Nine‐Month Angiographic and Intravascular Ultrasound Outcomes After Resolute Zotarolimus‐Eluting Stent Implantation for the Treatment of In‐Stent Restenosis

Objectives

We aimed to evaluate the mid‐term outcomes of resolute zotarolimus‐eluting stent (R‐ZES) implantation for in‐stent restenosis (ISR).

Background

There has been a paucity of data regarding the effects of new‐generation drug‐eluting stent to treat ISR.

Methods

From 2009 to 2010, a total of 98 patients with 98 ISR lesions were prospectively enrolled after R‐ZES implantation for the treatment of ISR. Among 98 patients, 73 patients underwent follow‐up angiography at 9 months. Serial intravascular ultrasound (IVUS) at both postprocedure and 9 months was evaluated in 55 patients. The overlapped segment of R‐ZES was defined as the portion of R‐ZES superimposed on previous stent.

Results

Late loss and binary restenosis rate were 0.3 ± 0.5 mm and 5.5% at 9 months. On IVUS, the percentage of neointimal volume and maximum percentage of neointimal area were 3.9 ± 6.3% and 17.3 ± 15.5%, respectively. There was no significant change of vessel volume index between postprocedure and 9 months (16.9 ± 4.7 mm³/mm vs. 17.1 ± 4.6 mm³/mm, P = 0.251). Late‐acquired incomplete stent apposition was observed in 5 (5/55, 9.1%) cases. Compared with nonoverlapped segments of R‐ZES, the overlapped did not show larger neointimal volume index (0.3 ± 0.5 mm³/mm vs. 0.2 ± 0.3 mm³/mm, P = 0.187) on 9‐month IVUS. During follow‐up (median, 353 days), repeat target‐lesion revascularization was performed in four cases, but there were no death or stent thrombosis.

Conclusions

This study suggested that R‐ZES implantation for the treatment of ISR was effective up to 9 months and showed favorable vascular responses on serial IVUS assessment.

     

Day Hospital Treatment for Anorexia Nervosa: A 12‐Month Follow‐up Study

Day hospitals (DHs) represent a treatment option for anorexia nervosa (AN), a mental disorder that is difficult to treat and has no evidence‐based treatments available. We aimed to determine the effectiveness of a DH treatment that was specifically focused on the emotions of severe AN patients. Body mass index and eating psychopathology were the primary outcome measures. Fifty‐six adult patients with AN were assessed upon admission, at the end of treatment (EOT) and at a 12‐month follow‐up evaluation (T18) using Eating Disorders Inventory‐2, Beck Depression Inventory, Hamilton Rating Scale for Anxiety and Brief Social Phobia Scale. All participants received a multidisciplinary treatment programme that focused on psychodynamic psychotherapy. Seventy‐eight per cent of participants reported positive outcomes at EOT and 68% at T18. Moreover, 82.1% and 65.4% of long‐standing patients showed positive outcomes at EOT and T18, respectively. All measures of psychopathology were significantly improved at EOT and were maintained at follow‐up. Our DH was effective at treating severe AN patients; however, further investigations of the processes of change are warranted. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.     

Trends in In‐Hospital Outcome After Percutaneous Coronary Intervention in the Drug‐Eluting Stents Era

Background

The introduction of drug‐eluting stents (DES) dramatically changed the practice of percutaneous coronary intervention (PCI) in the 2000s. Little is known about trends in in‐hospital outcome after PCI in the DES era.

Hypothesis

The in‐hospital outcomes after PCI might be continuously improved over time.

Methods

We analyzed in‐hospital outcomes of 21 667 patients who underwent PCI at Fu Wai Hospital in the past 5 years. The patients were divided into 5 groups according to the time of their intervention: group 1 (June 2004 to May 2005), group 2 (June 2005 to May 2006), group 3 (June 2006 to May 2007), group 4 (June 2007 to May 2008), and group 5 (June 2008 to May 2009).

Results

Procedural success rates for the 5 groups were 93.6%, 95%, 94.4%, 94.2%, and 94.3%, respectively (P = 0.39). Significant reduction in in‐hospital major adverse cardiac events (3.1%, 3.4%, 2.8%, 1.6%, and 1.0%, P < 0.001) and need for target‐vessel revascularization (2.0%, 2.2%, 1.5%, 0.4%, and 0.2%, P < 0.001) was noted over time, which was associated with a significant increase in use of DES (from 56.6% to 97.0%, P < 0.001). On multivariate analysis, use of DES, dissection during procedure, left main lesion, prior myocardial infarction, and age ≥ 65 years were independent predictors of major adverse cardiovascular events.

Conclusions

There were substantial reductions in in‐hospital major adverse cardiac events and target‐vessel revascularization over the past 5 years. This reduction was associated with the concurrent increased use of DES. Copyright © 2010 Wiley Periodicals, Inc. This work was performed at the Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Predictors of In‐Hospital and Long‐Term Clinical Outcome in Elderly Patients with Massive Pulmonary Embolism Receiving Thrombolytic Therapy

OBJECTIVES: To determine the clinical, historical, and instrumental findings associated with unfavorable short‐term and long‐term prognosis in elderly patients (≥65) receiving thrombolytic therapy for pulmonary embolism (PE). DESIGN: Case‐control retrospective study. SETTING: General medicine acute care ward. PARTICIPANTS: Sixty‐seven elderly patients with PE complicated by hemodynamic instability (massive PE) admitted to the “Antonio Cardarelli” Hospital from January 1, 2002, to December 31, 2004, and evaluated during their hospital stay and 174.4±4.6 days after discharge. MEASUREMENTS: PE diagnosis was confirmed using spiral computed tomography angiography. Hemodynamic instability was defined as cardiogenic shock and systolic blood pressure less than 90 mmHg or a pressure drop of 40 mmHg or more for longer than 15 minutes not due to new‐onset arrhythmia, hypovolemia, or sepsis. INTERVENTION: Weight‐adapted unfractionated heparin and recombinant tissue plasminogen activator. RESULTS: Nine patients (13.4%) died during hospitalization. Higher troponin‐I (cTn‐I) serum levels at admission to the emergency department and the occurrence of thrombocytopenia after thrombolysis were significantly associated with in‐hospital death. Nineteen of the 58 survivors (32.7%) died during follow‐up. The risk factors for long‐term death were historical findings of cancer and cardiovascular disease at hospital admission. CONCLUSION: Higher cTn‐I serum levels in the acute phase and the occurrence of thrombocytopenia after thrombolysis were significantly associated with in‐hospital mortality in elderly patients with massive PE. In the same setting, historical findings of cancer and cardiovascular disease are strong predictors of death in the long term.     

Left Main Coronary In‐Stent Intimal Hyperplasia and Hemodynamics as Detected by Contrast‐Enhanced Transesophageal Echocardiography

Patients and methods: In‐stent hemodynamics were studied by transesophageal echocardiography (TEE) in a group of 54 patients after left main coronary artery stenting, during a 6‐month follow‐up. TEE was performed within 24 hours after stenting and at 1‐ and 3‐month follow‐up. Pulsed wave and color Doppler signals were enhanced by IV administration of Levovist. Results: Angiographic immediate success was obtained in all patients. No in‐hospital death occurred. Ten patients (18.4%) complained of recurrent angina at the follow‐up of 4.8 ± 1.2 months. Both TEE and coronary angiography confirmed in‐stent restenosis in all. Thirty‐nine patients (68.5%) remained symptoms free. Mean late loss in these patients was 0.69 ± 0.20 mm. A linear significant positive relation between mean late loss values and diastolic coronary velocity (r: 0.89, P < 0.001) was found. After 3‐ and 6‐month follow‐up, PDV showed a significant increase in comparison with basal values (0.7 ± 0.3 and 0.6 ± 0.26 vs. 0.32 ± 0.2 cm/sec, P < 0.01). All patients with restenosis showed a significant increase of diastolic coronary velocity in comparison with basal values (2.89 ± 0.25 cm/sec, P < 0.001). Conclusion: TEE can predict the development of in‐stent intimal hyperplasia in patients with unprotected left main coronary artery stenting.     

Determining the In‐Hospital Cost of Bleeding in Patients Undergoing Percutaneous Coronary Intervention

Background: The economic impact of bleeding in the setting of nonemergent percutaneous coronary intervention (PCI) is poorly understood and complicated by the variety of bleeding definitions currently employed. This retrospective analysis examines and contrasts the in‐hospital cost of bleeding associated with this procedure using six bleeding definitions employed in recent clinical trials. Methods: All nonemergent PCI cases at Christiana Care Health System not requiring a subsequent coronary artery bypass were identified between January 2003 and March 2006. Bleeding events were identified by chart review, registry, laboratory, and administrative data. A microcosting strategy was applied utilizing hospital charges converted to costs using departmental level direct cost‐to‐charge ratios. The independent contributions of bleeding, both major and minor, to cost were determined by multiple regression. Bootstrap methods were employed to obtain estimates of regression parameters and their standard errors. Results: A total of 6,008 cases were evaluated. By GUSTO definitions there were 65 (1.1%) severe, 52 (0.9%) moderate, and 321 (5.3%) mild bleeding episodes with estimated bleeding costs of $14,006; $6,980; and $4,037, respectively. When applying TIMI definitions there were 91 (1.5%) major and 178 (3.0%) minor bleeding episodes with estimated costs of $8,794 and $4,310, respectively. In general, the four additional trial‐specific definitions identified more bleeding events, provided lower estimates of major bleeding cost, and similar estimates of minor bleeding costs. Conclusions: Bleeding is associated with considerable cost over and above interventional procedures; however, the choice of bleeding definition impacts significantly on both the incidence and economic consequences of these events.     

Prevalence,Correlation and Clinical Outcome of Intra‐Procedural Stent Thrombosis in Patients Undergoing Primary Percutaneous Coronary Intervention for Acute Coronary Syndrome

Objectives

To assess the occurrence, correlation, and clinical outcome of intraprocedural stent thrombosis (IPST) in patients undergoing primary percutaneous coronary intervention (PCI) in the setting of acute coronary syndromes (ACSs).

Background

Stent thrombosis (ST), a rare complication of PCI, is more common in the setting of ACS. It is not known whether IPST carries the same prognosis as postprocedural ST.

Methods

This retrospective study comprised a review of 1,901 consecutive ACS patients who received primary PCI in our center from January 2006 to January 2011. IPST was defined as new, reappearing or increased thrombus within the deployed stent before the index PCI procedure was completed. All angiograms were independently reviewed frame by frame for the incidence of IPST. Patients with and without IPST were compared with respect to clinical characteristics, angiographic parameters, and major adverse cardiac events (MACEs) at 30 days and 1‐year follow‐up.

Results

Overall, there were 23 cases of IPST detected, thus, the prevalence of IPST was 1.2%. There were no significant differences in baseline clinical characteristics between the 2 groups. Patients with compared to those without IPST had significantly more bifurcation lesions involved, and more thrombus burden at baseline. IPST group compared to no IPST group had more MACEs on 30 days (26.1% vs. 8.7%, P = 0.01) and 1‐year follow‐up (30.4% vs. 14.4%, P = 0.02).

Conclusions

IPST was a rare complication of PCI in the setting of ACS. It correlated with lesion morphology, presence of thrombus at baseline and was more likely to cause MACEs in 30 days and 1‐year follow‐up. (J Interven Cardiol 2013;26:215–220)

     

The Paclitaxel‐Eluting Coroflex™ Stent Study II (PECOPS II) Acute and 6‐Month Clinical and Angiographic Follow‐Up, 1‐Year Clinical Follow‐Up

Background and Objectives: Paclitaxel‐coated stents have proven their efficacy for reducing restenosis in de novo coronary artery lesions and in‐stent restenoses with superiority compared to bare metal stents. This study was performed to evaluate the procedural and 1 year results of the Paclitaxel‐eluting Coroflex? Please stent in coronary artery lesions. Methods: One‐hundred and twenty‐nine patients (66.2 ± 8.2 years, 31.0% diabetics, 20.2% unstable angina, 41.8% multivessel disease) were enrolled per protocol for elective single stent deployment into native de novo or post‐PTCA restenotic coronary lesions.The mean reference diameter was 2.84 ± 0.43 mm, the lesion length 12.51 ± 4.6 mm, and the minimal lumen diameter 0.75 ± 0.29 mm. Follow‐up was performed clinically in 129/129 (100%) after 6 and 12 months and angiographically in 120/129 (93%) patients after 6 months. Results: The success rates of the procedure and deployment were 100% and 95.3%, respectively. The in‐stent late loss and the late‐loss index were 0.27 ± 0.59 mm and 0.17 ± 0.40 resulting in binary in‐stent restenoses in 16/120 (13.3%) subjects and in‐segment restenoses in 20/120 (16.7%) subjects. Major adverse cardiac events occurred in 23/129 (17.8%) during the first 6 months of follow‐up with 3/129 (2.3%) myocardial infarctions, 1/129 (0.8%) secondary to stent thrombosis. From 6 to 12 months, 2/129 (1.6%) nonlesion related PCI were performed. Conclusion: The data of the Paclitaxel‐eluting Coroflex? Please stent evaluated in PECOPS II are within the range of the other currently available Paclitaxel‐eluting stent. (J Interven Cardiol 2010;23:160‐166)     

Impact of Coronary Artery Disease Burden on 12‐Month Mortality of Patients After Transcatheter Aortic Valve Implantation

Objectives

The aim of the study was to compare 12‐month mortality rate of patients with and without complete coronary revascularization before transcatheter aortic valve implantation (TAVI).

Background

There are limited data on the impact of coronary artery disease burden in patients with severe aortic stenosis undergoing TAVI.

Methods

One hundred and one consecutive patients undergoing TAVI were enrolled. Of them 16 (15.8%) had an incomplete coronary revascularization. The primary endpoint was 12‐month all‐cause mortality.

Results

Twelve‐month all‐cause mortality was higher in patients with incomplete coronary revascularization than in patients with complete coronary revascularization or without significant lesions (75.0% vs 7.1%; P < 0.001). Importantly, incomplete coronary revascularization was an independent predictor of higher mortality rate after 12 months (hazard ratio (HR) for incomplete coronary revascularization 10.86, 95% CI 3.72–31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95% confidence interval (CI) 1.39–11.07; P < 0.001; HR for blood transfusion 2.84 95% CI (1.06–7.63); P = 0.039). In 9 of 16 (56.3%) patients, incomplete revascularization was related to the presence of chronic total occlusions (CTO). Patients with CTO had an increased mortality rate after 12 months (55.6% vs 14.1%; P = 0.008) as compared to patients without the CTO.

Conclusions

Incomplete coronary revascularization and a history of stroke or TIA may be independent predictors of all‐cause mortality in patients undergoing TAVI. However, further studies are recommended to confirm the results, especially in terms of the impact of CTO presence on long‐term mortality after TAVI.

     

冠状动脉临界病变是否支架治疗的临床预后比较研究

目的观察和比较冠状动脉临界病变的非心肌梗死患者,采用介入、药物两种不同治疗方案的临床预后。方法选取2005年12月-2009午9月于我院住院的非心肌梗死冠心痛患者,经冠状动脉造影（CAG）证实为冠状动脉临界病变患者105例。根据患者意愿是否行冠状动脉内介入治疗将患者分为介入治疗组（PCI组）51例和单纯药物治疗组（MT组）54例,临床观察6～18个月内稳定心绞痛、不稳定心绞痛及心血管不良事件（心肌梗死,冠状动脉内血运重建,心源性死亡）发生情况。结果PCI组和MT组共发生心血管不良事件4例,PCI组发生1例为心脏性死亡,MT组发生3例为再次血运重建术。两组患者稳定型心绞痛的发生率分别为31．4％和37．0％,不稳定型心绞痛的发生率分别为19．6％和29．6％。以上比较差异均无统计学意义（P〉0．05）。结论冠状动脉临界病变患者行PCI与MT治疗相比发生心绞痛及心血管不良事件无显著差异。