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BACKGROUND: Rescue angioplasty (rPCI) for failed fibrinolysis is associated with a low mortality if successful, but a high mortality if it fails. The latter may reflect a high-risk group or harm in some patients. Predictors of success or failure of rPCI may aid selection of patients to be treated. METHODS: Unselected patients referred for rPCI from March 1994 to March 2005 were studied to determine the predictors of a failed procedure and 1-year mortality. RESULTS: Of 440 patients undergoing emergency coronary angiography for failed fibrinolysis (1-year mortality 18%), 101 had thrombolysis in myocardial infarction flow grade (TFG) 3 in the infarct-related vessel. rPCI was attempted in 318 of 339 patients with 75 years, shock, and final TFG < 3 were independent predictors of 1-year mortality. CONCLUSIONS: Cardiogenic shock is an independent predictor of a failed rPCI. Age group >75 years and shock were the only independent clinical predictors of 1-year mortality. These clinical variables may help in selecting patients for either a strategy of rescue angioplasty after failed fibrinolysis, or in selecting specific patients who might do better with a policy of primary angioplasty.

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INTRODUCTION: For many years, coronary angiography has been used to define coronary artery lesions. Angiographic assessment of coronary flow using the TIMI flow grade system (TFG) and the TIMI frame count (TFC) methods have played a significant role in our understanding of coronary artery disease and they have proved useful in prediction of long-term clinical outcomes after myocardial infarction. The availability of invasive techniques to assess the physiological significance of coronary artery lesions allows a more rationale approach to the management of patients, particularly those with intermediate lesions. The TIMI scores and other angiographic parameters such as the TIMI myocardial perfusion grade (TMPG) are now integrated into clinical practice, as are the use of flow wires and pressure recording wires. Other angiographic techniques, (e.g. digital subtraction angiography), which at this time are predominantly research tools, will require software integration into the imaging chain to facilitate real-time analysis. CONCLUSION: In this article, we provide a comprehensive descriptive review of the different means of assessment of coronary flow in the cardiac catheterization laboratory, focusing on scores deducted from angiography as well as invasive haemodynamic measurements of blood flow and pressure.

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UNLABELLED: The impact of chronic coronary obstructions on resting blood flow in stable cardiac patients and the response to percutaneous coronary intervention (PCI) using the TIMI frame count method has not been well documented. We studied the impact of coronary artery stenosis severity on the corrected TIMI frame count (cTFC) in chronically stenosed coronary arteries. We prospectively and quantitatively determined the impact of stenting on the cTFC during elective PCI. METHODS: In substudy 1, analysis was performed to obtain the mean cTFC for arteries with <50% stenosis (Group A), 51-75% stenosis (Group B), 76-85% stenosis (Group C1), 86-95% stenosis (Group C2) and 96-99% stenosis (Group C3). In substudy 2, the cTFC and quantitative coronary angiography were performed pre- and post-PCI. RESULTS: In substudy 1, the cTFC increased exponentially beyond a diameter stenosis of 75% (P < 0.01). However there was no significant difference in the cTFC for coronary arteries with <75% stenosis. In substudy 2, the overall pre- and poststenting cTFC was 17.1 +/- 11.7 and 7.8 +/- 2.7 (P < 0.01) and the TFC index [calculated by dividing the mean cTFC for the relevant artery by the mean cTFC for the corresponding coronary artery in a previously derived control group in our laboratory] was 1.6 +/- 1 and 0.7 +/- 0.2 (P = < 0.01), respectively. CONCLUSION: We have demonstrated that there was a significant increase in the cTFC when the coronary artery stenosis was more than 75% reflecting significant flow abnormalities at this degree of stenosis in chronically diseased coronary arteries. Following stenting there is a significant improvement in the cTFC, which is better than the cTFC for arteries with normal flow, suggesting early hyperaemia.

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UNLABELLED: The TIMI frame count (TFC) is a useful measure of coronary flow. To be widely applicable, the effect of different catheter sizes and the use of intracoronary glyceryl trinitrate (ICGTN) must be determined when films are acquired at lower acquisition rates (12.5 frames/s, f/s). METHODS: We compared 6F versus 5F diagnostic catheters (n = 44), 6F versus 7F diagnostic catheters (n = 45) and 6F diagnostic versus 7F guide catheters (n = 44). In the nitrate angiography group (n = 141), coronary angiography was performed before and after 200 micrograms of ICGTN. In the nitrate percutaneous coronary intervention (PCI) group (n = 48), coronary angiography was performed before and after 200 micrograms of ICGTN after the completion of the elective PCI procedure. RESULTS: The mean difference in the uncorrected TFC using 6F and 5F was 0.02 (95 % CI -0.5, 0.6; P = 0.9); using 6F and 7F diagnostic catheters it was 0.3 (95% CI -0.49, 1.1; p = 0.4); and using 6F diagnostic and 7F guide catheters it was 0.4 (95% CI -2.6, 3.4; P = 0.7) respectively. In the nitrate angiography group, the uncorrected TFC before and after ICGTN was 13.1+/-6.2 and 15+/-7.5 (equivalent to 31.4+/-14.9 and 36+/-2 at 30 f/s), with a mean difference of 1.9 (95% CI 1.3, 2.5; P = or <0.0001). In the nitrate PCI group, the uncorrected TFC before and after ICGTN administration was 9.2+/-3.7 and 10.3+/-4.2 (equivalent to 22.6+/-9.6 and 25.2+/-11 at 30 f/s) respectively with a mean difference between the two injections of 1.2 (95% CI -0.4, 1.9; P = 0.003). CONCLUSION: We have demonstrated that the catheter sizes did not significantly affect the TFC when angiography was performed at 12.5f/s. The use of ICGTN significantly increased the TFC in both normal and diseased coronary arteries. This effect was also observed when ICGTN was administered into the culprit vessels after the completion of the elective PCI procedure. This effect must be considered when investigating the impact of specific treatments or drugs on coronary flow.

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UNLABELLED: The large randomized trials on rescue angioplasty (rPCI) have been interpreted by some as showing differing results. We compared the protocols, demographics and 6-month clinical outcomes of the MERLIN trial with the RESCUE I and REACT trials to assess their differences. RESULTS: The RESCUE I trial did not involve the use of stenting or glycoprotein IIb/IIIa inhibitors, and patients with previous MI were excluded. The recruitment rate in MERLIN was 30.7 patients per center per year vs. 3.3 in REACT and 2.4 in the RESCUE I trial. The patients in the MERLIN trial were older. Streptokinase was used more commonly in the MERLIN trial: 96% vs. 60% in REACT. In the rPCI arm, pain onset to lysis time was longer, 180 vs. 140 minutes in MERLIN, but lysis to angiography (146 vs. 274 minutes) and pain onset to angiography (327 vs. 414 minute) times were shorter compared with the REACT trial. In the rPCI arms, mortality at 6 months was lower in the REACT trial than in the MERLIN trial although the difference was not statistically significant. This numeric difference in mortality is unlikely to be explained by the differences in the use of glycoprotein IIb/IIIa inhibitors or stenting. In the rPCI arms, reinfarction rates were higher in the MERLIN trial (7.8% vs. 2.1%), possibly due to lower rates of stenting (50.3% vs. 68.5%) and less use of glycoprotein IIb/IIIa inhibitors (3.3% vs. 43.4%). The three trials used different definitions of heart failure, with a trend towards a reduction in heart failure in all three studies. CONCLUSION: These trials differ in various aspects. The RESCUE I trial enrolled lower-risk patients than the MERLIN trial and was done without the use of stents and glycoprotein IIb/IIIa inhibitors. The MERLIN trial is widely applicable to patients receiving streptokinase and had no age limit. REACT patients were younger and were enrolled more selectively. Although some outcomes were similar, differences in patient recruitment and protocols may have accounted for the numerical difference in mortality rates at 6 months in the MERLIN and REACT trials. Meta-analysis suggests an overall clinical benefit from rescue PCI (lower mortality, less reinfarction and less heart failure) at the expense of an increased risk of stroke and bleeding.

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Percutaneous coronary interventions of ostial right coronary artery stenoses are associated with increased procedural complications as well as with higher rates of angiographic and clinical restenosis. Ideally, the ostium is treated by positioning the stent with a slight degree of overhang in the aorta to ensure coverage of the aorto-ostial junction. This can potentially complicate further intervention should restenosis occur. We report a case in which in-stent restenosis of an overhanging stent had been treated with an also overhanging sirolimus-coated Cypher stent (Cordis Corporation, Roden, The Netherlands). Late repeat restenosis was treated with a third (Taxus, Boston Scientific, Maple Grove, Minnesota, USA) stent that was deployed through the previously implanted stent struts.

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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients requiring tricuspid replacement should have a mechanical or a biological valve. Using the reported search, 561 papers were identified. Thirteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, weaknesses, results and study comments were tabulated. We conclude that there are no major differences between the insertion of a mechanical or biological tricuspid valve. Aggregating the available data it is found that the reoperation rate is similar with bioprosthetic degeneration rate being equivalent to the mechanical thrombosis rate. Conversely up to 95% of patients with a bioprosthesis still receive anticoagulation. Survival in over 1000 prostheses pooled by meta-analysis was equivalent between biological and mechanical valves.

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UNLABELLED: The intra-aortic balloon pump (IABP) is the most commonly used temporary cardiac assist device. The precise role and the mechanism of any benefit in high-risk patients undergoing percutaneous coronary intervention (PCI) have not been fully determined. We hypothesized that the use of an IABP following PCI in high-risk non-shocked patients would immediately increase coronary blood flow, tissue perfusion and hence preserve left ventricular function. METHODS: Predefined high-risk, but non-shocked, patients were randomized to either an IABP or no IABP following PCI. Angiography was performed pre-PCI, immediately post-PCI and 10 minutes after the completion of the procedure. TIMI flow grade (TFG), TIMI frame count (TFC) and myocardial blush grade (MBG) were measured. Echocardiographic wall motion index (WMI) was measured on days 1 and 30 following PCI. RESULTS: Of 33 patients, 17 received IABP and 16 did not. At final angiography, the TFG was 2.8 +/- 0.7 and 2.9 +/- 0.3 (p = 0.6), the TFC was 19.9 +/- 23 and 16.9 +/- 16.9 (p = 0.7), and the MBG was 2.5 +/- 0.9 and 2.5 +/- 0.7 (p = 0.9) in the IABP and the no-IABP arms. The WMI on day 1 was 1.7 +/- 0.4 and 1.7 +/- 0.4 (p = 0.7), and on day 30, it was 1.5 +/- 0.4 and 1.5 +/- 0.4 (p = 0.9). There was no difference in the total sum of ST-segment elevation prior to PCI (12.6 +/- 7.7 vs. 13.5 +/- 7.9; p = 0.8), nor in the summed ST change in subsequent electrocardiograms (ECGs) to 48 hours in both of the groups. CONCLUSION: Whether an IABP is of any benefit in non-shocked, but high-risk, patients undergoing PCI remains to be established, but any potential benefit does not appear to be associated with early improvement in coronary flow. Whether the insertion of an IABP improves coronary flow beyond 10 minutes is not known. However, the IABP did not significantly affect subsequent left ventricular wall motion index or ECG ST-segment resolution in this study.

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BACKGROUND: Stentless aortic bioprostheses have been advocated as being superior to conventional bioprosthetic valves, with benefits including superior left ventricular mass regression and larger effective orifice area. Several high-quality randomized studies now exist on this topic, and we sought to summarize them by meta-analysis. METHODS: The literature was searched from 1995 to 2006, in MEDLINE, EMBASE, CRISP, metaRegister of Controlled Trials, and the Cochrane database. Experts were also contacted and reference lists searched. Studies were combined using the inverse variance fixed-effects model. Heterogeneity was assessed and a sensitivity analysis performed. Publication bias was also investigated. RESULTS: Ten studies were identified that included 919 patients in which the Freedom (Sorin Biomedica Cardio, Via Crescentino, Italy), Freestyle (Medtronic, Minneapolis, MN), Prima Plus (Edwards Life Sciences, Irvine, CA) and the Toronto and Biocor (St Jude Medical, St. Paul, MN) valves were used. The mean aortic valve gradient was lower in the stentless groups, with a weighted mean difference (WMD) of -3.57 mm Hg (95% confidence interval [CI], -4.36 to -2.78; p < 0.01). The left ventricular mass index was significantly lower in the stentless groups at 6 months (WMD, -6.42; 95% CI, -11.63 to -1.21; p = 0.02), but this improvement disappeared after 12 months (WMD, 1.19; 95% CI, -4.15 to 6.53; p = 0.66). The weighted mean increase in cross-clamp time was 23 minutes, and the increase in bypass time was 29 minutes with a stentless valve. CONCLUSIONS: This meta-analysis showed that stentless aortic valves provide an improved level of left ventricular mass regression at 6 months, reduced aortic gradients, and an improved effective orifice area index, at the expense of a 23-minute longer cross-clamp time and a 29-minute longer bypass time.

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BACKGROUND: Trials of rescue angioplasty (rPCI) following failed fibrinolysis have excluded patients with cardiogenic shock and the benefit of rPCI in this setting is unknown. We compared the clinical, angiographic characteristics, 30-day and 1-year outcomes of cardiogenic shock patients undergoing rPCI with those undergoing primary percutaneous coronary intervention (PPCI). METHODS: Of the 171 patients undergoing PCI for cardiogenic shock between 1994 and 2005 at our institution, the indication was for PPCI in 65 and rPCI in 59 patients. Clinical, procedural, 30- day and 1-year mortality data were compared. RESULTS: There were no differences between the cohorts with regard to clinical and pre-PCI angiographic variables, except that patients who underwent rPCI were more likely to be interhospital transfers (64% vs. 43%; p = 0.02) and had a longer door-to-balloon time (median 298 [IQR 395 to 180] minutes in the rPCI group vs. 131 [IQR 215 to 90] minutes in the PPCI group; p <0.01). Glycoprotein IIb/IIIa inhibitors were used less often (20% vs. 42%; p = 0.01), but use of stents was similar in both groups. Patients undergoing rPCI had a lower rate of final TIMI 3 flow grade (56% vs. 74%; p = 0.04) and a higher 1-year mortality (71% vs. 49%; p = 0.01). In the patients with final TIMI flow 3, 1-year mortality was higher in the rPCI group (61% vs. 37%; p = 0.04). In patients with successful procedures (survived procedure, no emergency CABG, TIMI 3 flow), 1-year mortality was higher in the rPCI group (59% vs. 33%; p = 0.02). One-year mortality was 85% in both groups if the procedure was unsuccessful. One-year mortality in patients >70 years old with cardiogenic shock undergoing rPCI was 100% (n = 15) and 70% (n = 14) with PPCI. Rescue angioplasty, anterior myocardial infarction, multivessel disease and postprocedure TIMI flow grade <3 were found to be independent predictors of mortality at 30 days. CONCLUSIONS: In the setting of cardiogenic shock, rPCI patients were treated later than those undergoing PPCI. They had a lower final TIMI 3 flow and higher 1-year mortality. Even patients with a successful rPCI procedure had a higher 1-year mortality than those with a successful PPCI. Rescue angioplasty in the setting of cardiogenic shock was found be an independent predictor of mortality. Rescue angioplasty in elderly patients in cardiogenic shock (>75 years) may be a futile treatment. Efforts should be made to improve reperfusion and survival in these patients, possibly by either adopting PPCI for all patients presenting with ST-elevation acute myocardial infarction or, if this is not logistically possible, adopting PPCI for selected high-risk patients or early referral for rPCI in high-risk groups receiving fibrinolysis.

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BACKGROUND: Early (30 days) and midterm (6 months) clinical outcomes in trials comparing rescue angioplasty (rescue percutaneous coronary intervention [rPCI]) with conservative treatment of failed fibrinolysis complicating ST-segment elevation myocardial infarction have shown variable results. Whether early rPCI confers late (up to 3 years) clinical benefits is not known. METHODS: The MERLIN trial compared rPCI and a conservative strategy in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction. Three hundred seven patients with electrocardiographic evidence of failure to reperfuse at 60 minutes were included. Patients in cardiogenic shock were excluded. Thirty-day and 1-year results have been reported. Results of 3 years of follow-up are presented. RESULTS: Three-year mortality in the conservative arm and rPCI, respectively, was 16.9% versus 17.6% (P = .9, relative difference [RD] -0.8, 95% CI [-9.3 to 7.8]). Death rates were similar (3.9% vs 3.2%) between 1- and 3-year follow-up, respectively. The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularization, or heart failure was significantly higher in the conservative arm (64.3% vs 49%, P = .01, RD 15.3, 95% CI [4.2-26]). There was no significant difference in the rate of reinfarction (0.7% vs 0.7%) or heart failure (1.3% vs 2.7%) between 1 and 3 years between the conservative and rPCI arms, respectively. The incidence of subsequent unplanned revascularization at 3 years was significantly higher in the conservative arm (33.8% vs 14.4%, P < .01, RD 19.4, 95% CI [10-28.7]), most of which occurred within 1 year; the rates between 1 and 3 years were 3.9% in the conservative arm versus 2% in the rPCI arm. There was a trend toward fewer strokes in the conservative arm at 3 years (conservative arm 2.6% vs rPCI 6.5%, P = .1, RD -3.9%, 95% CI [-9.4 to 0.8]), with similar stroke rates (1.3% vs 1.3%) between 1- and 3-year follow-up. CONCLUSIONS: Rescue angioplasty did not confer a late survival advantage at 3 years. The composite end point occurred less often in the rPCI arm mainly because of fewer unplanned revascularization procedures in the early phase of follow-up. The highest risk of clinical events in patients with failed reperfusion is in the first year, beyond which the rate of clinical events is low.

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BACKGROUND: Failure to achieve adequate myocardial reperfusion often occurs during PCI in patients with STEMI. This is in part due to atheromatous and thrombotic distal embolization. Several anti-embolic devices have been developed to protect against distal embolization during percutaneous coronary interventions (PCI) to improve myocardial reperfusion and enhance event free survival. Evidence from current studies has not shown a consistent benefit, but anti-embolic devices continue to be used. METHODS: We conducted a systemic overview (meta-analysis) of randomized trials of thrombectomy or distal protection devices versus standard PCI to evaluate the effects of reducing distal embolization during PCI for native vessel acute myocardial infarction (AMI). We identified randomized trials by searching PubMed, OVID, the Cochrane databases, references of articles, and abstracts of conference proceedings (all from September 2000 to October 2005). Each trial tested the hypothesis that anti-embolic therapy would result in better clinical or angiographic results than standard PCI alone. RESULTS: Fourteen trials (n = 2630) were identified comparing a distal protection device or a thrombectomy device (n = 1320) versus standard PCI (n = 1310). When the studies were combined, primary endpoints of death or reinfarction were not improved by the use of anti-embolic devices (4% [52/1309] vs. 4.5% [59/1303], odds ratio [OR] 0.82 [95% CI 0.55 to 1.24, P= 0.35]). In subgroup analysis, analyzing the class of device separately, use of thrombectomy devices (4.4% [33/758 vs. 4.2% [32/763], OR 0.98 CI 0.53 to 1.83, P = 0.95]), and the use of distal protection device 3.5% [19/551] vs. 5% [27/540], OR 0.68 CI 0.37 to 1.23, P = 0.20]) during PCI for native vessel AMI did not improve the clinical outcome of death or reinfarction. The secondary endpoints of death, reinfarction, and major adverse cardiac events did not improve with the use of anti-embolic devices. CONCLUSION: The combined experience from randomized trials suggests that the use of anti-embolic devices does not decrease early mortality or reinfarction during PCI for native vessel AMI. Whether their use improves longer term outcomes is unknown. Further research is needed to clarify the indication and optimal devices for anti-embolic protection.

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UNLABELLED: A new generation of intravascular contrast agents, the non-ionic monomers have safety profiles that are superior to those of older ionic compounds. There are, however, significant differences between these agents. AIM: The aim of this study was to determine the incidence of early (<24h) and late (>24h to 7 days) reactions to two non-ionic contrast agents currently used during cardiac catheterisation: iopamidol 340 (Niopam Bracco UK Ltd.) and iomeprol 350 (Iomeron Bracco UK Ltd.). METHODS: This was a prospective, randomised, double blinded trial. One thousand nine hundred and eighty-five patients undergoing cardiac catheterisation received one of the following contrast agents on a weekly basis: iopamidol 340 (Niopam) and iomeprol 350 (Iomeron). Reactions that were possibly related to the contrast agents were recorded on predefined data collection forms during the first 24h of the procedure (early reaction) and after 24h to 7 days (late reaction) by means of a questionnaire. RESULTS: The baseline characteristics were matched in both the groups. There was no significant difference in the incidence of heat sensation experienced between the two groups (p=0.1). Early non-heat reactions occurred in 2.7% of patients receiving iopamidol 340 (Niopam) and 4% of those receiving iomeprol 350 (Iomeron) (p=0.1). Significant electrocardiographic changes were recorded in 1.7% of patients who received iopamidol 340 (Niopam), and 1% of those who received iomeprol 350 (Iomeron) (p=0.2). Bradycardia occurred more frequently in the iopamidol 350 group (0.8%) compared to the iomeprol 350 group (0.1%) p=0.02. Late reactions occurred in 16.2% of those receiving iopamidol 340 (Niopam) and 21.7% of those receiving iomeprol 350 (Iomeron) (p=0.02). A total of 23 (3.7%) patients in the iopamidol group and 39 (6.2%) patients in the iomeprol group reported nausea, p=0.01. CONCLUSIONS: The incidence of early adverse reactions was similar with the two non-ionic contrast agents. Although bradycardia was slightly more frequent using iopamidol 340, nausea was reported more commonly 24h after the procedure in patients receiving Iomeron 350 (Iomeron). We conclude that there were only minor clinical differences between these agents; both are safe and well tolerated.

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UNLABELLED: We determined the effectiveness of the Rescue device in restoring flow and achieving optimal tissue perfusion during percutaneous coronary intervention (PCI) in thrombus-laden coronary arteries. METHODS: A total of 30 patients with an acute coronary syndrome underwent PCI using the Rescue device. RESULTS: The mean age was 65.5 +/- 9.8 years. Although the Rescue device could not be passed across the lesion in 6 (20%) cases, debris was aspirated in 26 (87%). The uncorrected TIMI frame count improved following the use of the Rescue device and improved further at the completion of PCI (92.2 +/- 23.9 pre-PCI vs. 38.7 +/- 31.3 post-Rescue vs. 21.96 +/- 24 post-PCI, P < 0.0001). The thrombus score improved from 4 +/- 0 to 2.2 +/- 1.29 to 0.86 +/- 1.4 (P < 0.0001). TIMI flow grade (TFG) 3 was restored in 60% of cases following the Rescue device and in 87% after PCI. Myocardial blush grade 3 occurred in only 13% of patients following the Rescue device and 37% of patients after PCI. CONCLUSION: These data suggest that the Rescue device can aspirate considerable amounts of debris in the majority of patients and significantly improves the angiographic epicardial coronary blood flow. How effective such a device is in improving tissue perfusion and, thereby, clinical outcomes for patients remains to be seen.

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UNLABELLED: Antiarrhythmic agents enhance maintenance of sinus rhythm (SR) after direct current cardioversion (DCC) for atrial fibrillation but there are few comparative trials. BACKGROUND: The aims of the study were (1) to establish whether patients successfully cardioverted to SR are more likely to stay in SR over 6 months if taking amiodarone or sotalol, and if so, to establish whether one agent is better than the other; (2) to establish whether taking amiodarone or sotalol is better at achieving chemical cardioversion within the 6 weeks before DCC; and (3) to establish whether DCC is more likely to be successful on a drug. METHODS: Randomized, prospective, nonblinded, controlled study of treatment with either amiodarone (n = 27), sotalol (n = 36), or no antiarrhythmic agent (n = 31). RESULTS: Chemical cardioversion occurred in 7 patients in the amiodarone group (A), 7 patients in the sotalol group (S), but none in the no-antiarrhythmic group (N). A total of 33 (92%) patients in the sotalol group, 22 (81%) patients in the amiodarone group, and 23 (74%) patients in the no-antiarrhythmic group were in SR after cardioversion. Of the original cohort of patients, 17 (63%) patients in the amiodarone group remained in SR at 6-month follow-up, compared with 14 (39%) in the sotalol group and 5 (16%) in the no-antiarrhythmic group (A vs N, P < .0002, P < .0006B [after Bonferroni correction]; A vs S, P = .05, P = .15B; and S vs N, P = .03, P = .09B). CONCLUSIONS: Amiodarone and sotalol achieved chemical cardioversion before planned electrical cardioversion in 26% and 19% of patients, respectively. After successful cardioversion, amiodarone appears better than sotalol at maintaining SR at 6 months.

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BACKGROUND: Intravascular contrast agents presently used in modern digital catheter laboratories during cardiac catheterization are superior to older agents as regards patient tolerance. There are, however, significant differences between these agents. PURPOSE: The aim of this study was to determine the incidence of early (< 24 hours) and late (> 24 hours to 7 days) reactions to 2 contrast agents currently used during cardiac catheterization: iopamidol 340 (Niopam) and iobitridol 350 (Xenetix). METHODS: This was a prospective, randomized, double-blinded trial. Two thousand and nineteen patients undergoing cardiac catheterization received one of the following contrast agents: iopamidol 340 (Niopam) and iobitridol 350 (Xenetix). Reactions that were possibly related to the contrast agents were recorded during hospital admission (early reaction) and after discharge (late reaction) by means of a questionnaire. RESULTS: The baseline characteristics were matched in both the groups. There was no significant difference in the incidence of heat sensation experienced between the 2 groups, (p = 0.1). Early non-heat reactions occurred in 3.2% of patients receiving iopamidol 340 (Niopam) and 3.6% of those receiving iobitridol 350 (Xenetix), (p = 0.65). Electrocardiographic changes were recorded in 0.7% of patients who received iopamidol 340 (Niopam), and 2.6% of those who received iobitridol 350 (Xenetix), (p = < 0.01). Seven patients (0.8%) receiving iobitridol 350 suffered ventricular fibrillation requiring DC cardioversion compared with none in the iopamidol 340 group (p = < 0.01). Late reactions (post discharge symptoms) occurred in 13.9% of those receiving iopamidol 340 (Niopam) and 18.5% of those receiving iobitridol 350 (Xenetix) (p = 0.02). CONCLUSIONS: Iobitridol 350 (Xenetix) was associated with more ECG changes and, importantly, ventricular fibrillation, than iopamidol (Niopam). There were no features to suggest other benefits from iobitridol 350. These results suggest that iopamidol 340 is a preferable contrast agent in cardiac catheterization.

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The original description of the TIMI frame count (TFC) method was based on angiograms acquired at 30 f/sec. Modern digital angiograms are acquired at lower frame rates (between 12.5 and 25 f/sec). Coronary angiography was acquired at 12.5 and 25 f/sec after 200 mug of intracoronary glyceryl trinitrate. Results of the corrected TIMI frame count (cTFC) at 12.5 and 25 f/sec for each vessel were: right coronary artery, 19.5 +/- 5.2 and 20.4 +/- 6.6 (P = 0.15); circumflex artery, 25.6 +/- 8.2 and 25.9 +/- 8.7 (P = 0.5); and left anterior descending artery, 22.5 +/- 8.1 and 23.8 +/- 10.4 (P = 0.15), respectively. The mean difference in the TFC between two injections by the same operator and by two operators was 0.4 (P = 0.7) and 0.4 (P = 0.2), respectively. The mean difference in the TFC for repeat measurements by the same observer and between two observers was 0.26 (P = 0.3) and 0.06 (P = 0.8), respectively. We confirm that the cTFC is a quantitative method to assess coronary flow that can be applied in a modern digital laboratory.

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