תוצאת חיפוש

Characteristics, Management and Prognosis of Acute Myocardial Infarction (Israel 1990-1996)

Israeli Survey Group On Acute Myocardial Infarction

From 1990 to 1996 we conducted consecutive 2-month surveys in all CCUs (n=26) in Israel. The aim was to compare the characteristics, management, and prognosis of patients with acute myocardial infarction (AMI) between the 4 surveys.

Patient characteristics were similar in all surveys. About 75% of patients were males and had a first MI. Mechanical and arrhythmic complications decreased slightly between 1990 and 1996. In contrast, frequency of treatment with thrombolysis, aspirin, beta-blockers and ACE-I, as well as coronary interventional procedures, increased tremendously.

In parallel, 30-day and 1-year mortality decreased significantly, from 16.5% and 22.5%, respectively, to 9.0% and 13.9%. After multiple adjustment for factors associated with mortality, the 30-day relative risk of death for patients hospitalized in 1992, 1994 and 1996 was 0.79 (95% CI 0.59-1.08), 0.75 (95% CI 0.56-1.01) and 0.54 (95% CI 0.39-9.74), respectively, as compared with 1990.

Although there is no direct proof that changes in management of AMI are related to the reduction in mortality seen during the course of the surveys, the association seems likely.

Transurethral Microwave Thermotherapy

Boaz Moskovitz, Shahar Madjar, Sarel Halachmi, Ofer Nativ

Dept. of Urology, Bnai Zion Medical Center, Haifa

The effectiveness of transurethral microwave thermotherapy (TUMT) for benign prostatic hypertrophy in poor surgical risk patients (ASA class IV) with indwelling catheters, was assessed. All had had an indwelling catheter for 1-12 months. Removal of the catheter was possible in 14 out of the 24 (58.3%). Urinary peak flow rates were 12.2±3.5 ml/sec at 3 months of follow-up and post-voiding residual urine volumes of less than 50 ml were recorded in 13 catheter-free patients. Our data suggest that TUMT is an effective procedure for management of high risk patients with indwelling catheters in whom surgery or anesthesia are contraindicated.

Emergency Stenting for Acute Left Main Coronary Artery Closure during Cardiac Catheterization

Alberto Hendler, Oren Agranat

Catheterization Laboratory, Rama Marpeh Hospital, Petah Tikva

We report a case of acute closure of the left main coronary artery, a rare complication of diagnostic cardiac catheterization, treated by emergency stenting prior to aorto-coronary by-pass surgery. We suggest encroachment of the Judkins catheter into a calcified left main ostium, with dissection and acute thrombosis of this segment, as the possible mechanism.

Clinically, the patient's condition deteriorated to cardiogenic shock and loss of consciousness. Remarkably, there was no angiographic evidence of significant left main coronary artery disease, besides the presence of calcification in the proximal part of the left coronary system and ventricularization of coronary pressure at the time of engagement. We chose to slide quickly the angioplasty guidewire through the left main coronary artery, which allowed prompt mechanical recanalization and rapid restoration of coronary flow, with dramatic clinical and hemodynamic improvement. This relatively simple procedure allowed stenting the left main artery after brief predilation, and the patient came to by-pass surgery in excellent condition. The rationale for surgery in this case was the need for complete coronary revascularization because of significant 3-vessel coronary artery disease.

Skeletonized Internal Mammary Arteries for Coronary Bypass Grafting

Jacob Gurevitch, Yosef Paz, Menachem Matsa, Amir Kramer, Dimitri Pevni, Oren Lev-Ran, H. Locker, Raphael Mohr

Dept. of Thoracic and Cardiovascular Surgery, Sourasky-Tel Aviv Medical Center

The skeletonized internal mammary artery (IMA) is longer, and its immediate spontaneous blood flow is greater than that of the pedicled IMA, thus providing increased versatility for complete, arterial myocardial revascularization without the use of saphenous vein grafts. From April 1996 to May 1997, 583 patients underwent coronary artery bypass grafting here and in 415 (71%) complete arterial revascularization was achieved using bilateral skeletonized IMA. The right gastroepiploic artery was used in 57 (13%); there were 329 males (79%) and 86 women (21%); average age was 64 (30-87) and 175 (36%) were older than 70; 131 (32%) were diabetics. Average number of grafts was 3.2 (range 2-6 grafts). At 30 days, 5 (1.2%) had died and there had been 6 perioperative infarcts (1.4%), 5 CVA's (1.2%), and 6 had sternal wound infections (1.4%). Up to 1-12 months of follow-up was achieved in 409 (99%). Late mortality was 1.4% (of which 3 were noncardiac). 394 (97%) were angina-free at latest follow-up. We conclude that arterial revascularization using bilateral skeletonized IMA is safe, as postoperative morbidity and mortality are low, even in old and diabetic patients.

Percutaneous Revascularization of the Left Main Coronary Artery as Coronary Artery Bypass in High Surgical Risks

Yoseph Rozenman, Chaim Lotan, Hisham Nassar, Mervyn S. Gotsman

Cardiology Dept., Hadassah-University Hospital (Ein Kerem) and Hebrew University-Hadassah Medical School, Jerusalem

Coronary artery bypass grafting is the treatment of choice for obstructive disease of the left main coronary artery. Its proximal location and easy accessibility make the left main artery an inviting target for percutaneous intervention, an approach contraindicated by the high associated risk. We describe 2 patients at high operative risk in whom the obstructed main coronary artery was successfully revascularized percutaneously. Coronary stenting and rotational ablation of calcified arteries are essential for successful outcome and minimize complications.

Effect of Alpha-Alpha Esterol on Plasma Cholesterol and Antioxidants

Y. Levy, E. Paster, G. Dankner, A. Ben-Amotz, J.G. Brook

Lipid Research Unit, Medical Dept. D, Rambam Medical Center; Rappaport Faculty of Medicine, The Technion; and Israel National Oceanographic Research Institute, Haifa

16 patients with hypercholesterolemia were treated with an extract of alpha-alpha leaves (esterol) while on a low-fat, low-cholesterol diet. Esterol is believed to inhibit the absorption of cholesterol and bile acids and may interfere with the absorption of essential nutrients. As oxidative modification of lipoproteins is required for the process of atherosclerosis, plasma antioxidant vitamins were followed. After 4 months of treatment, plasma cholesterol decreased by 10% from 282 to 250 mg/dl (p<0.001) and LDL cholesterol by 13%, from 203 to 177 mg/dl (p<0.001). Plasma antioxidant vitamins E, A and β-carotene were unchanged. Thus, esterol has a cholesterol-lowering effect but apparently does not lower fat-soluble, plasma antioxidant vitamins. Both cholesterol-lowering and plasma antioxidant vitamins are important for the primary prevention of coronary artery disease in hypercholesterolemia.

Diagnosis of Cerebral Embolism by Transesophageal Echocardiography

A. Mahagney, D. Sharif, B. Weller, E. Abineder, B. Sharf

Depts. of Neurology and Cardiology, Bnai Zion Hospital, Haifa

Cerebrovascular events have high mortality and morbidity, especially in the elderly. Ischemia is the main cause and 30% of the ischemic events are embolic and of cardiac origin. The clinical picture is not always typical of the type of stroke, but diagnosis of the mechanism of the event determines treatment. Transesophageal echocardiography (TEE) is a sensitive procedure more appropriate for diagnosing emboli of cardiac origin than transthoracic echocardiography (TTE). We therefor compared TEE and TTE in the determination of the source of emboli in 65 patients with ischemic stroke but without significant atherosclerotic changes in their carotid arteries, and compared these findings with those in 50 patients without stroke. 68% of the patients had potential sources of emboli according to TEE, compared to only 15% according to TTE. In the control group only 24% had potential sources of emboli by TEE. The findings were: clots in the left atrium, severe aortic atheroma, patent foramen ovale with paradoxical shunt, spontaneous echocardiography contrast, vegetations and mitral valve prolapse. The study showed that TEE is better than TTE in detecting the etiology of embolic stroke in those with normal carotid arteries, thus determining appropriate management.