Objective: To examine the clinical outcome of percutaneous coronary intervention where the procedure was complicated by vessel perforation. Setting: Tertiary referral centre. Methods: The procedural records of 6245 patients undergoing coronary intervention were reviewed. In 52 patients (0.8%) the procedure was complicated by vessel perforation, ranging from wire exit to free flow of contrast into the pericardial space. The majority of lesions treated were complex (37% type B, 59% type C) and 9 of 52 (17%) were chronic occlusions. Ten patients (19%) received abciximab. Four underwent rotational atherectomy (8%). Results: In 28 of 52 patients (54%) the perforation was benign and managed conservatively without the development of haemodynamically significant sequelae. In 24 of 52 (46%) a significant pericardial effusion ensued requiring drainage. Of these 24 procedures 6 had involved the treatment of a chronic occlusion (25%). Eight of the 24 patients were referred for emergency bypass surgery (33%), 3 of whom died. Of the remaining 16 not referred for surgery, 3 died. Of the 10 procedures complicated by vessel perforation where abciximab had been administered, 9 (90%) led to pericardial tamponade. Latterly 2 vessel perforations were successfully treated by the deployment of a covered stent. Conclusions: Coronary artery perforation with sequelae during intervention is rare-26 of 6245 (0.4%). This complication was seen in the treatment of chronic occlusions, which are therefore not riskfree procedures. The development of pericardial tamponade carries a high mortality. While prompt surgical intervention may be life saving, expertise in the use of covered stents may provide a valuable rescue option for this serious complication. Caution should be exercised where coronary perforation occurs and abciximab has been used. V essel perforation during or following percutaneous coronary intervention (PCI) is a rare complication of this procedure. Previous reports cite an incidence of between 0.2-0.6% 1-6 and while some of these series were reported during the era of balloon angioplasty alone, more recent studies have referred to intervention using newer devices including stents and rotational and directional atherectomy. Not all authors have included the full spectrum of pathology in their definition of vessel perforation. This may range from mere vessel puncture by the guidewire resulting in minimal dye staining without adverse haemodynamic consequences, to "wire exit", to vessel rupture followed by brisk extravasation of blood and dye into the pericardial space leading to tamponade and abrupt haemodynamic collapse.As the range of equipment available to the interventional cardiologist evolves, together with necessary operator expertise, more complex coronary anatomy is being treated percutaneously. Abrupt vessel closure in the catheterisation laboratory is often successfully resolved by stent deployment, together with parenterally administered platelet inhibitors. Therefore, the demand for emergent surgical rescue for this sc...

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SUMMARY Detailed drinking histories were taken in 38 patients in whom dilated cardiomyopathy was diagnosed by cardiac catheterisation and left ventricular biopsy. On the basis of the drinking history twenty patients were classified as being in an abstinent or light drinking group and eighteen patients as being in a heavy drinking group (daily alcohol intake in excess of 80 g or cumulative lifetime intake exceeding 250 kg). Activities of myocardial creatine kinase, lactate dehydrogenase, a hydroxybutyric dehydrogenase, malic dehydrogenase, and aspartate aminotransferase were all higher in the heavy drinkers and myocardial enzyme activity correlated with cumulative lifetime alcohol intake, maximum daily intake, and recent daily intake. Activities of creatine kinase, a hydroxybutyric dehydrogenase, and malic dehydrogenase correlated with ejection fraction, irrespective of the alcohol intake of the patient. These findings were not altered by exclusion of patients with hypertension.The results indicate that among patients with dilated cardiomyopathy there is a group characterised by a high alcohol intake and raised myocardial tissue enzymes which supports the concept of alcoholic heart muscle disease as a distinct entity.Although the association between excessive alcohol consumption and congestive (dilated) cardio-i myopathy has long been known,1 2 a causal relation remains controversial.3 There are no studies that relate quantitative alcohol intake to myocardial damage, as there are for alcoholic liver disease.4" Indeed the clinical diagnosis of alcoholic heart muscle disease merely reflects the coexistence of global myocardial dysfunction in a heavy drinker in whom no other cause for myocardial disease has been found.Requests for reprints to Dr P J Richardson, Cardiac Department,

Objective-To create a risk model for predicting major adverse complicating events of percutaneous transluminal coronary angioplasty (PTCA), and to test the accuracy of the model on a prospective cohort of patients Setting-Tertiary cardiac centre Methods-Available software can predict probabilities of events using Bayes's theorem. To establish the accuracy of these predictive tools, a Bayes table was created to evaluate major adverse complicating events (MACE)-death, emergency coronary artery bypass grafting (CABG), or Q wave infarct occurring during the in-patient episode-on the first 1500 patients in the department PTCA database (development group); the predictive value of this model was then tested with the subsequent 1000 patients (evaluation group). The following probabilities were assessed to determine their association with MACE: age, sex, left ventricular function, American Heart Association lesion morphology classification, cardiogenic shock, previous CABG, diabetes, hypertension, multivessel PTCA. Main outcome measures-To establish the discriminatory ability of the predictive index, calibration plots and receiver operating characteristic (ROC) curves were obtained to compare the development and evaluation groups. Results-The ROC curve plotted to determine the discriminatory value of the Bayesian table created from the development group (n = 1500) in predicting MACE in the evaluation group (n = 1000) showed a moderately predictive area under the curve of 0.76 (SEM 0.07). This predictive accuracy was confirmed with separately constructed calibration plots. Conclusions-Accurate predictions of MACE can be identified in populations undergoing percutaneous intervention. The database used allows operators to obtain consent from patients appropriately from their own experience rather than from other published data. If a national PTCA database existed along similar lines, individual operators and interventional centres could compare themselves with nationally available data. (Heart 2001;85:69-72)