were classified according to the American College of Cardiology/American Heart Association grading system. Immediate angiographic success was defined as deployment of the stent at the site of the lesion with a residual stenosis < 30%. Clinical success was defined as angiographic success plus the absence of major adverse cardiac events (MACE) while in hospital for the index PCI—that is, myocardial infarction, the need for repeat revascularisation, coronary artery bypass grafting (CABG), or …

Beta-blockers and calcium antagonists are both effective monotherapy for stable angina. When symptoms persist, these two agents are commonly co-prescribed in the hope that this combination has added benefit compared with monotherapy alone. We investigated the additional efficacy of the calcium antagonists amlodipine and nifedipine when added to bisoprolol in patients with stable angina. Patients were randomised in a multicentre, single-blind study, with crossover of three treatments consisting of bisoprolol 10 mg once daily, bisoprolol plus nifedipine 20 mg twice daily, and bisoprolol plus amlodipine 5 mg once daily. Exercise tests were performed at the end of each four-week study period and the exercise time to onset of angina was assessed. A total of 198 patients from 17 centres were recruited of whom 147 were evaluable for efficacy. There were no statistically significant differences in exercise duration to onset of angina between any of the groups. The combination of bisoprolol plus nifedipine was least well tolerated. In summary, this study suggests there is little benefit in adding a calcium antagonist to bisoprolol in treating patients with stable angina.

Background The role of percutaneous transluminal coronary angioplasty (PTCA) in the management of patients with angina remains controversial, particularly in patients whose symptoms are adequately controlled by medical treatment.Methods RITA-2 is a randomised trial comparing the long-term effects of PTCA and conservative (medical) care in patients with coronary artery disease considered suitable for either treatment option. 1018 patients were recruited from 20 cardiology centres in UK and Ireland. The 504 randomised to PTCA were intended to have dilatation within 3 months. The 514 assigned to medical treatment received antianginal drugs; those whose symptoms were not controlled by optimum medical therapy could cross-over to myocardial revascularisation. The primary endpoint was the combined frequency of death from all causes and definite non-fatal myocardial infarction.Findings This report covers a median 2.7 years' follow-up. At randomisation 53% of patients had grade 2 or worse angina, and 40% had two or more diseased coronary arteries. 93% of patients randomised to PTCA had this procedure carried out, within a median of 5 weeks. Death or definite myocardial infarction occurred in 32 patients (6.3%) treated with PTCA and in 17 patients (3.3%) with medical care (absolute difference 3.0% [95% CI 0.4-5.7%], p=0.02). This difference was mainly due to one death and seven non-fatal myocardial infarctions related to the randomised procedures. There were 18 deaths (11 PTCA, seven medical) of which ten were not due to heart disease. Of the patients in the PTCA group, 40 (7.9%) required coronary artery bypass grafting (CABG), including nine instead of PTCA and seven emergencies following unsuccessful PTCA. 56 other PTCA patients (11.1%) required further non-randomised PTCA. In the medical group 118 patients (23.0%) underwent a revascularisation procedure during follow-up, mostly because of worsening symptoms. Angina improved in both groups, but more so in the PTCA group. There was a 165% absolute excess of grade 2 or worse angina in the medical group 3 months after randomisation (p<0.001), which attenuated to 7.6% after 2 years. Total exercise time (Bruce protocol) also improved in both groups, again with a treatment difference in favour of PTCA: mean advantage of 35 s at 3 months (p<0.001). These benefits of PTCA were greater in patients with more severe angina at baseline, judged by high initial grade of angina and short initial exercise-time.Interpretation In patients with coronary artery disease considered suitable for either PTCA or medical care, early intervention with PTCA was associated with greater symptomatic improvement, especially in patients with more severe angina. When managing individuals with angina, clinicians must balance these benefits against the small excess hazard associated with PTCA due to procedure-related complications.