There is still a lack of data on the influence of different stent designs on long-term restenosis rates and major adverse cardiac events (MACE) with the use of new antithrombotic regimens. We evaluated the midterm (6 months) clinical and angiographic and lateterm (2 years) clinical outcome of Helistent stent implantation.
The study population consisted of 150 patients with high risk factor rates who had single or multivessel disease and had undergone coronary Helistent stent implantation with new antiplatelet regimens. The control coronary angiographies were done at 6 months and they were followed clinically to the end of 2 years.
In 150 patients, 236 Helistent stents were implanted for 224 lesions. Helistent stent implantation was associated with a very high success rate (99%). The angiographic re-stenosis rate was 11.3% at 6 months. Only 16% of the patients experienced target lesion revascularization, 20% of the patients experienced MACE and of them, only 3.3% died at the end of two year follow-up period.
The results demonstrate that the Helistent stent can be implanted with a high success rate with encouraging 6 month angiographic and late clinical outcomes.

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Late potentials (LP) detected on the signal-averaged electrocardiogram (SAECG) predict arrhythmic events after acute myocardial infarction (AMI). It is also well established that successful thrombolytic therapy reduces the incidence of LP. Our aim was to evaluate the effects of a beta-blocker on LP in patients receiving thrombolytic therapy. We studied 40 patients presenting with anteroseptal AMI (< 6 hours). All patients received thrombolytic therapy and were evaluated with coronary angiography at predischarge. Eighteen patients received metoprolol (5 mg IV on admission followed by 50 mg BID). SAECG recordings were obtained serially using an ART system (40-250 Hz filter, noise < 0.5 mV) prior to thrombolytic therapy, after 48 hours and after 10 days. LP was defined as posi-tive if the SAECG met at least 2 of the Gomes criteria. Changes observed in SAECG recordings after thrombolytic therapy were correlated with angiographic and clinical data with regard to the usage of BB. The frequencies of LP before and after thrombolytic therapy were compared with the McNemar test. There were no significant differences between the clinical characteristics, risk factors, and angiographic findings (including infarct related artery patency and LV functions) of the groups. Baseline SAECG findings were also similar between the groups. The incidence of LP significantly decreased after TT in the BB group, however, this change was not observed in patients who did not receive BB (P = 0.012, McNemar test). Beta-blockers reduce the incidence of LPs following thrombolytic therapy in patients with anterior AMI. This might be explained by the possible beneficial effect of BB on the arrhythmogenic substrate.

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The current trend in coronary artery surgery is to revascularize the left coronary artery branches with bilateral internal thoracic arteries (ITA). For this procedure, the right ITA is usually grafted to the left anterior descending coronary artery while the circumflex coronary artery is revascularized by the left ITA. The mid to long-term results of the left ITA on the circumflex system were examined in this study.
Forty of 48 patients operated on between 1996 and 1998 who had undergone revascularization of the left coronary artery with both ITAs and who fulfilled the study criteria underwent control coronary arteriography to determine the mid to long-term patency of LITA grafts on the circumflex artery. The median time for follow-up was 53 months (range, 49 to 70 months). Of the 40 angiographically controlled patients, 35 had patent left ITA to circumflex artery anastomosis (87.5%). One graft stenosis and four graft occlusions were observed. In the same group, right ITA to left anterior descending coronary artery anastomoses were patent in 38 patients (95%).
Left ITA grafts seem to be the conduit of choice for revascularization of the circumflex coronary artery. In combination with the in situ right ITA to left anterior descending coronary artery anastomosis, in situ left ITA grafting to the circumflex system can be done with acceptably low mortality and excellent long-term patency rates. Its utilization is particularly advised in young patients where the importance of left coronary artery revascularization by bilateral ITA grafts is increased.

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The benefit of primary percutaneous coronary intervention is limited by a 5% to 20% incidence of suboptimal epicardial coronary blood (≤ TIMI-2 flow). Recently, data has demonstrated that when administered in conjunction with primary stenting for the treatment of acute myocardial infarction (AMI), abciximab improves the success rate of the stenting procedure and provides additional clinical benefits. But data on a combination of tirofiban and primary stenting for treatment of ST-segment elevated (ST-se) AMI is unknown.
Between May 1999 and September 2000, primary stenting without adjunctive tirofiban therapy was performed in 136 consecutive patients (control group) with ST-se AMI. Between January 2001 and May 2002, we routinely administered tirofiban to 133 consecutive patients (study group) with ST-se AMI before they underwent primary stenting. The angiographic and clinical outcomes of both groups were compared in a chronologically consecutive manner. The overall mortality rate was significantly higher in patients with failed (≤ TIMI-2 flow) than in patients with successful (TIMI-3) reperfusion (20.0% vs 3.5%, P < 0.0001). Univariate analysis demonstrated that there were no significant differences in the successful reperfusion (85.7% vs 84.6%, P = 0.84) or 30-day combined end points — death, recurrent ischemia or reinfarction (8.3% vs 11.0%, P = 0.59) between study and control group patients. Clinical variables were used to statistically analyze potential risk factors for unsuccessful reperfusion (≤ TIMI-2 flow) in the study group patients. Multiple stepwise logistic regression analysis demonstrated that the reference lumen diameter (RLD) of the infarct-related artery (IRA) ≥ 3.5 mm (P = 0.0004) and the lesion length of the obstruction ≥ 20.0 mm (P = 0.018) were the significant independent predictors of failed normalized coronary blood flow. There were no significant differences in the restenotic rate of IRA (29.2% vs 30.8%, P = 0.9) or mortality rate (1.6% vs 1.6%, P = 1.0) at six-month follow-up. In conclusion, our study demonstrates that primary stenting with adjunctive tirofiban therapy in ST-se AMI did not provide additional benefits in short-term and intermediate-term angiographic and clinical outcomes compared to conventional primary stenting.

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The baseline cardiac troponin T (cTnT) level strongly predicts short-term mortality in acute coronary syndromes, but the added value of predischarged (7^th day) measures to predict short-term outcome and left ventricular (LV) remodeling in patients with ST elevation myocardial infarction (MI) is controversial.
Baseline, peak and predischarged cTnT results were evaluated in 52 patients (15 females, 37 males, mean age, 54.4 ± 8.8 years) with first acute anterior MI. There were 4 deaths (all cardiac origin) during the 30 day follow up period. Kaplan-Meier analysis revealed patients with a predischarged serum cTnT level higher than the median level (1.2 ng/mL) had a higher mortality rate than those with submedian levels (P < 0.05). Additionally, the highest correlation rate was found between predischarged cTnT values and LV ejection fraction (LV-EF, r = -0.58, P < 0.002). There were no differences between the groups in the 7^th day left ventricular diastolic parameters, but the 30^th day isovolumetric relaxation time and mitral E wave deceleration time were shorter (146.9 ± 30.1 vs 129 ± 23.4 msec, P = 0.025 and, 185.8 ± 51.8 vs 144.6 ± 58.1 msec, P = 0.012) in patients with higher predischarged cTnT level.
High levels of predischarged cTnT levels in patients admitted with first acute anterior MI defines a subgroup. These patients have poor systolic and diastolic functions and are at increased risk of short term mortality. This group of patients may have benefit from early intensive treatment strategies before discharge.

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The purpose of the study was to compare the impacts of angiographically successful direct stent implantation and conventional stent implantation (stent implantation following predilatation) on long-term major cardiac events.
The authors prospectively studied 40 patients who had successful direct stent implantation and 46 patients who had successful conventional stent implantation. The end-point of the study was defined as the occurrence of a major cardiac event, including recurrent angina, acute myocardial infarction, death, and target vessel revascularization.
The demographic and clinical characteristics of the study groups were similar, except the indication of percutaneous angioplasty, which was more frequently unstable angina in the conventional stent group (63% vs 38%, P: 0.03). Procedural minor complications were more frequent in conventional stent implantation, and there was also a positive correlation between the conventional stent implantation and procedural minor complications (r = 0.231, P: 0.03), and postprocedural troponin elevation (r = 0.221, P: 0.04). The incidences of major cardiac events including recurrent angina, acute myocardial infarction, death, death or myocardial infarction, and target vessel revascularization were not different between the study groups during the long-term follow-up period (21 ± 7.1 months for direct stent group and 20 ± 7.5 months for conventional stent group). Overall end-points occurred in 9 patients (22%) in the direct stent group and in 9 patients (19%) in the conventional stent group. Kaplan-Meier survival analysis showed that there was no difference in event-free survival between the patients treated with direct stent implantation and conventional stent implantation (log-rank: 1.52, P = 0.21). Two-vessel intervention and hypertension were found to be related with long-term major cardiac events (r = 0.214, P: 0.048, r = 0.206, P: 0.04, respectively).
In addition to the procedural advantages, direct stent implantation may also provide comparable results with conventional stent implantation concerning the late cardiac events following successful percutaneous coronary angioplasty.

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Transesophageal atrial pacing study was used to document arrhythmias in 67 infants and children age 2 months to 16 years (mean, 8.3 years), who had palpitations or symptoms suggesting tachyarrhythmias but had no electrocardiographic documentation of cardiac dysrhythmias. The transesophageal pacing and medical records were reviewed retrospectively.
In 47 of 67 (70%) of the infants and children with suspected tachyarrhythmias, transesophageal atrial pacing induced various tachycardias, which may be the cause of symptoms. In 10 of 67 patients, tachycardia was induced during infusion of isoproterenol. During the study, tachycardia was initiated in 14 of 15 patients less than < 6 years-old and in 33 of 52 patients ≥ 6 years-old (P < 0.05). Of these induced tachycardias, 25 of 47 were atrioventricular reciprocating tachycardia, 16 atrioventricular nodal reentrant tachycardia, and 6 idiopathic left ventricular tachycardia. Both transesophageal study and invasive electrophysiologic study were performed in 10 patients. The mechanisms of tachycardia in the invasive study and transesophageal study were identical except for one patient.
In conclusion, transesophageal atrial pacing and recording was less invasive, safe and useful for documenting arrhythmias in infants and children who had symptoms suggesting tachyarrhythmias, especially in patients < 6 years of age. Evaluation of the mechanism of induced tachycardia provided useful information regarding the prognosis and therapeutic options in infants and children.

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A variety of myocardial lesions have been demonstrated in atrial muscle in patients with sick sinus syndrome (SSS), but the right ventricular myocardium has not been studied in detail in a large series. Therefore, we performed right ventricular endomyocardial biopsies in 25 patients with SSS (SSS group), and the presence or absence of ventricular myocardial lesions was determined histologically. As a control, biopsies of corresponding sites in 12 normal autopsied hearts were obtained (N group). The mean cardiac myocyte transverse diameter was 14.2 ± 3.6 μm in the SSS group and 11.7 ± 3.1 μm in the N group (P < 0.01). In the SSS group, cardiac myocyte hypertrophy was observed in 20 of 25 subjects (80%), and myocyte size variation was more frequent. Although the difference was not significant, myocyte disorganization, myocytolysis, nuclear deformity, interstitial large mononuclear cell proliferation, and endocardial lesions, which were not seen in the N group, were observed in the SSS group. A variety of myocardial lesions, including cardiac myocyte hypertrophy, are present not only in atrial, but also in ventricular muscle in SSS.

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Pulmonary veins are the most frequent origin of focal and paroxysmal atrial fibrillation. Although radiofrequency ablation has been attempted for the treatment of focal and paroxysmal atrial fibrillation, the anatomy of the pulmonary vein is still not fully understood. To investigate the dimensions and anatomical variation of the pulmonary vein in patients with paroxysmal atrial fibrillation, we performed breath-hold gadolinium enhanced magnetic resonance (MR) angiography using a 1.5 T cardiac MR imager (GE CV/i) in 32 patients with paroxysmal atrial fibrillation (61 ± 8 years old), 11 patients with chronic atrial fibrillation (64 ± 9 years old), and 26 patients with normal sinus rhythm (55 ± 15 years old). Three dimensional images of the pulmonary veins were thus obtained, and the diameters of the most proximal portion of the left or right superior pulmonary vein and left or right inferior pulmonary vein were measured. Pulmonary vein branching variations were determined by a visual qualitative analysis by two separate readers' agreements, who were blinded to any clinical information. We focused on the existence of a complex-branching pattern draining into the orifice of four pulmonary veins. Patients with either paroxysmal atrial fibrillation or chronic atrial fibrillation showed larger superior pulmonary veins than those with normal sinus rhythm (mean ± SD; in the left superior pulmonary vein, 20 ± 3 mm, 23 ± 3 mm vs 16 ± 3 mm, P <0.05; in right superior pulmonary vein, 19 ± 4 mm, 19 ± 2 mm vs 16 ± 2 mm, P < 0.05). Complex-branching pattern was frequently observed in inferior pulmonary veins in patients with either paroxysmal atrial fibrillation or chronic atrial fibrillation; 25/32 patients with paroxysmal atrial fibrillation, 11/11 patients with chronic atrial fibrillation, compared to 7/26 patients with normal sinus rhythm. Complex-branching patterns were not observed in superior pulmonary veins in any patients in this cohort. Conclusion; In patients with paroxysmal atrial fibrillation or chronic atrial fibrillation, significant pulmonary vein dilation occurred mainly in the superior pulmonary veins, while a complex-branching pattern was frequently observed in the inferior pulmonary veins. These MR angiographic findings might be useful when performing radiofrequency ablation procedures and catheter manipulation for the treatment of paroxysmal atrial fibrillation.

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To examine whether angiotensin-converting enzyme (ACE) inhibitors are effective at inhibiting further fibrous changes in atria in patients with chronic atrial fibrillation, we retrospectively evaluated the time course of fibrillatory wave amplitudes and the effects of an ACE inhibitor on the changes. We reviewed medical records and electrocardiographic files. The patients were eligible for inclusion if they had chronic atrial fibrillation for more than 10 years. The fibrillatory wave with the greatest amplitude was measured in lead V₁ of standard electrocardiograms. A total of 31 patients were enrolled and were divided into two groups according to treatment. Twelve patients were classified as the ACE inhibitor group and 19 as the non-ACE inhibitor group. There was no significant difference in the mean value of the fibrillatory wave amplitude at baseline between the 2 groups (ACE inhibitor group, 0.23 ± 0.02 mV; non-ACE inhibitor group, 0.18 ± 0.02 mV). The fibrillatory wave amplitude decreased significantly after 10 years in both groups (ACE inhibitor group, 0.10 ± 0.02 mV; non-ACE inhibitor group, 0.11 ± 0.01 mV) and the changes in the fibrillatory wave amplitude were similar between the 2 groups. These results suggest that ACE inhibitors are not effective at inhibiting further fibrous changes in atria in patients with chronic atrial fibrillation.

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Existing data on the effect of retained pacemaker leads on right ventricular (RV) and tricuspid valve function is limited.
Objective: In this echocardiographic study we investigated the long-term effect of retained ventricular leads on RV and tricuspid valve function in patients with permanent pacemakers.
Forty patients, 18 with two (group I) and 22 with one (group II) ventricular lead were assessed echocardiographically at an average of 39 months after the second lead implantation in group I and 80 months after the lead implantation in group II.
The sum of the lead body diameter in group I was significantly greater than the body diameter in group II (P < 0.000). There was no significant difference between the groups with respect to chamber diameters and ventricular or valvular functions. The distributions of the different tricuspid regurgitation (TR) grades were similar, with the majority of patients in both groups having mild TR.
Retained second pacemaker leads do not have an additional negative effect on right ventricular and tricuspid valve function.

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Abnormalities of proteoglycan, collagen, and elastic fibers were found in floppy mitral valves. Perlecan is one of the three major classes of heparan sulfate proteoglycans within the cardiovascular system. The role of perlecan genetic variant in mitral valve prolapse (MVP) has not been studied. We therefore performed a case-controlled study investigating the possible relation between the perlecan gene intron 6 BamHI polymorphism and MVP among the Chinese population in Taiwan.
We studied 100 patients with MVP diagnosed by echocardiography and 100 age- and sex-matched normal control subjects. The perlecan gene intron 6 BamHI polymorphism was identified by polymerase chain reaction-based restriction analysis.
There were no significant differences in either the genotype distribution or allelic frequencies between MVP cases and controls for perlecan gene intron 6 BamHI polymorphism (P = 0.20 and 0.76, respectively). Further categorization of the MVP patients into mild and severe subgroups also revealed no statistical difference from controls for perlecan gene intron 6 BamHI polymorphism.
It is concluded that perlecan gene intron 6 BamHI polymorphism is not a suitable genetic marker of MVP in Taiwan Chinese

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Cardiovascular risk factors are important causes of morbidity and mortality in postmenopausal women. The aim of this cross-sectional study was to evaluate the cardiovascular risk factors in 207 postmenopausal Turkish women over 45 years old in a rural district of West Anatolia, Manisa Muradiye district.
A questionnaire on socioeconomic and sociodemographic characteristics was conducted in the women followed by the measurement of blood pressure, fasting blood glucose, cholesterol levels, and waist-hip ratio along with an electrocardiogram (ECG). The European Cardiology Society risk index was used for cardiovascular risk evaluation.
The results showed that 86% percent of the women will be carrying more than a 5% probability of developing a cardiovascular risk in the next 10 years. Moreover, the results proved 7% of the women are at high risk for a cardiovascular condition. Hypertension, hypercholesterolemia, and impaired glucose tolerance, were observed in 62%, 35.3%, and 13.5% of the women, respectively. Seven percent had smoked for at least six months. Fourteen cases had complained of exercise angina and pathologic ECG signs were diagnosed in one-third of these 14 cases. The waist-hip ratio measured 0.8 or more in 66.2% of the cases, with a range of 68-147 cm (mean; 95.6 ± 11.55).
The results indicate that the risk of a cardiovascular condition developing is extremely high in postmenopausal West Anatolian women and increases with age. Morever, the prevalance of hypertension increased with age and was very closely related with low socioeconomic levels. These hazardous cardiovascular disease risk factors should be considered as high priority health problems in rural and low socioeconomic areas of developing communities. Intervention to modify the cardiovascular risk factors should be included in routine primary health care programs.

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Proliferation of vascular smooth muscle cells (VSMCs) is under the control of cell cycle regulator activity, which is induced by several growth factors. Recent attention has been drawn to treatments that target cell cycle regulators to prevent the proliferation of VSMCs after coronary angioplasty. However, histopathological evaluation of cell cycle regulator expression after human coronary stenting has not been sufficient.
Thirty-one coronary arteries of 23 cadavers were examined. Time from stent implantation to patient death ranged from 0 to 235 days. Sections were stained with antibodies against platelet-derived growth factor (PDGF), basic fibroblast growth factor (b-FGF), cyclin D1, p16, p21, and p27. Staining for macrophage colony stimulating factor receptor (MCSF-R) was conducted to detect dedifferentiated VSMCs.
MCSF-R-positive cells were observed in neointima but decreased in the late stage. PDGF was detected in neointima and decreased gradually. Expression of cyclin D1 appeared to be associated with the proliferation of VSMCs, whereas p27 was downregulated with the proliferation of neointima and upregulated in the late stage.
Our results suggest that one of the most promising methods for preventing excessive proliferation of neointima after stenting is to limit the decrease in p27 or the increase in cyclin D1.

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A 63-year-old Japanese man was readmitted to our hospital due to acute broad-anterior myocardial infarction (AMI). The proximal left anterior descending artery (LAD) at the prior stent, which was implanted 19 months earlier and in which no angiographic restenosis was recognized 13 months before the second study, was totally occluded. After crossing a guide wire and balloon angioplasty, angiographic radiolucency was observed at the prior stent, suggesting that AMI was induced by late coronary stent thrombosis. Intravascular ultrasound performed 19 days after the onset of AMI revealed superficial calcification without significant stenosis and an atherosclerotic plaque distal to the stent that was not significantly changed compared to 19 months previously, consistent with the culprit lesion being an intrastent site. AMI may thus be induced by late coronary stent thrombosis during long-term clinical follow-up without clinical symptoms or angiographic restenosis at the second study.

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Bidirectional flow in patients with normal coronary arteries is an indicator of intercoronary continuity, a rare variant of coronary circulation, distinct from collaterals. The case of an 18 year old Turkish male with bicuspid aorta and intercoronary artery is reported and different aspects of this interesting entity are emphasized.

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We report on a 51-year-old Japanese female with bilateral coronary artery aneurysms. Severe calcified aneurysms were detected in the proximal right coronary artery (RCA) and left anterior descending branch (LAD). The RCA was totally occluded and supplied by the blood flow via septal branches of the LAD. A two-stage management plan, including an off-pump coronary artery bypass grafting for the RCA with a right gastroepiploic artery and catheter angioplasty with an autologous vein graft-coated stent for the LAD, was successfully completed. Prophylactic treatments for coronary artery aneurysm are still controversial, therefore, minimal invasive procedures should be favored to prevent acute cardiac shock or sudden death related to aneurysmal obstruction.

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Brugada syndrome is characterized by right bundle branch block morphology and ST-segment elevation in the right precordial leads and a propensity to develop ventricular arrhythmias. Mutations in a cardiac sodium channel gene have been linked to this syndrome, and the ionic mechanisms responsible for the electrocardiographic phenotype are temperature-dependent. This case report describes a patient in whom a typical Brugada ECG pattern developed during fever and could be reproduced at normal body temperature by administration of pilsicainide.

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An asymptomatic 35 year-old man was referred to our hospital because of abnormal ECG findings. The ECG showed complete right bundle branch block and left anterior hemiblock. Echocardiography revealed a moderately enlarged right ventricle (RV) and an apical aneurysm. RV wall motion showed diffusely moderate impairment, while the systolic function of the left ventricle (LV) was slightly decreased. The ejection fractions (EF) of the RV and LV were calculated as 28.1% and 41.9% by Simpson's method using multiple cardiac computed tomography (CT) scans. A 24 hour ambulatory ECG showed only 372 single premature ventricular contractions (PVC). Cardiac catheterizaion revealed that the RV was enlarged with prominent trabeculation and decreased motion. In an electrophysiologic study, neither electrical stimulation of the RV nor electrical stimulation plus isoproterenol infusion could induce ventricular tachycardia. Pathological examination of a biopsy from the interventricular septum of the RV revealed fibrofatty change in the myocardium. Based on these results, we made a diagnosis of arrhythmogenic right ventriclular cardiomyopathy (ARVC) and administered 5 mg of carvedilol. Sixty days after the initiation of carvedilol therapy, we performed repeat cardiac CT. The EF of the LV was markedly improved from 41.9% to 62.0%, although the EF of the RV was not changed. The number of PVCs showed no change. This case suggests that carvedilol is not only useful for controlling arrhythmia but also for improving left ventriclular function in some patients with ARVC. Sympathetic overactivity is reported to cause sudden death, so carvedilol may be a first-line drug for some patients with ARVC.

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