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Biomedical subjects

J W Moses

Publications and source records attributed to J W Moses.

At least 55 records · Page 3Linked to original sources
PubMed1997

Predictors of acute and long-term outcome with transluminal extraction atherectomy: the New Approaches to Coronary Intervention (NACI) registry.

The New Approaches to Coronary Intervention (NACI) registry was established to define the role of new coronary devices in overcoming the limitations of balloon angioplasty. The purpose of the present study was to evaluate the acute and long-term efficacy of the transluminal extraction catheter (TEC) device utilizing data from the NACI registry and identify clinical and anatomic patient subsets who may benefit from this device. From 1990-1994, >4,300 patients from 39 clinical sites enrolled consecutive patients treated with one of the 7 new devices to the NACI registry. The study population consists of 331 patients (385 lesions) treated with planned TEC as the sole new device. Of these patients, 243 (292 lesions) were treated for saphenous vein graft (SVG) disease and 88 (93 lesions) for native disease. Patients undergoing SVG treatment were older and more likely to be male. They had lower ventricular function, more unstable angina, and a higher incidence of congestive heart failure. Multivessel disease was more prevalent in the SVG cohort, as was evidence of thrombus before treatment. Although device success was achieved in 50% of SVG lesions and 41% of native lesions, lesion success was achieved in 90% and 78%, respectively, after adjunctive balloon angioplasty, and procedure success rates were 86% and 79%, respectively. The in-hospital major complication (death/Q-wave myocardial infarction/emergency coronary artery bypass graft [CABG] surgery) rate was higher in the SVG cohort (6.2% vs 2.3%), mainly due to higher mortality rate (5.3% vs 1.1%). Multivariate analysis showed that SVG was not an independent predictor for either an in-hospital major complication or clinical failure. The risk factors for major in-hospital complications were history of congestive heart failure (odds ratio = 3.17) and thrombus (odds ratio = 3.36). For clinical failure the risk factors were diabetes (odds ratio = 1.88), thrombus (odds ratio = 2.08), and calcium (odds ratio = 3.09). One-year rates of death, Q-wave myocardial infarction, or any repeat revascularization were 51% in the SVG cohort and 41% in the native cohort. Following adjustment, patients treated for SVG disease did not have a higher risk when compared with those treated for native disease. The factors significantly associated with this composite event at 1 year are male (relative risk = 1.41), patients with history of congestive heart failure (relative risk = 1.56), and total occlusions (relative risk = 1.52). This study shows that for both SVG and native cohorts, device success rates were low with TEC alone, but acceptable lesion success rates were achieved when adjunctive PTCA was used. In-hospital as well as 1-year major complications were higher in the SVG cohort. However, after adjusting for other risk factors, SVG attempt was not significantly associated with either in-hospital or 1-year events.

Aged↗
PubMed1997

The use of the Gianturco-Roubin intracoronary stent: the New Approaches to Coronary Intervention (NACI) registry experience.

The objective of this study is to compare the in-hospital and follow-up outcome in patients receiving the Gianturco-Roubin stent (GRS) who were enrolled in the New Approaches to Coronary Intervention (NACI) registry. The GRS was approved by the US Food and Drug Administration (FDA) in August 1992 for the treatment of acute or threatened closure after a percutaneous intervention. The application of intracoronary stenting has broadened substantially in the last few years, but less is known about the use of this device for other indications. Since the NACI registry includes patients stented for other indications, a comparison of these groups with patients being stented for acute or threatened closure was undertaken. A GRS was deployed in 497 NACI registry patients. Of these, 466 patients received a GRS in 1 of 3 of the following ways: (1) 351 unplanned stenting after conventional angioplasty of the same lesion; (2) 54 after failed/suboptimal use of a new device in the same lesion; and (3) 61 in planned stenting procedures. This analysis focuses on these 3 patient subgroups and compares their in-hospital outcome and subsequent follow-up to 1 year. There were 520 stented segments in the 466 patients. The group with stenting after failed/suboptimal new-device use had a higher incidence of myocardial infarction (MI) and cardiogenic shock than either the patients with unplanned stenting after percutaneous transluminal coronary angioplasty (PTCA) or planned stenting (MI 22.2% vs 12.0% vs 0%, respectively, and cardiogenic shock 5.6% vs 0.9% vs 0%, respectively; p < 0.05). This group also had significantly lower procedural success (58.7% vs 75.3% vs 81.5%, respectively; p < 0.05). Although not statistically significant, the requirement for transfusion was higher in the unplanned and new-device stented groups than in the planned group (10.5% vs 16.7% vs 1.6%, respectively). Likewise, the incidence of Q-wave MI was higher in the new-device group (22.2% vs 12% vs 0%, respectively; p < 0.05). Despite a higher, in-hospital complication rate in the unplanned groups, follow-up from discharge to 1 year showed similar outcome. In particular, percutaneous reintervention of the stented segment occurred in: 13.0% in the unplanned after new device; 17.4% in the unplanned after PTCA; and 26.2% in the planned group. Although not statistically significant, the higher incidence of percutaneous target lesion revascularization in the planned group probably represents the greater incidence of restenotic lesions in this cohort. In this very heterogeneous group of patients, including those with failure of another new device, the use of the GRS is associated with acceptable in-hospital and follow-up complication rates, although complications were clearly greater when unplanned use of the stent was needed, particularly after failure of another new device. Although the experience is small, patients having the GRS placed in an elective fashion, i.e., the planned group, appear to experience lower in-hospital complication rates, although they have a higher rate of subsequent target lesion revascularization, in this group of predominantly restenotic lesions.

Aged↗
PubMed1997

Bailout and corrective use of Gianturco-Roubin flex stents after percutaneous transluminal coronary angioplasty: operator reports and angiographic core laboratory verification from the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention Registry.

OBJECTIVES: We sought to determine the in-hospital clinical outcome and angiographic results of patients prospectively entered into the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention (NHLBI/NACI) Registry who received Gianturco-Roubin stents as an unplanned new device. BACKGROUND: Between August 1990 and March 1994, nine centers implanted Gianturco-Roubin flex stents as an unplanned new device in the initial treatment of 350 patients (389 lesions) who were prospectively enrolled in the NHLBI/NACI Registry. METHODS: Patients undergoing implantation of the Gianturco-Roubin flex stent were prospectively entered into the Gianturco-Roubin stent portion of the NHLBI/NACI Registry. Only subjects receiving the Gianturco-Roubin stent as a new device in an unplanned fashion are included. RESULTS: The mean age of the patient group was 61.8 years, and the majority of the patients were men. A history of percutaneous transluminal coronary angioplasty (PTCA) was present in 35.4% of the group, and 16.9% had previous coronary artery bypass graft surgery. Unstable angina was present in 67.7%. Double- or triple-vessel coronary artery disease was present in 55.4%, and the average ejection fraction was 58%. The presence of thrombus was noted in 7.3%, and 7.2% had moderate to severe tortuosity of the lesion. The angiographic success rate was 92%. Individual clinical sites reported that 66.3% of the stents were placed after suboptimal PTCA, 20.3% for abrupt closure and 13.4% for some other technical PTCA failure. Major in-hospital events occurred in 9.7% of patients, including death in 1.7%, Q wave myocardial infarction in 3.1% and emergency bypass surgery in 6%. Abrupt closure of a stented segment occurred in 3.1% of patients at a mean of 3.9 days. Cerebrovascular accident occurred in 0.3%, and transfusion was required in 10.6%. Vascular events with surgical repair occurred in 8.6% of patients. CONCLUSIONS: Despite these complications, the use of this device for the treatment of a failed or suboptimal PTCA result remains promising given the adverse outcome of abrupt closure with conventional (nonstent) treatment.

Angioplasty, Balloon, Coronary↗
PubMed1995

In-hospital and one-year economic outcomes after coronary stenting or balloon angioplasty. Results from a randomized clinical trial. Stent Restenosis Study Investigators.

BACKGROUND: Coronary stenting has been shown to improve initial success, reduce angiographic restenosis, and reduce the need for repeat revascularization compared with conventional balloon angioplasty (PTCA). Although previous studies have demonstrated that initial hospital costs for stenting are considerably higher than those for conventional PTCA, the impact of coronary stenting on long-term medical care costs remains unknown. METHODS AND RESULTS: Between January 1991 and June 1993, 207 consecutive patients with symptomatic coronary disease requiring revascularization of a single coronary lesion were randomized to receive initial treatment by either PTCA (n = 105) or Palmaz-Schatz coronary stent implantation (n = 102) in the multicenter STRESS trial. Detailed resource utilization and cost data were collected for each patient's initial hospitalization and for any subsequent hospital visits for 1 year after randomization. Compared with conventional angioplasty, coronary stenting resulted in additional catheterization laboratory costs, increased vascular complications, and longer length of stay. Initial hospital costs were thus approximately $2200 higher for stenting than for PTCA ($9738 +/- 3248 versus $7505 +/- 5015; P < .001). Over the first year of follow-up, however, patients assigned to initial stenting were less likely to require rehospitalization for a cardiac condition and underwent fewer subsequent revascularization procedures. Follow-up medical care costs thus tended to be lower for stenting than for conventional angioplasty ($1918 +/- 4841 versus $3359 +/- 7100, P = .21). Nonetheless, cumulative 1-year medical care costs remained higher for patients undergoing initial stenting ($11,656 +/- 5674 versus $10,865 +/- 9073, P < .001). Even after adjustment for the higher incidence of vascular complications in the stent group, total 1-year costs were $300 higher for stenting than for balloon angioplasty. CONCLUSIONS: Elective coronary stenting, as performed in the randomized STRESS trial, increased total 1-year medical care costs by approximately $800 per patient compared with conventional angioplasty. Future studies will be necessary to determine whether ongoing refinements in stent design, implantation techniques, and anticoagulation regimens can narrow this cost difference further by reducing stent-related vascular complications or length of stay.

Aged↗
PubMed1995

Transluminal extraction catheter for the treatment of diseased saphenous vein grafts: a multicenter experience.

To evaluate the efficacy, safety, and long-term results of atherectomy using the Transluminal Extraction catheter (TEC), patients with diseased saphenous vein grafts were enrolled in a prospective nonrandomized trial. Patients were followed to hospital discharge for acute complications and underwent routine 6-mo reevaluation with repeat cardiac catheterization to assess restenosis. Atherectomy was performed on 650 graft lesions in 538 consecutive patients (male 81%; mean age 66 yr; range 37-81). Mean graft age was 8.3 yr; (range 0.3-20) with 85% of grafts > 3 yr of age. Complex lesion morphology included thrombus (28%), ulceration (13%), and eccentricity (50%). Lesion success was achieved in 606 lesions (93%) with clinical success in 479 patients (89%). Lesion success was achieved in 90% of thrombus containing lesions, 97% of ulcerated lesions, and 97% of grafts > 3 yr. Complications included nonfatal myocardial infarction in 4 (0.7%) of patients, emergency bypass surgery in 2 (0.41%), and in-hospital death in 17 patients (3.2%). Angiographic follow-up at 6 mo was obtained from 268 lesions in 227 patients. The overall lesion angiographic restenosis rate was 60%. TEC atherectomy can be performed in patients with diseased saphenous vein grafts with high primary success and low complication rates. It is suitable for use in aged grafts, particularly in the presence of thrombus and ulcerations, and may be superior to balloon angioplasty alone in this group of patients.

Adult↗
PubMed1994

Effectiveness of holmium laser-assisted coronary angioplasty. The Holmium Laser Coronary Registry.

The efficacy of holmium laser-assisted angioplasty was studied in 365 narrowings in 331 consecutive patients with coronary artery disease. Clinical indications for study were unstable angina pectoris in 140 patients (42%), stable angina in 136 patients (41%), postmyocardial infarction angina in 35 patients (10.5%), silent myocardial ischemia in 11 patients (3%), acute myocardial infarction in 1 patient (0.3%) and undefined in 8 patients (2%). Coronary morphology characteristics by Multivessel Angioplasty Prognosis Study group criteria were type A in 12.6%, type B1 in 34.2%, type B2 in 27.4% and type C in 25.4%. The laser successfully crossed the total length of the narrowing in 85.2%. Procedural success was 94.2%. Laser alone reduced mean percent luminal narrowing from 88 +/- 11% to 57 +/- 22%. Subsequent balloon angioplasty further reduced the mean luminal narrowing to 23 +/- 18%. Major complication rate was 2.7% (death 0.3%, Q-wave myocardial infarction 0.5%, and emergent bypass surgery 2.7%). Six-month angiographic restenosis (> 50% stenosis) rate was 44%.

Angioplasty, Balloon, Coronary↗
PubMed1991

Hemodynamic changes during retrograde left-heart catheterization in patients with aortic stenosis.

Pulmonary artery pressures in patients with aortic stenosis have been related to postoperative prognosis and surgical risk. However, while right- and left-heart pressures should be measured simultaneously, a catheter lying across the stenotic aortic valve might alter left- and right-heart pressures. To assess this phenomenon, right- and left-heart pressures were recorded before and after retrograde crossing of the aortic valve in 51 patients (30 patients with and 21 without aortic stenosis). In aortic stenosis, the mean pulmonary artery pressure increased (p less than 0.001) after transaortic valvular pressure catheter placement (average 4 mm Hg, peak 19 mm Hg); in the absence of aortic stenosis, the mean pulmonary artery pressure did not change (average 0 mm Hg; NS). A similar response was noted for the mean pulmonary capillary wedge pressure. Hemodynamic changes did not correlate with the severity of aortic stenosis or with left ventricular performance. Right-heart pressures should be determined without transaortic valvular catheter in place, if accurate interpretation of the hemodynamic effects of aortic stenosis is to be achieved.

Aortic Valve Stenosis↗
PubMed1991

Exercise-related atrioventricular block. Influence of myocardial ischemia.

A 62-year-old woman was noted to have complete heart block immediately following an exercise stress test. Coronary arteriography subsequently revealed a significant lesion in the right coronary artery, which was successfully dilated. Thallium-exercise testing following angioplasty showed no evidence of inducible ischemia and no arrhythmia was seen, supporting the idea that exercise-related heart block may occur secondary to myocardial ischemia.

Angioplasty, Balloon, Coronary↗
PubMed1990

Relative insensitivity of densitometric stenosis measurement to lumen edge determination.

Coronary artery stenosis measurement from coronary arteriograms is dependent on lumen edge determination. In theory, dependence may be minimized by densitometric integration of the entire lumen as compared with densitometric determination of edges alone coupled with calculation of lumen size by geometric formulas. To assess the impact of approximations of lumen border position when densitometric and geometric methods are employed, external, intermediate and internal borders were defined and used with each method to calculate lumen narrowing from images of contrast-filled, asymmetrically stenotic model vessels and from clinically generated coronary arteriograms. Actual cross-sectional area narrowing of models correlated almost perfectly with densitometric narrowing for each of the three border criteria (external: r = 0.99, n = 192; intermediate: r = 0.99, n = 192; internal: r = 0.99, n = 192). Lumen narrowing calculated by assuming a circular lumen geometry with a diameter equal to the distance between these identical borders correlated less well with true area narrowing (external: r = 0.79, n = 192; intermediate: r = 0.83, n = 192; internal: r = 0.78, n = 192); the residual variance of the densitometric regression was significantly less than that of the geometric regression for each of the three border criteria (external: 8.13 versus 372, p less than 0.001; intermediate: 7.39 versus 315, p less than 0.001; internal: 7.13 versus 531, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Angiography↗
PubMed1989

Valve injury and repair in balloon aortic valvuloplasty.

Aortic valves 0.5, and 4.5 months after successful percutaneous balloon aortic valvuloplasty (BAV) were examined. BAV caused macroscopic and microscopic fractures in calcific deposits. An inflammatory response was identified that may lead to valvular scarring. This process may be an important factor in the development of restenosis after BAV.

Aged↗
PubMed1988

Prevalence and clinical correlates of non-Wenckebach, narrow-complex second-degree atrioventricular block detected by ambulatory ECG.

Among 113 patients with transient, narrow-complex second-degree atrioventricular (AV) block detected by ambulatory ECG, there were 20 with non-Wenckebach behavior. Based on the presence or absence of PR interval shortening after single blocked complexes, patients with narrow-complex non-Wenckebach patterns could be separated into a pseudo-Mobitz II group of 16 patients (greater than or equal to 20 msec of PR shortening after the blocked complex) and a classic Mobitz II group of four patients (constant PR interval). These groups had additional distinct ECG and clinical features. Patients with the pseudo-Mobitz II pattern had a 44% prevalence of associated Wenckebach block during the same ambulatory recording, whereas Wenckebach behavior did not occur in patients with classic Mobitz II block. Pseudo-Mobitz II block occurred at significantly longer cycle lengths (876 vs 585 msec) and with significantly longer PR intervals (225 vs 165 msec) preceding the blocked complex than did classic Mobitz II block. Syncope was the presenting symptom in 38% of patients with pseudo-Mobitz II block and in all patients with classic Mobitz II block. Patients with pseudo-Mobitz II block had a 56% prevalence of associated coronary disease and a 44% prevalence of congestive heart failure; the mortality rate was 38% in this group over 4 years of follow-up, but in all instances death was due to associated disease rather than to conduction itself. In contrast, patients with classic Mobitz II block had hypertensive or valvular disease but no evidence of coronary disease or congestive failure; all are alive with pacemakers after 3 years of follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1986

Randomized double-blind trial of intravenous streptokinase for acute myocardial infarction.

To determine the efficacy of intravenously administered streptokinase (SK) on infarct artery patency, global left ventricular (LV) function and clinical course in transmural acute myocardial infarction (AMI), 38 patients were studied using a randomized, double-blind, placebo-controlled scheme. Nineteen patients received 1.0 million units of SK followed by 72 hours of heparin infusion and 19 received placebo followed by heparin infusion, all within 5 hours (mean 3.3 hours) after AMI onset. Patients ineligible for inclusion in the randomized trial were followed as a second, "historical control" group. Compared with placebo, SK caused a higher frequency of enzymatic evidence of reperfusion (6% vs 79%, p less than 0.001) and of patent infarct-related arteries at predischarge coronary arteriography (64% vs 88%, difference not significant). (Patients in the control group had a relatively low frequency of spontaneous thrombolysis--28%.) In the SK group LV ejection fraction increased from early (average 7.3 hours after AMI) to late (predischarge) study (from 40% early to 47% late, p less than 0.05); in the placebo group LV ejection fraction did not change significantly (from 41% to 42%). Predischarge exercise radionuclide ventriculography showed mild and similar degrees of inducible ischemia in both groups. After a mean of 12.8 months of follow-up, 1 SK patient and 4 placebo patients had died (difference not significant). In conclusion, intravenous SK is efficacious for thrombolysis in patients with AMI. It improves global LV function without augmenting exercise-inducible ischemia.

Adult↗
PubMed1986

Left atrial myxoma: diagnosis by digital subtraction intravenous angiography.

Digital subtraction intravenous angiography (DSIVA) represents an important technical advance in angiographic diagnosis. Herein we present three patients with left atrial myxoma assessed by DSIVA. We review the role of DSIVA in evaluation of patients with suspected cardiac tumors and the importance of careful atrial-phase scrutiny in examinations obtained for other purposes (ie, pulmonary angiography and assessment of ventricular function).

Angiography↗