Thrombus aspiration in primary percutaneous coronary intervention in high‐risk patients with ST‐elevation myocardial infarction: A real‐world registry

Objectives : To evaluate the effect of thrombus aspiration in a real‐world all‐comer patient population with STEMI undergoing primary PCI. Background : Catheter thrombus aspiration in primary PCI was beneficial in randomized clinical trials. Methods : We enrolled 313 STEMI patients presenting with TIMI Flow Grade 0 or 1 in the infarct related artery at baseline angiogram undergoing primary PCI. Patients were divided in two groups based on whether thrombus aspiration was attempted. This decision was left at operator's discretion. Procedural and long‐term clinical outcomes were compared between the two groups. Results : Baseline characteristics were similar between groups: 194 (62%) received thrombus aspiration and 119 underwent conventional PCI. Thrombus aspiration was associated with significantly lower post‐PCI TIMI Frame Count values (19 ± 15 vs. 25 ± 17; P = 0.002) and higher TIMI Flow Grade 3 (92% vs. 73%; P < 0.001). Postprocedural myocardial perfusion assessed by myocardial blush grade (MBG) was significantly increased in the thrombus aspiration group (MBG 3: 44% vs. 21%; P < 0.001). No significant difference was found between the two groups in clinical outcome at 30 days. At one year, patients treated with thrombus aspiration showed significantly higher overall survival (HR 0.41, 95% CI 0.20–0.81; log‐rank P = 0.010) and MACE‐free survival (HR 0.49, 95% CI 0.28–0.85; log‐rank P = 0.011). Conclusions : In real‐world all‐comer STEMI patients with occluded infarct‐related artery, thrombus aspiration prior to PCI improves coronary flow, myocardial perfusion, and long‐term clinical outcome as compared with PCI in the absence of thrombus aspiration. © 2010 Wiley‐Liss, Inc.     

Comparison of the angiographic myocardial blush grade with delayed‐enhanced cardiac magnetic resonance for the assessment of microvascular obstruction in acute myocardial infarctions

Background: Both myocardial blush grade (MBG) and cardiac magnetic resonance (CMR) are imaging tools that can assess myocardial reperfusion after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Objectives: We studied the relation between MBG and gadolinium‐enhanced CMR for the assessment of microvascular obstruction (MVO) in patients with acute ST‐elevated myocardial infarction (STEMI) treated by primary PCI. Material and Methods: MBG was assessed in 39 patients with initial TIMI 0 STEMI successfully treated by PCI, resulting in TIMI 3 flow grade and complete ST‐segment resolution. These MBG values were related to MVO determined by CMR, performed between 2 and 7 days after PCI. Left ventricular (LV) volumes were determined at baseline and at 6‐month follow‐up. Results: No statistical relation was found between MBG and MVO extent at CMR (P = 0.63). Regarding MBG 0 and 1 as a sign of MVO, the sensitivity and specificity of these scores were 53.8 and 75%, respectively. In this study, CMR determined MVO was the only significant LV remodeling predicting factor (β = 31.8; P = 0.002), whatever the MBG status was. Conclusion: MBG underestimates MVO after an optimal revascularization in AMI compared with CMR. This study suggests the superior accuracy of delayed‐enhanced magnetic resonance over MBG for the assessment of myocardial reperfusion injury that is needed in clinical trials, where the principal endpoint is the reduction of infarct size and MVO. © 2009 Wiley‐Liss, Inc.     

替罗非班在老年人急诊经皮冠状动脉介入治疗中预防无复流的临床观察

目的观察老年人急诊PCI术中冠状动脉内注射替罗非班对术后无复流的影响。方法选择急性心肌梗死行急诊PCI患者163例,随机分为替罗非班组(83例)和对照组(80例)。替罗非班组在导丝通过病变后经导管冠状动脉内注射替罗非班10μg/kg,之后予替罗非班0.15μg/(kg·min)持续静脉滴注24 h。对照组给予常规治疗。观察2组患者TIMI、心肌灌注分级(TMPG),入院后30 d LVEF和左心室舒张末内径,心血管事件及出血并发症。结果替罗非班组TIMI血流3级和TMPG 2～3级比例较对照组明显升高,TIMI血流0～2级和TMPG 0～1级比例较对照组明显降低,差异有统计学意义(P<0.05)。替罗非班组LVEF较对照组明显改善,主要心血管事件较对照组明显降低,差异有统计学意义(P<0.05)。结论急诊PCI术中冠状动脉内注射替罗非班减少无复流,改善心肌灌注和心功能,且不增加心血管事件和并发症。     

Multicentre experience with MGuard™ net protective stent in ST‐elevation myocardial infarction: Safety,feasibility, and impact on myocardial reperfusion

Objective : To report, for the first time, angiographic and ECG results as well as in‐hospital and 1‐month clinical follow‐up, after MGuard net protective stent (Inspire‐MD, Tel‐Aviv, Israel—MGS) implantation in consecutive, not randomized, STEMI patients undergoing primary or rescue PCI. Background : Distal embolization may decrease coronary and myocardial reperfusion after percutaneous coronary intervention (PCI), in ST‐elevation myocardial infarction (STEMI) setting. Methods : One‐hundred consecutive patients underwent PCI, with MGS deployment for STEMI, in five different high‐volume PCI centres. Sixteen patients presented cardiogenic shock at admission. Results : All patients underwent successful procedures: mean TIMI flow grade and mean corrected TIMI frame count—cTFC(n)—improved from baseline values to 2.85 ± 0.40 and to 17.20 ± 10.51, respectively, with a mean difference in cTFC(n) between baseline and postprocedure of 46.88 ± 31.86. High‐myocardial blush grade (90% MBG 3; 10% MBG 2) was also achieved in all patients. Sixty minutes post‐PCI, a high rate (90%) of complete (≥70%) ST‐segment resolution was achieved. At in‐hospital follow‐up, seven deaths occurred: noteworthy, 5 of 16 patients with cardiogenic shock at admission died. After hospital discharge, no Major Adverse Cardiac Events have been reported up to 30‐day follow‐up. Conclusions : MGS might represent a safe and feasible option for PCI in STEMI patients, providing high perfusional and ECG improvement. Further randomized trials comparing this strategy with the conventional one are needed in the near future to assess the impact on clinical practice of this strategy. © 2009 Wiley‐Liss, Inc.     

The effect of thrombectomy on myocardial blush in primary angioplasty: The randomized evaluation of thrombus aspiration by two thrombectomy devices in acute myocardial infarction (RETAMI) trial

Background: In patients with ST‐segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) may cause thrombus dislodgment leading to microvascular function impairment, which is a negative independent predictor of myocardial function recovery. Compared with conventional stenting, pretreatment with aspiration thrombectomy during primary PCI significantly improves coronary epicardial flow and myocardial tissue perfusion parameters. We sought to evaluate the angiographic findings of two different manual aspiration thrombectomy devices (Diver‐Invatec® (DI) and Export‐Medtronic®® (EM)) in STEMI patients undergoing primary angioplasty. Methods: We randomized 103 STEMI patients referred to our hospital to undergo primary PCI (<12 hr from symptoms onset) to DI (n = 52) and EM (n = 51) devices. The primary angiographic composite end‐points were the rates of post‐thrombectomy thrombus score (TS) ≤≤2, TIMI flow grade ≥≥2, and post‐stenting myocardial blush grade (MBG) ≥≥2 in the two groups. Results: Baseline, clinical, and angiographic preprocedural findings did not differ between the two groups. After aspiration thrombectomy, a TS ≤≤ 2 was more frequently present in EM group (92.3 vs. 69.3%, P = 0.0052). Also the rate of post‐thrombectomy TIMI ≥≥ 2 (69.3 vs. 92.2%, P = 0.0052) and post‐stenting MBG ≥≥2 (88.2 vs. 69.3%, P = 0.029) were significantly higher in EM group. No significative differences were observed in terms of clinical events at 1 and 12 months. Conclusions: In this single‐center, prospective, randomized study, a EM use before stenting in STEMI patients seems to remove more thrombotic burden compared with DI, providing a greater post‐thrombectomy epicardial flow and a better post‐stenting microvascular perfusion. © 2008 Wiley‐Liss, Inc.     

Effects of aspiration thrombectomy on necrosis size and ejection fraction after transradial percutaneous coronary intervention in acute ST‐elevation myocardial infarction

Background: The use of routine aspiration thrombectomy in primary percutaneous coronary intervention (PCI) remains controversial. Methods: Patients in the EArly Discharge after Transradial Stenting of CoronarY Arteries in Acute Myocardial Infarction (n = 105) study were treated with aspirin, clopidogrel, and abciximab within 6 hr of symptoms onset. Operators were allowed to use 6 Fr Export aspiration catheter at their discretion. In this observational analysis, we compared acute and late results in patients treated with and without thrombectomy using cardiac biomarkers, angiographic, cardiovascular magnetic resonance (CMR), and clinical parameters. Results. Patients in the thrombectomy group (n = 44) had longer symptoms to balloon time (196 ± 86 min vs. 164 ± 62, P = 0.039) and higher incidence of preprocedural TIMI flow grade 0 or 1 (84% vs. 64%, P = 0.028). Following PCI, both groups had similar incidence of TIMI flow grade 3 (93 vs. 92%, P = 0.73) and myocardial blush grade 2 or 3 (80 vs. 77%, P = 0.86), respectively. Patients in thrombectomy group had significantly higher post‐PCI maximum values of creatine kinase‐MB (P = 0.0007) and troponin T (P = 0.0010). Accordingly, post‐PCI myocardial necrosis by CMR was higher (P = 0.0030) in patients in the thrombectomy group. At 6‐month follow‐up, necrosis size remained higher (20.7% ± 13.3% vs. 13.5% ± 11.1%, P = 0.012) in the thrombectomy group. Ejection fraction at 6 months was 65% ± 9% in patients in thrombectomy group compared to 70% ± 11% in patients without (P = 0.070). Results were not affected by initial TIMI flow or symptoms to balloon time. Clinical events remained comparable in both groups at 12 months follow‐up. Conclusion: In patients with ST‐segment elevation myocardial infarction presenting within 6 hr of symptoms and undergoing primary angioplasty with maximal antiplatelet therapy, acute and late results did not suggest significant benefit for additional aspiration thrombectomy, irrespective of initial TIMI flow or total ischemic time. © 2010 Wiley‐Liss, Inc.     

The Index of Microcirculatory Resistance as a Predictor of Echocardiographic Left Ventricular Performance Recovery in Patients With ST‐Elevation Acute Myocardial Infarction Undergoing Successful Primary Angioplasty

Background

This study aims to evaluate the relationship between IMR (Index of Microcirculatory Resistance) and the echocardiographic evolution of left ventricular (LV) systolic and diastolic performance after ST‐elevation acute myocardial infarction (STEMI), undergoing primary angioplasty (P‐PCI).

Methods

IMR was evaluated immediately after P‐PCI. Echocardiograms were performed within the first 24 hours (Echo1) and at 3 months (Echo2): LV volumes, ejection fraction (LVEF), wall motion score index (WMSI), E/é ratio, global longitudinal strain (GLS), and left atrial volume were measured.

Results

Forty STEMI patients were divided in 2 groups according to median IMR: Group 1 (IMR < 26), with less microvascular dysfunction, and Group 2 (IMR > = 26), with more microvascular dysfunction. In Echo1 GLS was significantly better in Group 1 (?14.9 vs. ?12.9 in Group 2, P = 0.005). However, there were no significant differences between the two groups in LV systolic volume, LVEF and WMS. Between Echo1 and Echo2, there were significant improvements in LVEF (0.48 ± 0.06 vs. 0.55 ± 0.06, P < 0.0001), GLS (?14.9 ± 1.3 vs. ?17.3 ± 7.6, P = 0.001), and E/é ratio (9.3 ± 3.4 vs. 8.2 ± 2.0, P = 0.037) in Group 1, but not in Group 2: LVEF (0.49 ± 0.06 vs. 0.50 ± 0.05, P = 0.47), GLS (?12.9 ± 2.4 vs. ?14.4 ± 3.2, P = 0.052), and E/é ratio (8.8 ± 2.4 vs. 10.0 ± 4.7, P = 0.18). WMSI improved significantly more in Group 1 (reduction of ?17.1% vs. ?6.8% in Group 2, P = 0.015).

Conclusion

Lower IMR was associated with better myocardial GLS acutely after STEMI, and with a significantly higher recovery of the LVEF, WMSI, E/E' ratio and GLS, suggesting that IMR is an early marker of cardiac recovery, after acute myocardial infarction. (J Interven Cardiol 2016;29:137–145)

     

Microvascular Coronary Flow Comparison in Acute Myocardial Infarction Angioplasty treated with a mesh covered stent (MGUARD Stent) versus Bare Metal Stent: MICAMI–MGUARD

BackgroundDistal embolization of thrombus/platelet aggregates decreases myocardial reperfusion during primary percutaneous coronary intervention (PCI), and is associated with worse immediate and long-term prognosis of patients with ST-elevation myocardial infarction (STEMI).ObjectiveAssess the efficacy of a mesh covered stent (MGuard? stent, MGS) in preventing distal embolization and microvascular reperfusion impairment during primary PCI, compared with a bare metal stent (BMS).MethodsForty patients with STEMI referred for primary PCI were randomized for stenting the culprit lesion with the MGS (n = 20) or a BMS (n = 20). Blinded experts performed off-line measurements of angiographic epicardial and microvascular reperfusion criteria: TIMI flow grade, myocardial blush, corrected TIMI frame count (cTFC).ResultsAt baseline clinical, angiographic and procedural variables were not different between groups. Post PCI TIMI flow grade was similar in both groups. We observed better myocardial Blush grade in group MGS compared to BMS (median value 3.0 vs 2.5, 2p = 0.006) and cTFC (mean cTFC: MGS 19.65 ± 4.07 vs BMS 27.35 ± 7.15, 2p < 0.001, cTFC mean difference MGS-BMS: 7.7, CI 95%: 3.94 to 11.46). MGS stent group had a higher percentage of successful angioplasty (cTFC ≤ 23: MGS 85% vs BMS 30%, 2p < 0.001). We had two cases of acute stent thrombosis (one for each group) at 30 days follow up, but no clinical events at 6 months follow up.ConclusionsIn this exploratory study, MGS significantly improved microvascular reperfusion criteria compared with a BMS in primary PCI. However its safety and impact on clinical outcomes should be verified in larger randomized clinical trials.     

Incidence,predictors, and prognostic value of intramyocardial hemorrhage lesions in ST elevation myocardial infarction

Background: Intra myocardial hemorrhage lesions (IMH) are underdiagnosed complication of ST elevation myocardial infarction (STEMI). We sought to determine the incidence, predictors and the prognostic value of IMH in STEMI using cardiac MR imaging (CMR) techniques. Methods: We screened for inclusion consecutive patients with STEMI treated by percutaneous coronary intervention (PCI) within the first 12 hr of evolution. IMH lesions were identified on T2‐weighted sequences on CMR between days 4 and 8 after PCI. Adverse cardiac events were defined as a composite of death + severe ventricular arrhythmias + acute coronary syndrome + acute heart failure. Results: N = 114 patients were included and n = 11 patients (10%) presented IMH lesions. Patients with IMH lesions had a larger myocardial infarction extent (25.6 ± 1.8 vs. 13.5 ± 1.0 % LV mass, P < 0.01), microvascular obstructive lesions extent (4.6 ± 1.0 vs. 1.3 ± 0.3% LV mass, P < 0.01) and lower LV ejection fraction (40.7 ± 2.3% vs. 50.7 ± 1.3%, P < 0.01). The value of glycemia at admission was an independent predictor of IMH development (Odd ratio 1.8 [1.1–2.8] per mmol l^?1, P = 0.01). The incidence of adverse cardiac events was higher in the IMH group than in the non‐IMH group during the first year following STEMI (P = 0.01, log‐rank analysis). Cox regression analysis identified the presence of IMH lesions as an independent predictor of adverse clinical outcome (Hazard Ratio = 2.8 [1.2–6.8], P = 0.02). Conclusion: Our study indicates that IMH is a rare but severe finding in STEMI, associated with a larger myocardial infarction and a worse clinical outcome. Per‐PCI glycemia might influence IMH development. © 2011 Wiley Periodicals, Inc.     

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis

BackgroundPrimary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST.MethodsA sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed.ResultsMale patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%.ConclusionIn-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.     

Feasibility of primary clot extraction prior to percutaneous coronary intervention in acute myocardial infarction

Objectives : To test the feasibility, safety, and in‐hospital outcomes of utilizing the FilterWire EZ to extract clot prior to percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (MI). Background : PCI in patients with acute MI is associated with a higher incidence of distal embolization, no‐reflow, or slow flow partly due to the presence of clot burden. Methods : The authors describe the feasibility, safety, and outcomes of using a FilterWire EZ distal protection device as a clot extraction device in patients who presented with acute MI and documented clot on coronary angiography. Results : Fifteen consecutive male patients with a mean age of 54 ± 8 years presented with acute MI (60% ST elevation MI). MI involved left anterior descending artery (n = 4), circumflex artery (n = 3), and right coronary artery (n = 8). Clot extraction followed by PCI reduced the percent diameter stenosis from 94 ± 12 to 65 ± 11 (P < 0.001) and restored TIMI 3 flow in all patients without distal embolization. The angiographic, procedural, and clinical success rates were 100%. The mean left ventricular ejection fraction (LVEF) was 52 ± 8% (range 30–62%) with only three patients (15%) who had an LVEF <50% and five patients (33%) without apparent wall motion abnormalities on echocardiography. Conclusions : Clot extraction before PCI during acute MI in native coronaries is feasible, safe, and effective in restoring TIMI 3 flow without distal embolization. Whether this approach results in better outcomes and improved LV function compared with standard therapy alone requires further investigation. © 2008 Wiley‐Liss, Inc.     

Aspiration coronary thrombectomy for acute myocardial infarction increases myocardial salvage

Objectives : The aim of the study was to assess if aspiration thrombectomy in high risk patients with STEMI and angiographic evidence of thrombus may improve myocardial salvage. Background : It is unclear if thrombus aspiration before percutaneous intervention (PCI) improves myocardial salvage. Methods : The trial was a prospective randomized study. The inclusion criteria were: first STEMI within 12 hr from symptoms onset, culprit lesion in left anterior descending or right coronary artery, culprit artery TIMI flow ≤ 2 and angiographic evidence of thrombus. The primary endpoint was myocardial salvage index (MSI) as assessed by ^99mTc‐sestamibi SPECT imaging. Results : We randomized 137 patients (98 male, mean age 64.1 ± 12.5 years) either to aspiration thrombectomy followed by standard PCI with stent implantation (n = 67) or to standard primary PCI (n = 70). Index perfusion defect was similar in both study groups: 34.2% ± 13.1% in thrombectomy group versus 37.1% ± 12.0% in primary PCI group (P = 0.2). MSI was larger in aspiration thrombectomy group than in control patients [25.4% (IQR 13.5–44) vs. 18.5% (IQR 7.7–30.3) respectively, P = 0.02]. The final infarct size was smaller in patients treated with aspiration thrombectomy (23.1% ± 13.3% vs. 28.9% ± 10.2% in the control group, P = 0.002). Conclusions : Aspiration thrombectomy improves myocardial salvage in high risk STEMI patients with angiographic evidence of thrombus. © 2011 Wiley‐Liss, Inc.     

Percutaneous coronary intervention in cardiogenic shock complicating acute ST-elevation myocardial infarction-a single centre experience

BackgroundMortality in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) approaches 70 – 80%, regardless of the type of pharmacological treatment. Early revascularisation improves survival in AMI with CS. Our aim is to assess the predictors of mid-term outcome after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and CS.MethodsForty-one patients who underwent primary or rescue PCI for CS were analysed comparing their baseline, angiographic, PCI data, 30-day and 1-year survival.ResultsThere were no significant differences between survivors and non-survivors in baseline characters, except for more number of transfer admissions (P= 0.0005), and cardiopulmonary resuscitations (P= 0.015) in the later group. The mean time between myocardial infarction (MI) onset to shock and MI onset to revascularisation were 12.8 ± 12.9 hours and 17.0 ± 16.8 hours, respectively. Patients with better pre-procedure thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery (IRA) had better survival (P= 0.0005). Successful PCI was achieved in 48.8% of patients. The 30-day mortality was 56.1% and all were prior to hospital discharge. Patients with successful PCI had better short-term survival in comparison with patients with failed PCI (80% vs 9.6%). Eighteen patients who survived at 30 days were followed up for 12–72 months (mean 28.5 ± 5.4 months). Fifteen patients survived at 1 year after PCI and all were in good functional status.ConclusionMortality remains high even with PCI. Achieving IRA patency with TIMI 3 flow is the main determinant of survival. Survival and functional status are good in patients who are discharged from hospital.     

Impact of thrombus aspiration use and direct stenting on final myocardial blush score in patients presenting with ST-elevation myocardial infarction

BackgroundMany studies have reported that low final thrombolysis in myocardial infarction (TIMI) flow and/or myocardial blush grade (MBG) are independent predictors of mortality in patients with ST-elevation myocardial infarction (STEMI). In addition, distal coronary embolization is a major pitfall of conventional percutaneous coronary intervention (PCI) in such a context.AimThis study aimed to assess the impact of thrombus aspiration (TA) use before primary PCI on final myocardial reperfusion in patients presenting with STEMI.MethodsFrom January to December 2006, 100 patients presenting with STEMI in our catheterization laboratory were considered for the present study. During this time period, 50 patients underwent TA before primary PCI for treatment of STEMI and were then matched 1:1 to 50 controls who underwent conventional primary PCI for treatment of STEMI without TA. Patients of the control group were chosen after matching on age±3 years, sex, history of diabetes, and distribution of the infarct related coronary artery during the same period.ResultsBaseline clinical characteristics, initial TIMI flow and initial MBG of both groups were similar. There was a trend for a better final TIMI flow in the group with TA and the final MBG was significantly improved in the group with TA compared to the group without TA: final MBG of two or three in 70% versus 30% of the cases (P=.001). In addition, direct stenting was significantly more often used in the TA group (92% versus 64%, P=.001). There were four patients with evident distal embolizations in the group without TA and none in the group with TA.ConclusionTA use before primary PCI for STEMI treatment resulted in improved final myocardial reperfusion. Of importance, TA use may have led to a better choice of the stent size and more frequent direct stenting. This benefit may directly improve patient outcomes.     

血栓抽吸导管在急性心肌梗死患者经皮冠状动脉介入治疗中的应用

目的评价急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)中应用Diver CE血栓抽吸导管的可靠性、实用性与安全性。方法选择我院2006年7月至2007年7月接受直接PCI的AMI患者64例,分成血栓抽吸后经皮冠状动脉介入治疗组(PT+PCI)与单纯PCI组,比较两组间TIMI血流、心肌灌注分级(TMP)(2.65±0.54)级、2 h ST段回落率56.07%±9.20%、左室射血分数(LVEF)及血管重建率。结果PT+PCI组的TIMI血流(2.54±0.18)级、TMP(2.65±0.54)级、2 h ST段回落率89.73%±9.43%、LVEF值56.07%±9.20%及血管重建率0%,明显优于单纯PCI组的TIMI血流(2.01±0.28)级、TMP(1.52±0.47)级、2 hST段回落率56.41%±12.59%、LVEF值51.11%±8.97%及血管重建率3.33%(P<0.05)。结论PCI中应用Diver CE血栓抽吸装置能明显减少冠状动脉血栓及远端栓塞,有效地改善心肌灌注,减少无复流发生,使用安全,效果明显。     

择期PCI大面积STEMI患者术前应用IABP临床预后观察

目的研究择期行经皮冠状动脉介入治疗(PCI)的大面积急性ST段抬高型心肌梗死(STEMI)患者早期应用主动脉内气囊反搏术(IABP)对临床预后的影响。方法选取发病12～72 h的STEMI患者100例,随机分为两组,IABP组52例、对照组48例,对照组给予规范的药物治疗,IABP组在规范药物治疗的基础上床旁应用IABP 3～5 d。两组均于10～14 d后行冠脉造影及PCI术。评价梗死相关血管PCI术前及术后冠脉血流(TIMI)和术后4周心功能及主要不良心脏事件的发生情况。结果 IABP组PCI术前、术后TIMIⅢ级高于对照组,PCI术后4周主要不良心脏事件的发生率低于对照组,左心室射血分数高于对照组,P均<0.05。结论对于大面积STEMI患者择期行PCI,早期应用IABP能改善梗死相关血管的TIMI血流,减少术后4周主要不良心脏事件的发生率,改善心功能,临床应用安全有效。     

Early and mid-term clinical outcome of emergency PCI in patients with STEMI due to unprotected left main coronary artery disease

Objectives: Evaluation of acute and mid‐term outcomes of patients with ST‐elevation myocardial infarction (STEMI) undergoing emergency PCI due to unprotected left main coronary artery (ULMCA) disease. Background: STEMI patients due to ULMCA disease represent a rare, high risk group. Percutaneous coronary intervention (PCI) may be the preferred strategy of myocardial revascularization but there are few data about this topic. Methods: We analyzed 30‐day and mid‐term mortality of 58 patients with STEMI and ULMCA disease as culprit lesion treated in our centre by emergency PCI between 2000 to 2010. Results: Mean age was 67.3 ± 11.5 years. Thirty (51.7%) patients had cardiogenic shock on admission. PCI success was achieved in 54 patients (93.1%). Mean follow‐up was 15.8 ± 10.9 months (median 14, range 6–45). Thirty‐day and mid‐term mortality rates were 39.7% and 44%. Backward binary logistic regression model identified cardiogenic shock at presentation (OR 12.6, 95% CI 2.97–53.6, P < 0.001), age ≥75 years (OR 5.9, 95% CI 1.3–26.5, P = 0.019) and post‐PCI TIMI flow grade <3 (OR 2.9, 95% CI 1.8–5.7 P = 0.02) as independent predictors of 30‐day mortality. Cox proportional hazard ratio (HR) identified shock at presentation (HR 5.2, 95% CI 1.8–14.3, P < 0.002), age ≥75 years (HR 3.9, 95% CI 1.8–8.7, P < 0.001), post‐PCI TIMI flow grade <3 (HR 4.9, 95% CI 1.6–14.6; P < 0.005) as independent predictors of mid‐term mortality. Conclusions: In patients with STEMI and ULMCA as culprit lesion, emergency PCI is a valuable therapeutic strategy. Early and mid‐term survival depends on cardiogenic shock, advanced age, and PCI failure. Patients surviving the first month have good mid‐term prognosis. (J Interven Cardiol 2012;25:215–222)     

No‐Reflow Phenomenon Following Percutaneous Coronary Intervention for Acute Myocardial Infarction: Incidence,Outcome, and Effect of Pharmacologic Therapy

Background: No‐reflow (NR) phenomenon is a well‐known problem, often accompanying percutaneous coronary intervention for acute ST elevation myocardial infarction (STEMI). There are little data on effects of pharmacologic therapy on the resolution, outcome, and long‐term natural history of NR. Objective: Retrospectively assess incidence, management, and prognosis of NR in a tertiary referral hospital. Methods: Study included patients with STEMI, treated with percutaneous coronary intervention (PCI). Effect of pharmacologic therapy and long‐term outcome were assessed. NR was defined by thrombolysis in myocardial infarction (TIMI) < 3 or myocardial blush grade (MBG) < 3. Results: Of 347 identified subjects, NR occurred in 110 (32%) by TIMI and 198 (57%) by MBG. Higher incidence was identified in men versus women (34% vs. 25% by TIMI, P = 0.08; and 60% vs. 48% by MBG, P = 0.04). Pharmacologic therapy was equally effective in restoring normal flow, increasing TIMI score from 1.62 ± 0.07 to 2.78 ± 0.06 (P < 0.0001) and MBG score from 0.43 ± 0.08 to 2.09 ± 0.11 (P < 0.0001). Twenty‐three percent who did not receive pharmacologic therapy developed clinical composite of congestive heart failure, cardiogenic shock, and/or death; only 9% of patients who received pharmacologic therapy developed this composite. Patients with severe NR despite treatment had poorer prognosis. Sixty‐five percent of patients who survived and had repeat angiogram about 1.5 years later had spontaneous improvement in coronary flow by MBG. Conclusion: NR is common in STEMI. Treatment with nicardipine, nitroprusside, and verapamil are equally effective in improving flow. If not treated, prognosis is poor. (J Interven Cardiol 2010;23:429–436)     

Impact of thrombus aspiration on angiographic and clinical outcomes in patients with ST-elevation myocardial infarction

BackgroundPrimary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) may be limited by thrombus embolization. Export aspiration catheter (EAC) is a thrombectomy device which may enhance angiographic results, but its impact on clinical outcomes is unclear. This trial objective was to assess the impact of EAC on angiographic and clinical outcomes in patients with STEMI.MethodsAll STEMI patients undergoing primary or rescue PCI in a tertiary care center were included. Patients were divided in two groups according to the use of the EAC. Patients were followed up prospectively for death, reinfarction, revascularization, or stroke. Thrombolysis In Myocardial Infarction (TIMI) flow in the culprit vessel was assessed before and after PCI.ResultsIncluded in the analysis were 535 patients. EAC was used in 165 patients before angioplasty (Group 1) and 370 patients underwent PCI without thrombus aspiration (Group 2). More patients in Group 1 had initial TIMI flow 0–1 compared to Group 2 (88% vs. 62%, P<.001). Proportion of patients with a final TIMI flow 3 was the same in both groups (89.1% vs. 87.6% for Groups 1 and 2, respectively; P=.67). An analysis restricted to patients with initial TIMI flow 0–1 yielded similar results. No difference in clinical outcomes was observed between the two groups (P=.70).ConclusionsSelective use of the EAC based on the judgment of operators results in excellent angiographic and clinical results. Further clinical investigation is needed to definitely answer whether thromboaspiration needs to be performed in all STEMI patients undergoing primary PCI.     

Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction

OBJECTIVES: This study was designed to investigate whether elevated glucose is associated with impaired Thrombolysis In Myocardial Infarction (TIMI) flow before primary percutaneous coronary intervention (PCI). BACKGROUND: Reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) is associated with an improved outcome. Hyperglycemia in patients with STEMI is associated with an adverse prognosis. Hyperglycemia may induce a pro-thrombotic state and therefore be of influence on TIMI flow before PCI. METHODS: A total of 460 consecutive patients with STEMI treated with primary PCI were included in this analysis. Hyperglycemia was defined as a glucose > or =7.8 mmol/l (140 mg/dl). RESULTS: Hyperglycemia was observed in 70% and TIMI flow grade 3 before primary PCI in 17% of the patients. Patients with hyperglycemia less often had TIMI flow grade 3 before primary PCI (12% vs. 28%, p < 0.001). After adjustment for differences in baseline variables, hyperglycemia was a strong predictor of absence of reperfusion before primary PCI (odds ratio 2.6, 95% confidence interval 1.5 to 4.5). CONCLUSIONS: Hyperglycemia in patients with STEMI is an important predictor of impaired epicardial flow before reperfusion therapy has been initiated. Investigation of methods improving coronary flow before primary PCI in these patients is warranted.