To determine whether low platelet response to the P2Y
12 receptor antagonist clopidogrel as assessed by VAsodilator Stimulated Phosphoprotein flow cytometry test (VASP-FCT) has the same deleterious ...clinical impact in patients with or without chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI).
Whilst both CKD and impaired platelet responsiveness to clopidogrel are strong predictors of unfavourable outcome after PCI, the deleterious impact of their association is unknown. The platelet VASP-FCT assay is specific of the P2Y
12 ADP receptor-pathway. In this test, platelet activation is expressed as Platelet Reactivity Index (PRI).
440 unselected patients (CKD: 126 (eGFR<60
ml/min/1.73
m
2), NoCKD: 314 eGFR>60
ml/min/1.73
m
2) undergoing urgent (n = 336) or planned (n = 104) PCI were prospectively enrolled. In each sub-group, patients were classified as low-responders (LR: PRI≥61%) and responders (R: PRI<61%) to clopidogrel. The 61% threshold was previously defined as the optimal cut-off value to predict cardiac death following PCI.
At a mean follow-up of 9 ± 2 months, cardiac death, probable and possible stent thrombosis rates were higher in CKD patients. In this sub-group, cardiac death, total stent thrombosis and MACE were dramatically increased in LR patients, especially when treated with drug eluting stent (DES). Conversely, in NoCKD patients, LR was not associated with poorer cardiovascular outcome. Multivariate analysis identified Killip class ≥3, DES implantation and the interaction between LR and CKD (HR 11.96 1.22–116.82; p = 0.033) as independent predictors of cardiac death.
In CKD patients, cardiovascular mortality following PCI is mainly related to impaired P2Y
12 inhibition.
ST segment resolution (STR) is a recognized intermediate prognosis parameter in STEMI reflecting the quality of tissue reperfusion. The aim of our study was to identify clinical, biological and ...angiographic determinants of STR.
157 consecutive patients treated by primary PCI within 6 hours of symptom onset were included. STR was calculated in the lead with maximal ST segment elevation. Complete STR was defined as a regression more than 70%.
Mean age of the population was 58,7±13,7 ans, the sex ratio 4 men for one woman. Maximal ST segment elevation was 0,33±0,18 mV before and 0,16Âc0,19 mV 59± minutes after PCI. Complete STR was achieved in 43,3% of patients. STR significantly correlated with enzymatic peak CPK (r= -0,33 p<0,00001), peak troponine I (r= -0,26 p=0,01), echographic LVEF (r=0,35 p<0,0001) and plasmatic creatinin concentration 48 hours after admission (r= -0,31 p=0,0001). In univariate analysis, complete STR was significantly associated with young age, an elevated SpO
2, angiographic TIMI flow grade 2 or 3 before angioplasty, low plasmatic BNP or HbA1c or fibrinogen concentrations. A trend of association for complete STR was observed with Killip class (p=0,075), number of Q waves (p=0,075), the use of direct stenting (p=0,08) and the use of abciximab (p=0,07). In multivariate analysis the independant predictors of STR were inferior location of infarction (OR=1,35 ; IC 1,16-1,55), TIMI risk score<5 (OR=1,24 ; IC 1,05-1,59) and angiographic TIMI flow grade 2 or 3 before angioplasty (OR=1,07 IC 1,009-1,15).
Our results suggest that STR is related to the size of myocardial infarction. The resolution of ST elevation is multifactorial and mainly deriven by inferior location of myocardial infarction, low TIMI risk score and better angiographic TIMI flow grade before PCI (>1).
Cardiac magnetic resonance imaging (MRI) is the gold standard to quantify the infarct size and the extend of microvascular obstruction in ST-elevation myocardial infarction (STEMI). ST-segment ...resolution (STR) after primary percutaneous intervention (PCI) is currently used to assess the reperfusion quality in the acute phase myocardial infarction. The relation between STR and microvascular obstruction evaluated by MRI is unknown. The aim of this study was to determine the relationship between the ST-segment resolution, the infarct size and the extend of microvascular obstruction.
41 patients undergoing primary PCI for STEMI within 6 hours of symptom onset were prospectively included. ST-segment resolution was evaluated one hour after reperfusion. MRI was performed in all patients. Complete STR was defined as a STR>70%.
Mean age of the patients was 54 ± 12 yo, 85 waer males. The percent of infarct size was 18,6 ±16% of the left ventricular volume. Microvascular obstruction was present in 68% of patients. Mean STR was 59 ± 39% and 14 patients (34%) presented complete STR. A large infarct size (> 75
th percentile) was associated with anterior localisation and left descending artery obstruction. STR significantly correlated with infarct size measured by MRI (r=-0,38 p=0,026). Incomplete STR (<70%) predicted large infarct size with a sensitivity of 78%, a specificity of 42% and high degree of microvascular obstruction with sensitivity of 80% and specificity of 45%.
STR one hour after primary PCI is associated with the level of infarct size and microvascular obstruction in STEMI patients. Incomplete STR after PCI is a strong prognostic marker of large infarct size and high degree of micro vascular obstruction.
Diagnostic value of circulating D-Dimer (DD) in acute aortic dissection (AAD) has been shown recently. However, there is no data concerning the kinetics of DD in AAD and few is known about prognostic ...value of DD in AAD.
to describe the kinetics of circulating DD during the in-hospital period of AAD in patients and to analyse its prognostic value.
consecutive patients presenting with AAD in our institution were included. Follow-up was obtained to determine the total mortality and major events related to AAD i.e. : re-intervention, aneurismal evolution, persistence of a circulating false lumen). DD were assessed by immunoturbidimetric method (Stago®, France).
109 patients (mean age 62
±
14 years) were included. 76 patients were Stanford A (70%, surgery in 97%), and 33 Stanford B (30%, surgery in 9%). DD levels at admission were 10032
±
7955 ng/ml. The kinetic of DD followed a “V” curve with a significant decrease until day 2 (nadir) and a slow increase thereafter up to day 8 without difference between the type of dissection or whether the patients were operated or not. Cumulative mortality was 16% in-hospital and 28% at a mean of follow up 3.4
±
3 years. In-hospital mortality was associated with DD level at admission and at day2 (nadir). Cumulative long-term mortality was only associated with DD level at day 2 (nadir) at the cut off of 2000ng/ml. DD were not associated with re-intervention, aneurismal evolution or persistence of a circulating false lumen.
DD kinetic in AAD follows a biphasic “V” curve, with a nadir at day 2. In hospital mortality is associated with DD at admission and at day2, whereas cumulative long-term mortality is only associated with DD levels at day 2. These results suggest that a DD dosage at admission and at day 2 in AAD might be of help for the patient prognosis evaluation.
BACKGROUNDPercutaneous closure of patent foramen ovale (PFO) is recommended for patients presenting with PFO-related stroke. Acute high-grade conduction disturbances occurring during PFO closure ...procedure have not been previously reported. CASE SUMMARYWe describe for the first time a case of reversible complete atrioventricular block which occurred during closure of a PFO. DISCUSSIONWe hypothesized that the block was the result of atrioventricular node compression-likely caused by the right-atrial disc of the 35-mm PFO closure device. We suggest implanting smaller devices in order to prevent atrioventricular conduction disturbances.
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