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Biomedical subjects

D R Holmes

Publications and source records attributed to D R Holmes.

At least 109 records · Page 6Linked to original sources
PubMed2000

Decreasing mortality with primary percutaneous coronary intervention in patients with acute myocardial infarction: the Mayo Clinic experience from 1991 through 1997.

OBJECTIVE: To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI). PATIENTS AND METHODS: We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year. RESULTS: The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997. Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P < .001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P < .001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P < .001). An increase in beta-blocker (58.3% to 75.3%; P < .001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%; P < .001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%; P < .001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%; P < .001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%; P = .05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P = .09). After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89; 95% confidence interval, 0.79-1.00; P = .05) and during long-term follow-up (odds ratio, 0.93; 95% confidence interval, 0.87-1.00; P = .04). CONCLUSIONS: Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.

Abciximab↗
PubMed2000

Noninvasive revascularization by enhanced external counterpulsation: a case study and literature review.

Nearly 8 million people in the United States suffer from symptoms of coronary artery disease (CAD). Unfortunately, the population of patients with ischemic coronary disease that is not readily amenable to surgical or percutaneous revascularization continues to grow. For patients who are not candidates for standard revascularization procedures and in whom aggressive medical therapy fails to control symptoms, enhanced external counterpulsation (EECP) is a new, noninvasive outpatient method to improve quality of life by decreasing ischemic symptoms and permit increased activity. We report the case of a 56-year-old woman with severe, symptomatic CAD receiving maximal medical therapy who underwent a course of EECP therapy because she was not a good candidate for other forms of revascularization. She demonstrated dramatic improvement in her anginal symptoms and complete resolution of myocardial ischemia on repeat nuclear stress imaging. This case suggests that EECP is a safe and effective method for reducing symptoms of myocardial ischemia in patients for whom standard percutaneous or surgical revascularization is not suitable treatment.

Activities of Daily Living↗
PubMed2000

Trans-urethral ultrasound (TUUS) imaging for visualization and analysis of the prostate and associated tissues.

The incidence of prostate disease is high. However, accurate assessment of pathological conditions is still difficult. Although CT, MRI, and TRUS imaging methods provide useful information, each has specific drawbacks. Our work examines the potential and utility of 3D trans-urethral ultrasound (TUUS) for improved imaging of the prostate. Four normal canines were examined with TUUS. The catheter was placed in the urethra and used to image the prostate, rectum, bladder, ureter, neuro-vascular bundles, arteries, and surrounding tissue. 2D and 3D datasets were acquired and digitized. The 2D data provides useful visualization of the tissue. The clinician was also able to watch urine enter the bladder and perform a digital rectal exam in real-time. 3D data visualization required torodial reconstruction. The algorithm was optimized to provide very fast 3D reconstructions of the prostate. Segmentation of the data proved challenging, but 3D visualization, including volume rendered data and surface rendered data, were well accepted by clinicians. Clinicians and researchers determined a number of potential applications of these new techniques, including: prostate cancer diagnosis and staging, assessment of Benign Nodular Enlargement, assessment of physiologic function of the bladder, evaluation of morphologic properties of the prostate, and image guided biopsy and therapy.

Animals↗
PubMed2000

Imaging Angiogenesis with Three-Dimensional Microscopic Computed Tomography.

An increasing number of patients with advanced coronary artery disease remain symptomatic, despite maximal interventional or medical treatment. A high demand exists for alternative anti-anginal therapies and ways to improve survival. One of the most intriguing new approaches to increase blood flow to ischemic myocardium is therapeutic angiogenesis, the induction of new vessel growth. Current methods involve local angiogenic growth factor administration, transfection of genes expressing angiogenic proteins, or direct myocardial revascularization. These new therapeutics are undergoing intensive basic and clinical investigation.

Journal Article↗
PubMed2000

Pitfalls and results of immediate angiography after off-pump coronary artery bypass grafting.

BACKGROUND: We sought to determine the feasibility of off-pump coronary artery bypass grafting (OPCAB) in a consecutive series and prospectively assess the value of immediate post-operative coronary angiography. METHODS: All patients referred for coronary artery bypass grafting, within a four-month period, were approached as candidates for OPCAB. All 50 OPCAB patients were studied by immediate post-operative coronary angiography. RESULTS: The OPCAB procedure was feasible in 67% of patients (50/75). Five of 55 patients (9.1%) were converted to on-pump procedures, three for hemodynamic instability, and two because of deeply intramyocardial vessels. The other 20 underwent on-pump revascularization for anatomical and physiological reasons. The average age of OPCAB patients was 68.1 +/- 9.6 years; 26% were female, 74% male. Two (4%) were redo operations. Mean number of grafts was 2.9 +/- 0.8, 51 internal thoracic artery grafts (ITA), 17 radial artery grafts (RA), and 76 saphenous vein grafts (SVG). Angiographic graft patency was 90.2% for ITA, 88.2% for RA, and 96.1% for SVG. Interpretation of catheterization results was confounded by significant native and arterial graft spasm. Six of seven occluded arterial grafts and one of three SVG were probe patent at immediate reoperation (all had adequate flow by intra-operative doppler at the initial operation). Only two graft occlusions were noted in the 18 patients who did not receive protamine. The patency rate was 95.6% (131/137) when the probe patent anastomoses were excluded. Seven patients (14%) returned to the OR as a result of the catheterization findings; five to revise occluded grafts, one to improve the lie of a kinked SVG, and one to graft an intramyocardial intermediate ramus when an adjacent high diagonal was grafted instead (two of seven on-pump). All graft problems were found in the absence of hemodynamic instability or electrocardiogram changes. In-hospital mortality was 2% (1). Complications in survivors were atrial fibrillation in 12 patients (24.5%), permanent pacemaker in one (2%), endotracheal bleeding in one (2%), and take-back for bleeding in one (2%). CONCLUSIONS: There were a significant number of unexpected arterial graft occlusions. The reversal of heparin and ITA spasm appeared to be contributory. All patients with occluded grafts had no signs of trouble. Interpretation of immediate post-operative catherization is difficult because of significant native vessel and graft spasm. It reliably determines patency but it's value is suspect for determination of long-term graft adequacy.

Adult↗
PubMed1999

Systemic amyloidosis presenting with angina pectoris.

BACKGROUND: Manifestations of cardiac amyloidosis may include congestive heart failure and sudden cardiac death. Although vascular involvement in patients with amyloidosis is common, systemic amyloidosis presenting with angina is rare. OBJECTIVES: To report on patients with systemic amyloidosis presenting with angina pectoris. DESIGN: Case series. SETTING: Academic medical center. PATIENTS: Five patients who presented with angina pectoris and normal coronary angiogram as the initial manifestation of systemic amyloidosis. MEASUREMENTS: Endothelial-dependent and endothelial-independent coronary flow reserve. RESULTS: All patients had coronary flow reserve abnormalities and subsequently developed congestive heart failure and systemic manifestations of amyloidosis. Histologic evaluation revealed amyloid deposition in the intramyocardial coronary vessels. CONCLUSIONS: Cardiac amyloidosis can present as angina pectoris associated with coronary flow reserve abnormalities despite normal coronary angiograms. This finding may have major therapeutic and prognostic implications in this patient population.

Aged↗
PubMed1999

Long-term prognostic value of Duke treadmill score and exercise thallium-201 imaging performed one to three years after percutaneous transluminal coronary angioplasty.

The value of exercise nuclear perfusion imaging performed beyond the 6-month restenosis window for percutaneous transluminal coronary angioplasty (PTCA) has not been explored. This study evaluates the long-term prognostic value of exercise thallium (Tl)-201 imaging after PTCA. We studied the late outcome of a series of 211 patients with tomographic Tl-201 exercise studies performed between 1 to 3 years after PTCA. Follow-up was 96% complete at a median duration of 7.3 years. Most (73%) had 1- or 2-vessel coronary artery disease and normal left ventricular function and 193 (91%) had successful PTCA. Two thirds of the patients were symptomatic at the time of testing. The mean Duke score was 5+/-6 and 125 (60%) patients had a low-risk Duke score. Mean summed stress score was 50+/-9 and mean summed reversibility score was 3+/-4. The 5-year overall survival was 95%, yielding a low annual mortality rate of 1%/year. The summed stress score exhibited a significant association (p = 0.047) with the end point of cardiac death or myocardial infarction. The Duke score was predictive of the combination end point of hard and soft cardiac events (p = 0.002). This study demonstrates that exercise Tl-201 perfusion imaging performed 1 to 3 years after PTCA was predictive of cardiac events.

Angioplasty, Balloon, Coronary↗
PubMed1999

Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation.

BACKGROUND: Cardiogenic shock is usually considered a sequela of ST-segment elevation myocardial infarction. There are limited prospective data on the incidence and significance of shock in non-ST-segment elevation patients. This study assessed the incidence and outcomes of cardiogenic shock developing after enrollment among patients with and without ST-segment elevation in the Global Use of Strategies To Open Occluded Coronary Arteries (GUSTO)-IIb trial. METHODS AND RESULTS: Among 12,084 patients in GUSTO-IIb who did not present with cardiogenic shock, 4092 (34%) had and 7991 (66%) did not have ST-segment elevation on the enrollment ECG. Cardiogenic shock developed in 4.2% of ST-segment elevation patients compared with 2.5% of patients without ST-segment elevation (odds ratio, 0. 581; 95% CI, 0.472 to 0.715; P<0.001). Shock developed significantly later among patients without ST-segment elevation. There were significant differences in baseline characteristics between shock patients with and without ST-segment elevation: Patients without ST-segment elevation were older, more frequently had diabetes mellitus and 3-vessel disease, but had less TIMI grade 0 flow at angiography. Regardless of the initial ECG, mortality was high: 63% among patients with ST-segment elevation and 73% in those without ST-segment elevation. CONCLUSIONS: Cardiogenic shock occurs in the setting of acute ischemic syndromes regardless of whether ST-segment elevation is present. The incidence, patient characteristics, timing, clinical course, and angiographic findings differ between the 2 groups. Mortality from cardiogenic shock is similarly high among patients with and without ST-segment elevation.

Aged↗
PubMed1999

Baseline clinical and angiographic variables associated with long-term outcome after successful intracoronary stent implantation.

Although randomized studies have demonstrated improved outcomes with stents over balloon angioplasty in straightforward coronary narrowings in low-risk patients, this advantage is less clear for complex lesions and high-risk patients. This study was designed to identify clinical and angiographic variables that are associated with long-term outcome after stent implantation. We identified 1,709 patients undergoing successful stent placement without in-hospital major adverse events. We analyzed clinical, lesional, and procedural variables to determine their correlation with outcome. Mean duration of follow-up was 1.6 +/- 1.4 years. Cox proportional-hazards models and stepwise methods were used to assess which covariates were potentially related to each end point. The occurrence of death/myocardial infarction (MI) was associated with any history of congestive heart failure (relative risk [RR] 3.3, 95% confidence interval [CI] 2.3 to 4.7, p <0.0001), procedure within 24 hours of MI (RR 2.3, CI 1.3 to 4.1, p = 0.0048), vein graft intervention (RR 1.8, CI 1.3 to 2.6, p = 0.0007), and prior MI (RR 1.8, CI 1.2 to 2.6, p = 0.004). Repeat revascularization was associated with multivessel stent placement (RR 1.8, CI 1.2 to 2.8, p = 0.006) and stent for abrupt closure (RR 1.7, CF 1.1 to 2.7, p = 0.03), but was less frequent with de novo lesions and right coronary artery lesions (RR 0.6, CI 0.5 to 0.8, p = 0.0007, and RR 0.8, CI 0.6 to 1.0, p = 0.05, respectively). The cumulative end point of death/MI/repeat revascularization was associated with congestive heart failure (RR 1.7, CI 1.3 to 2.2, p <0.0001), multivessel stent placement (RR 1.6, Cl 1.1 to 2.3, p = 0.03), warfarin therapy (RR 1.4, CI 1.2 to 1.8, p = 0.001), and procedure within 24 hours of MI (RR 1.5, CI 1.1 to 2.1, p = 0.02), but was less frequent with complete revascularization and right coronary artery intervention (RR 0.8, CI 0.7 to 0.99, p = 0.04, and RR 0.7, CI 0.6 to 0.9, p = 0.009, respectively). Thus, this study demonstrates that there are readily identifiable characteristics in patients treated successfully with stents that are associated with long-term outcome.

Anticoagulants↗
PubMed1999

Measuring maximal percent area stenosis poststent placement with intracoronary Doppler and the continuity equation and correlation with intracoronary ultrasound and angiography.

Quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS) are methods for anatomic assessment of stent deployment. Intracoronary Doppler is primarily a method for the physiologic assessment of coronary stenoses. It correlates well with traditional noninvasive measurements of lesion significance. Intracoronary Doppler was used for the anatomic assessment of de novo coronary artery stenosis with variable success; however, its use for anatomic assessment of adequate stent deployment is unavailable. A rapid, automated software program was developed based on a modified continuity equation to calculate the maximal in-stent percent area stenosis by comparing the maximal in-stent velocity to an average reference velocity (proximal and distal). This study was designed to compare the Doppler method of an anatomic assessment with QCA and ICUS in 15 patients. Physiologic success of stent deployment was determined by the distal coronary flow reserve to 24 to 36 microg of intracoronary adenosine. Following successful stent deployment, distal coronary flow reserve increased significantly from a baseline of 1.6 +/- 0.5 to 2.9 +/- 1.1. There was a significant correlation between the maximal in-stent percent area stenosis as measured by Doppler and both QCA (r = 0.78, p <0.01) and ICUS (r = 0.84, p <0.01). This study demonstrates that maximal in-stent percent area stenosis can be measured by intracoronary Doppler and a novel software program. The intracoronary Doppler guidewire method can assess the adequacy of stent deployment using both anatomic and physiologic principles and may supplement other quantitative methodologies.

Adenosine↗
PubMed1999

Comparison of long-term results of percutaneous mitral balloon valvotomy with closed transventricular mitral commissurotomy at a single North American Institution.

Long-term (>3 years) follow-up data were obtained from 102 consecutive patients undergoing percutaneous mitral balloon valvotomy (PMBV). Data were collected prospectively by review of the medical record, mailed questionnaire, and/or telephone. Data on patients with closed mitral commissurotomy (CMC) at our institution have been previously reported and serve as the comparison group. Follow-up data was 98% complete at a mean of 57 months for PMBV patients. Compared with patients undergoing CMC, these patients were older (54+/-14 vs 43.6+/-10 years, p <0.001) and more likely to have undergone previous mitral valve surgery (17% vs 4%, p <0.001). The observed 5-year survival in the PMBV group was no different from that observed in the CMC group (83% vs 90%, p = NS) or from that predicted by the model developed from the CMC patients. Commissural calcium was associated with death and death or repeat mitral valve procedure in the multivariate analysis. Long-term survival free from repeat procedures was equivalent when patients with commissural calcium were excluded. Thus, PMBV offers long-term survival and freedom from subsequent mitral valve procedures similar to CMC.

Adult↗
PubMed1999

Increased incidence of periprocedural complications among patients with peripheral vascular disease undergoing myocardial revascularization in the bypass angioplasty revascularization investigation.

BACKGROUND: Risks of coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) may be different in the presence of peripheral vascular disease (PVD). METHODS AND RESULTS: We analyzed outcomes of 550 patients with PVD enrolled in the Bypass Angioplasty Revascularization Investigation randomized trial and registry. Compared with 1770 patients without PVD, those with PVD were older and had a greater prevalence of medical comorbid conditions. No significant differences in coronary anatomy or PTCA success rates were found. The risk of any major complication (death, myocardial infarction, stroke, coma, or emergency revascularization) after PTCA was significantly higher among patients with PVD (11.7% versus 7.8%, P=0.027). In multivariate analysis, this represented a 50% increase in the odds of having any major complication (multivariate odds ratio, 1.5; P=0. 032). Among patients undergoing CABG, the risk of major complications was found to be markedly higher for patients with PVD (12%) than those without (6.1%, P=0.003) even after controlling for baseline differences (multivariate odds ratio, 1.8; P=0.018). Major differences between the PTCA and CABG groups were related primarily to a higher risk of neurological complications in PVD patients who had CABG (multivariate odds ratio, 2.8; P<0.001). CONCLUSIONS: We conclude that patients with PVD are at high risk for periprocedural complications after myocardial revascularization, in particular neurological events.

Aged↗
PubMed1999

Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial.

BACKGROUND: Time to treatment with thrombolytic therapy is a critical determinant of mortality in acute myocardial infarction. Little is known about the relationship between the time to treatment with direct coronary angioplasty and clinical outcome. The objectives of this study were to determine both the time required to perform direct coronary angioplasty in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) trial and its relationship to clinical outcome. METHODS AND RESULTS: Patients randomized to direct coronary angioplasty (n=565) were divided into groups based on the time between study enrollment and first balloon inflation. Patients randomized to angioplasty who did not undergo the procedure were also analyzed. The median time from study enrollment to first balloon inflation was 76 minutes; 19% of patients assigned to angioplasty did not undergo an angioplasty procedure. The 30-day mortality rate of patients who underwent balloon inflation </=60 minutes after study enrollment was 1.0%; 61 to 75 minutes after enrollment, 3.7%; 76 to 90 minutes after enrollment, 4.0%; and >/=91 minutes after enrollment, 6.4%. The mortality rate of patients assigned to angioplasty who never underwent the procedure was 14.1% (P=0.001). Logistic regression analysis revealed that the time from enrollment to first balloon inflation was a significant predictor of mortality within 30 days; after adjustment for differences in baseline characteristics, the odds of death increased 1.6 times (P=0.008) for a movement from each time interval to the next. CONCLUSIONS: The time to treatment with direct PTCA, as with thrombolytic therapy, is a critical determinant of mortality.

Adult↗
PubMed1999

Chronic endothelin receptor antagonism preserves coronary endothelial function in experimental hypercholesterolemia.

BACKGROUND: Endothelin-1 (ET-1) is an endothelium-derived peptide that constricts coronary vessels through stimulation of the ET-A and ET-B receptors. Experimental porcine hypercholesterolemia is associated with impaired coronary endothelial function and elevated ET-1 concentrations. This study was designed to test the hypothesis that chronic endothelin receptor antagonism preserves coronary endothelial function in experimental hypercholesterolemia. METHODS AND RESULTS: Acetylcholine (10(-6) to 10(-4) mol/L) was serially infused into the left anterior descending coronary artery in pigs at baseline and after 12 weeks of a high-cholesterol diet. In the interim, the animals were randomized to 3 groups: Group 1 received no therapy, group 2 received 3 mg/kg per day RO 48-5695, a combined ET-A/ET-B receptor antagonist, and group 3 received 4 mg/kg per day ABT-627, a selective ET-A receptor antagonist. Percent change in coronary artery diameter, coronary blood flow, and coronary vascular resistance were calculated on the basis of quantitative coronary angiography and intracoronary Doppler. At 12 weeks, total cholesterol was significantly and similarly increased in all groups. Chronic endothelin receptor antagonism significantly increased coronary blood flow in response to acetylcholine at 12 weeks (group 1: -41.6%+/-10.7%, group 2: -4.7%+/-11.9%, group 3: 11.4%+/-7.4%). CONCLUSIONS: Chronic endothelin receptor antagonism preserves coronary endothelial function in experimental hypercholesterolemia. This study supports the role for ET-1 in the pathogenesis of endothelial function. Moreover, endothelin receptor antagonists may have a therapeutic role by maintaining coronary endothelial function in pathophysiological states.

Administration, Oral↗
PubMed1999

Timing of coronary stent thrombosis in patients treated with ticlopidine and aspirin.

In patients receiving coronary stents treated with aspirin and coumadin, the peak incidence of stent thrombosis occurs on the fifth and sixth days following the implantation procedure. Little is known about the timing of stent thrombosis in patients treated with aspirin and ticlopidine. We compared the timing of coronary stent thrombosis in patients treated with ticlopidine and aspirin with the timing in those receiving coumadin and aspirin. A retrospective databank analysis was performed and 39 patients were identified who experienced stent thrombosis after successful coronary stent implantation. Of these, 21 had been treated with ticlopidine and aspirin and 18 with coumadin and aspirin therapy. The median time from stent implantation to stent thrombosis in the ticlopidine and aspirin group was 12 hours (interquartile range 6 to 72 hours) compared with 4 days in the coumadin and aspirin group (interquartile range 21 to 68 hours) (p <0.0001). There was no significant difference between the timing of stent thrombosis in patients treated with abciximab in addition to ticlopidine and aspirin (median 17 hours, interquartile range 6 to 29) versus ticlopidine and aspirin patients who did not receive abciximab (median 11 hours, interquartile range 9 to 12, p = 0.57). Thus, in patients who receive coronary stents, stent thrombosis occurs much earlier after the procedure in patients treated with ticlopidine and aspirin than in patients treated with anticoagulation therapy.

Angioplasty, Balloon, Coronary↗
PubMed1999

One-year survival among patients with acute myocardial infarction complicated by cardiogenic shock, and its relation to early revascularization: results from the GUSTO-I trial.

BACKGROUND: Although 30-day survival is increased in patients with acute myocardial infarction complicated by cardiogenic shock who undergo coronary revascularization, the longer-term outcome in such patients and the duration of benefit from revascularization are unknown. METHODS AND RESULTS: We analyzed 30-day survivors of acute myocardial infarction in the Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial and identified 36 333 who had not had cardiogenic shock (systolic blood pressure <90 mm Hg for >/=1 hour, group 1) and 1321 patients who had shock (group 2). Group 2 patients were older and sicker. At 1 year, 97.4% of group 1 patients were alive versus 88.0% of group 2 (P=0.0001). Among group 2 patients, 578 (44%) had undergone revascularization within 30 days (group 2A) and 728 (56%) had not (group 2B). Revascularization was not required by protocol but was selected by the attending physicians. At 1 year, 91.7% of group 2A patients were alive versus 85.3% of group 2B (P=0.0003). With the use of multivariable logistic regression analysis to adjust for differences in baseline characteristics of shock patients alive at 30 days, revascularization within 30 days was independently associated with reduced 1-year mortality (odds ratio 0.6, [95% confidence interval 0.4, 0.9], P=0.007). CONCLUSIONS: Most patients (88%) with acute myocardial infarction complicated by cardiogenic shock who are alive at 30 days survived at least 1 year. Shock patients who underwent revascularization within 30 days had improved survival at 1 year compared with shock patients who did not receive revascularization, even after adjustment for differences in baseline characteristics between the 2 groups.

Aged↗