The aim of this study was to provide contemporary data on chronic total occlusion (CTO) prevalence and management in a large unselected population representing the daily activity of cathlabs, in the ...greater Paris area, and to compare percutaneous coronary intervention (PCI) features in patients with and without CTO. Procedures were collected from the CARDIO-ARSIF (Agence Régionale de Santé Ile de France) registry from 2012 to 2015. Patients with acute coronary syndrome or previous coronary artery bypass grafting were excluded. CTO features were assessed and PCIs with and without CTO were compared. Among 128,739 included patients, 10,468 (8.1%) had at least 1 CTO. Cardiovascular risk-factor burden was higher in the CTO group, which had more patients with multivessel disease (74% vs 24%) and with referral for interventional management (59% vs 33%). Of all PCIs during the study period, 5.7% involved a CTO; this proportion increased significantly over the study period. PCI success rate was 75.9% in the CTO group. CTO-PCI volume per center did not correlate with CTO-PCI success rate. In conclusion, CTO is common in patients who underwent scheduled coronary angiography. Invasive management is done more often in patients with than without CTO. The success rate of PCI in CTO is not associated with case volume per center.
The frequency of complex percutaneous coronary interventions (PCIs) has increased in the last few years, with a growing concern on the radiation dose received by the patients. Multicenter data from ...large unselected populations on patients' radiation doses during coronary angiography (CA) and PCI and temporal trends are lacking. This study sought to evaluate the temporal trends in patients' exposure to radiation from CA and PCI.
Data were taken from the CARDIO-ARSIF registry that prospectively collects data on all CAs and PCIs performed in the 36 catheterization laboratories in the Greater Paris Area, the most populated regions in France with about 12 million inhabitants. Kerma area product and Fluoroscopy time from 152 684 consecutive CAs and 103 177 PCIs performed between 2009 and 2013 were analyzed. A continuous trend for a decrease in median interquartile range Kerma area product was observed, from 33 19-55 Gy cm
in 2009 to 27 16-44 Gy cm
in 2013 for CA (
<0.0001), and from 73 41-125 to 55 31-91 Gy cm
for PCI (
<0.0001). Time-course differences in Kerma area product remained highly significant after adjustment on Fluoroscopy time, PCI procedure complexity, change of x-ray equipment, and other patient- and procedure-related covariates.
In a large patient population, a steady temporal decrease in patient radiation exposure during CA and PCI was noted between 2009 and 2013. Kerma area product reduction was consistent in all types of procedure and was independent of patient-related factors and PCI procedure complexity.
Stenting reduces both acute complications of coronary angioplasty and restenosis rates but increases subacute thrombosis rates and hemorrhagic complications when used with coumadin anticoagulation.
...To simplify postcoronary stenting treatment and to reduce these drawbacks, we evaluated the 1-month outcome of a prospective registry of 2900 patients in whom successful coronary artery stenting was performed without coumadin anticoagulation. Patients received 100 mg/d aspirin and 250 mg/d ticlopidine for 1 month. Low-molecular-weight heparin (LMWH) treatment was progressively reduced in four consecutive stages, from 1-month treatment to none. Event-free outcome at 1 month was achieved in 2816 patients (97.1%). Major stent-related cardiac events were subacute closure in 51 patients (1.8%), including death in 12 (0.5%), acute myocardial infarction in 17 (0.6%), and coronary artery bypass graft surgery in 9 (0.3%). Stent thrombosis was more frequent with balloon size of < 3.0 mm (< or = 2.5 mm, 10%; 3.0 mm, 2.3%; > or = 3.5 mm, 1.0%; P < .001), bail-out situations (6.67% versus 1.38%, P < .001), and patients with unstable angina or acute myocardial infarction (2.2% versus 1.12%, P = .02). Bleeding complications that required transfusion, surgical repair, or both occurred in 55 patients (1.9%). Bleeding complications were related to female gender (4.0% versus 1.51%, P < .001), duration of LMWH treatment (3.83% in phase II/III versus 0.69% in phase IV/V, P < .001), sheath size (6F, 0.52%; 7F, 1.04%; > or = 8F, 4.23%; P < .001), bail-out situations (4.76% versus 1.67%, P < .01), and saphenous graft stenting (4.38% versus 1.75%, P = .04).
These results suggest that poststenting treatment by ticlopidine/aspirin is an effective alternative to coumadin anticoagulation, achieving low rates of subacute closure and bleeding complications. LMWH treatment does not improve subacute reocclusion rates but increases bleeding complications. Furthermore, as bleeding complications were independently related to sheath size, we suggest that stenting with 6F guiding catheters may prevent local complications. Furthermore, the ticlopidine/aspirin combination allows a low-cost stenting strategy without ultrasound assessment of stent deployment and permits short inhospital stay.
OBJECTIVES
We tested the hypothesis that the reperfusion syndrome (RS), defined as an additional elevation of the ST segment upon reperfusion, may be a marker of microcirculatory reperfusion injury ...during acute myocardial infarction (AMI).
BACKGROUND
The pathophysiology of the RS is unknown, and its prognostic implications are controversial.
METHODS
Twenty-one patients with an anterior AMI treated ≤12 h after onset by primary coronary angioplasty (PTCA) were studied. Coronary velocity reserve (CVR), an index of microcirculatory function, was measured using a Doppler guidewire. Left ventricular (LV) ejection fraction, infarct size (percent defect) and LV end-systolic volume index (LVESVi) were evaluated by radionuclide ventriculography, 201T1 single-photon emission computed tomography and contrast ventriculography, respectively.
RESULTS
Baseline ST elevation and pain-to-TIMI 3 time were similar in patients with and without RS. Patients with RS (10/21) had a lower post-PTCA CVR than patients without RS (median 95% confidence interval: 1.2 1–1.3 vs. 1.6 1.5–1.7, p < 0.005). Even though predischarge CVR was similar in the two groups, infarct size at six weeks (26 21 to 37 vs. 14 10–17 % 201T1 defect, p = 0.001) and predischarge LVESVi (45% 40 to 52 vs. 30% 29 to 38 mL/m2, p = 0.001) were larger, and LV ejection fraction at six weeks (40% 37 to 46 vs. 55% 50 to 60, p = 0.004) was lower in patients with RS than in patients without RS.
CONCLUSIONS
Patients with RS during primary PTCA for an anterior AMI have a transiently lower CVR than patients without RS, but sustained LV dysfunction and larger infarct size, suggesting that RS is a marker of microcirculatory reperfusion injury.
Background: Despite high patency rates, primary angioplasty for myocardial infarction does not necessarily result in optimal myocardial reperfusion and limitation of infarct size. Experimentally, ...trimetazidine limits infarct size, decreases platelet aggregation, and reduces leukocyte influx into the infarct zone. To assess trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction a prospective, double-blind, placebo-controlled pilot trial was performed.
Methods: 94 patients with acute myocardial infarction were randomized to receive trimetazidine (40 mg bolus followed by 60 mg/day intravenously for 48 h) (
n=44) or placebo (
n=50), starting before recanalization of the infarct vessel by primary angioplasty. Patients underwent continuous ST-segment monitoring to assess return of ST-segment deviation to baseline and presence of ST-segment exacerbation at the time of vessel recanalization. Infarct size was measured enzymatically from serial myoglobin measurements. Left ventricular angiography was performed before treatment and repeated at day 14.
Results: Blinded ST segment analysis showed that despite higher initial ST deviation from baseline in the trimetazidine group (355 (32) vs. 278 (29) μV,
P=0.07), there was an earlier and more marked return towards baseline within the first 6 h than in the placebo group (
P=0.014) (change: 245 (30) vs. 156 (31) μV respectively,
P=0.044). There was a trend towards less frequent exacerbation of ST deviation at the time of recanalization in the trimetazidine group (23.3 vs. 42.2%,
P=0.11). There was no difference in left ventricular wall motion at day 14, or in enzymatic infarct size. There was no side effect from treatment. Clinical outcomes were similar between groups.
Conclusion: Trimetazidine was safe and led to earlier resolution of ST-segment elevation in patients treated by primary angioplasty for acute myocardial infarction.
This study sought to assess the rate of acute Thrombolysis In Myocardial Infarction (TIMI) trial grade 3 patency that can be achieved with the combination of prehospital thrombolysis and standby ...rescue angioplasty in acute myocardial infarction. No large angiographic study has been performed after prehospital thrombolysis to determine the 90-minute TIMI 3 patency rate in the infarct-related artery. Hospital outcome and artery patency were compared to 170 matched patients treated with primary angioplasty. Prehospital thrombolysis was applied 151 ± 61 minutes after the onset of pain in 170 patients (56 ± 12 years, 86% men), using recombinant tissue-type plasminogen activator, streptokinase, or eminase. Emergency 90-minute angiography was performed in every case. All patients in whom thrombolysis failed underwent rescue angioplasty. After thrombolysis alone, TIMI grade 3 flow in the infarct-related artery was observed in 108 patients (64%), TIMI grade 2 in 12 (7%), and TIMI grade 0 or 1 in 50 (29%). Rescue angioplasty was successful in 47 of 50 attempts. Overall, TIMI 3 patency was achieved in 91%, and additionally TIMI 2 flow in 7% of patients, an average of 113 ± 39 minutes after thrombolysis and 55 ± 19 minutes after admission. Therefore, <2 hours after thrombolysis, only 2% of patients had persistent occlusion (TIMI 0 or 1) of the infarct-related artery. In-hospital mortality was 4% overall (7 of 170), and 3% in the 155 patients in whom TIMI 3 was obtained during the acute phase. Severe hemorrhagic complications occurred in 14 patients (8%) with 2 fatal cerebral hemorrhages (7% of patients required transfusions). The matched comparison with primary PTCA showed no significant difference in hospital outcome. Combined prehospital thrombolysis, 90-minute angiography, and rescue angioplasty yield a high rate of acute TIMI 3 patency rate early after thrombolysis and hospital admission. A randomized, prospective comparison between these 2 reperfusion strategies may be now warranted.
The role of systematic emergency percutaneous transluminal coronary angioplasty (PTCA) in patients with spontaneous reperfusion during myocardial infarction is debated. We retrospectively examined ...the inhospital outcome of 47 consecutive patients with myocardial infarction <6 hours and angiographically proven spontaneous patency of the infarct artery managed without initial PTCA. There was one death (2.1%) and no incidence of reinfarction. Predischarge angiography showed regression of the culprit coronary lesion to <50% stenosis in 23% of the patients, therefore obviating the need for PTCA. However, 17% of the patients had acute recurrent ischemia, requiring emergency intervention in 10.6%. Comparison with matched patients in whom Thrombolysis in Myocardial Infarction grade 3 patency was achieved by thrombolysis or by primary PTCA showed that patients with spontaneous patency tended to have smaller infarctions, as judged from a lower peak creatine kinase level (1132 ± 1002, 2051 ± 1536, and 2715 ± 2146 IU, respectively;
p = 0.001) and a higher left ventricular ejection fraction (56.4%, 47.9%, and 48.7% respectively;
p = 0.02). In conclusion, these patients have an excellent inhospital outcome, with evidence of less myocardial damage than in patients in whom reperfusion therapy was required to achieve TIMI 3 patency. Initial conservative treatment appears safe.
PDF
