Prevention of Contrast‐Induced Nephropathy in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: A Systematic Review

Objective

To evaluate the current prophylactic strategies against CIN in patients with STEMI treated by primary percutaneous coronary intervention.

Background

Contrast‐induced nephropathy (CIN) is the third leading course of acute renal failure and a recognized complication to cardiac catheterization. CIN is associated with increased risk of cardiac adverse events and mortality, and recent studies point at the risk of developing a transient or persistent renal dysfunction. Patients with ST‐elevation myocardial infarction treated by primary percutaneous coronary intervention have a markedly increased risk of developing CIN. At present no strategy is universally accepted in the prevention of CIN in the acute setting of primary percutaneous coronary intervention.

Method

We performed a systematic search in Pubmed and EMBASE and ended up including nine randomised clinical trials; six studies of N‐acetylcysteine, one study of early and late hydration regimens, one study of recombinant human brain natriuretic peptide and one study comparing a low‐osmolar contrast agent with an iso‐osmolar contrast agent.

Results

Recombinant human brain natriuretic peptide and the regimens of hydration significantly reduced the incidence of CIN and administration of N‐acetylcysteine in one of the six studies significantly reduced the occurrence of CIN. The iso‐osmolar contrast agent was not proven to be superior to the low‐osmolar contrast agent in terms of preventing CIN.

Conclusion

Preliminary studies are promising but further studies are needed before any prevention strategy against CIN can be recommended in routine care of patients undergoing primary percutaneous coronary intervention for STEMI. (J Interven Cardiol 2013;26:97–105)

     

Low‐Dose Heparin for Elective Percutaneous Coronary Intervention

Objectives

We evaluated the safety and efficacy of low‐dose heparin (40 IU/kg) for elective percutaneous coronary intervention (PCI).

Background

Current guidelines recommend a 70–100 IU/kg bolus of heparin for elective PCI, but this dose may be associated with increased bleeding risk. Low‐dose heparin may have an advantage in this regard, but has not been well studied.

Methods

From January 2008 to October 2012, 300 patients underwent elective transfemoral PCI and were treated with an initial bolus of 40 IU/kg of heparin at the UCLA Medical Center. Dual antiplatelet therapy with clopidogrel and aspirin was administered prior to or just after diagnostic coronary angiography. The primary end‐point was the composite of cardiac death, myocardial infarction, urgent target vessel revascularization for ischemia, or major bleeding within 30 days after PCI.

Results

The mean activating clotting time was 233 ± 28 seconds. The primary end‐point occurred in 2.3%. The cardiac death rate was 0.3% but was not related to the PCI. The myocardial infarction rate was 1.3%. Urgent target vessel revascularization occurred in 1 patient (0.3%). The major bleeding rate was 0.3%. No stent thrombosis occurred.

Conclusion

Using a lower dose of heparin with dual antiplatelet therapy is safe and is associated with a low bleeding risk after transfemoral PCI while providing suppression of ischemic events. This may also represent a cost savings compared with other antithrombotic strategies. A randomized clinical trial comparing low‐dose heparin with bivalirudin in patients is required to determine the optimal anticoagulation strategy. (J Interven Cardiol 2014;27:58–62)

     

Women With Cardiogenic Shock Derive Greater Benefit From Early Mechanical Circulatory Support: An Update From the cVAD Registry

Objectives

The aim of this analysis was to assess survival differences between men and women supported with Impella 2.5 (Abiomed Inc., Danvers) in the setting of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS).

Background

Data on sex differences in outcomes of CS with mechanical circulatory support are sparse.

Methods

Patients enrolled in the cVAD Registry who underwent percutaneous coronary intervention (PCI) and Impella 2.5 support for CS complicating an AMI were included. Differences between men and women were examined.

Results

In total, 180 patients were analyzed. Women (n = 49, 27.2%) were older (71.0 ± 12.8 years vs 63.8 ± 13.0, P = 0.001), smaller (BSA 1.82 ± 0.22 vs 2.04 ± 0.24 m², P < 0.001), and had a higher STS mortality risk score than men (27.9 ± 17.0 vs. 20.8 ± 16.8 P = 0.01). There was no difference in survival to discharge (P = 0.3). Patients receiving the Impella 2.5 pre‐PCI had significantly lower inpatient mortality than those who received support post‐PCI (P = 0.003). However, the magnitude of the survival benefit was significantly greater in women who received the Impella pre‐PCI as compared to men. Overall, 68.8% of women survived with pre‐PCI Impella 2.5 versus 24.2% post‐PCI (P = 0.005) whereas 54.2% of men survived with pre‐PCI Impella 2.5 versus 40.3% post‐PCI (P = 0.1, p‐interaction = 0.07). No differences in timing to intervention were found between men and women.

Conclusions

Early initiation of hemodynamic support prior to PCI with Impella 2.5, in the setting of AMI complicated by CS, was associated with a greater survival benefit to hospital discharge in women compared to men, despite a higher predicted risk of mortality and a greater revascularization failure rate for women. (J Interven Cardiol 2016;29:248–256)

     

Longitudinal Geographic Miss (LGM) in Robotic Assisted Versus Manual Percutaneous Coronary Interventions

Objectives

To evaluate the impact of robotic‐assisted percutaneous coronary intervention (RA‐PCI) versus manual PCI (M‐PCI) on the incidence of Longitudinal Geographic Miss (LGM).

Background

The safety and feasibility of RA‐PCI has been established in preclinical animal trials and human clinical trials. Patients with LGM have been shown to have worse clinical outcomes including significantly increased incidences of MACE.

Methods

Patients with significant coronary artery disease underwent RA‐PCI in the PRECISE study (n=164) and standard M‐PCI in the STLLR trial (n = 1,509). Longitudinal geographic miss was defined as cases where the entire length of the injured or stenotic segment was not fully covered by the total length of the stent. The incidence of LGM was compared between RA‐PCI and M‐PCI cohorts.

Results

The RA‐PCI cohort had a significantly greater prevalence of previous MI, previous coronary revascularization, and unstable angina. The robotic cohort exhibited a lower incidence of LGM when compared to the M‐PCI patients, 12.2% to 43.1%, respectively (P < 0.0001). To account for the differences in baseline characteristics between the two studies, a propensity score analysis was conducted. The propensity modeling showed similar rates of LGM in both a larger group of patients that met key PRECISE study inclusion/exclusion criteria adjusted for propensity score (9.3% vs 55.0%; P < 0.0001) and in a smaller, matched on propensity score, subset of patients (10.3% vs 64.1%; P < 0.0001).

Conclusion

Robotic‐assisted PCI had significantly lower incidence of LGM compared to standard M‐PCI. Reducing LGM potentially improves long‐term clinical outcomes through reduction in MACE. (J Interven Cardiol 2015;28:449–455)

     

An Audit of Outcomes After Same‐Day Discharge Post‐PCI in Acute Coronary Syndrome and Elective Patients

Objectives

To investigate the outcomes of a cohort of acute and elective percutaneous coronary intervention (PCI) patients who were discharged home 6 hours postprocedure.

Background

Contemporary PCI is safe with a low rate of acute complications. It is well established as a day procedure in elective cases; however, data are lacking in acute cases.

Methods

We describe a prospective observational audit of routine clinical practice in the 3 PCI centers in Northern Ireland. Patients were selected for same‐day discharge after 6 hours of post‐PCI observation. Both elective and acute coronary syndrome (ACS) cases were included. Criteria for same‐day discharge were based on the technical result of the procedure rather than lesion complexity or clinical presentation. Radial access was preferred but not mandatory. Patients were contacted directly to assess for 30‐day major adverse cardiovascular events (MACE). Reported events were corroborated with the general practitioner or hospital notes.

Results

A total of 1,059 patients were selected for same‐day discharge with 30‐day follow‐up available for all cases. Of these, 766 (72.3%) were elective and 293 (27.7%) were ACS patients. Radial access was almost universal (98%). A total of 1,224 lesions were stented, of which 432 (40.8%) were high risk (highest risk lesion in each case by AHA/ACC classification). MACE rate at 30 days was 0.85% with a sub‐acute stent thrombosis rate of 0.4%. There were no MACE events from discharge to 24 hours.

Conclusions

Selected acute and elective patients with a range of lesion complexity and risk can be discharged safely home early after PCI.

     

Age is not a bar to PCI: Insights from the long‐term outcomes from off‐site PCI in a real‐world setting

Objectives

We sought to analyze the percutaneous coronary intervention (PCI) outcomes of very elderly patients (V. Eld. group, age >80 years) and compare their outcomes to a less elderly cohort (Eld. group, age 75‐80 years) traditionally reported in the literature.

Background

Limited data exist on peri‐procedural and long‐term outcomes following PCI in the V. Eld. (age >80 years), with under‐representation of this cohort in randomized controlled trials. These patients present with advanced complex coronary disease and multiple comorbidities.

Methods

All 580 consecutive patients aged ≥75 years (age 80 ± 4.9 years, 57.4% males) undergoing PCI between April 2006 and November 2011 were included. A total of 624 consecutive lesions were identified and analyzed. All V. Eld. patients (n = 253) were subsequently selected, and their outcomes compared to Eld. patients (n = 327). Mean follow‐up was 30.8 ± 2.7 months with 98% clinical follow‐up achieved.

Results

All comparative data are expressed as (V. Eld. vs Eld.) unless otherwise specified. All‐cause mortality was significantly higher in the V. Eld. group (11.9% vs 6.1%), although this did not translate into a significant difference in cardiac mortality (6.3% vs 3.7%) or major adverse cardiac and cerebrovascular events (16.2% vs 12.5%). The composite incidence of myocardial infarction (MI), stroke, definite/probable stent thrombosis, and TIMI major bleed was 4.7%, 1.4% 1.9%, and 6.4%, respectively with no significant difference between both cohorts.

Conclusions

This study demonstrates an acceptable occurrence of MI, death, repeat intervention, and stent thrombosis in a high‐risk group of V. Eld. patients with de novo lesions. Age alone in the absence of other non‐cardiac factors should not prohibit a patient from access to PCI.

     

Percutaneous Coronary Intervention of Complex Calcified Lesions With Drug‐Coated Balloon After Rotational Atherectomy

Objectives

We investigated the safety and efficacy of PCI using drug‐coated balloon (DCB) after rotational atherectomy (rotablation) in a retrospective single center study in patients with calcified de novo coronary lesions. The majority of patients had an increased risk for bleeding.

Background

DCB has been effective in the treatment of in‐stent restenosis, small vessels, and bifurcations. DCB enables short one month dual antiplatelet treatment. No published data exist on the use of DCB after rotablation.

Methods

82 PCIs were performed in 65 patients (mean age 72 ± 10 years) using rotablation followed by DCB treatment. The median follow‐up time was 17 months. 82% of the patients had at least one risk factor for bleeding such as oral anticoagulation. 32% had an acute coronary syndrome. Median duration of dual antiplatelet treatment was 1 month.

Results

MACE (the composite of cardiovascular death, ischemia‐driven target‐lesion revascularization [TLR] or non‐fatal myocardial infarction) occurred in 14% and 20% of the patients at 12 and 24 months, respectively. The rate of ischemia‐driven TLR was 1.5% at 12 months and 3.0% at 24 months. No acute closure of the treated vessel occurred. Bailout stenting was needed in 10% of the PCIs. The incidence of significant bleeding was 9% at 12 months.

Conclusions

This is the first study to show that PCI using DCB after preparation of calcified lesions with rotablation is safe and effective. This novel strategy may be considered especially in patients with a bleeding risk such as those using an oral anticoagulant.

     

Coronary revascularization for acute myocardial infarction in the HIV population

Objective

To analyze trends in management and outcomes of patients infected with the human immunodeficiency virus (HIV) undergoing percutaneous coronary intervention (PCI) for an acute myocardial infarction (AMI) in the United States.

Background

Infection with HIV is an independent risk factor for accelerated atherosclerosis associated with higher rates of AMI. Current trends and outcomes of HIV‐infected individuals presenting with AMI in the United States remain unknown.

Methods

Using the Healthcare Cost and Utilization Project National Inpatient Sample database we identified HIV‐infected individuals who underwent PCI for an AMI from 2002 to 2013. Multivariable logistic regression and propensity‐score matching were performed to analyze outcomes.

Results

We identified a total of 59 194 patients of which 7841 underwent PCI during index hospitalization (13.3%). Most patients were men (71%), ≥50 years of age (82%), and white (74%). ST‐elevation myocardial infarction was present in 21% of cases. Charlson comorbidity index (CCI) was 5.67 ± 0.4. Predictors of post‐procedural complications included female sex, black race, higher CCI, and placement of a bare metal stent, whereas predictors of mortality included occurrence of a complication, ST‐elevation myocardial infarction, age ≥70 years, and higher CCI. Conversely, placement of a drug‐eluting stent was associated with a reduced risk of complications and mortality. After propensity‐score matching, HIV‐infected individuals were less likely to undergo PCI and receive a drug‐eluting stent, while having longer length of stay, higher hospitalization costs, and higher in‐hospital mortality when compared to non‐infected individuals.

Conclusion

Significant disparities continue to affect HIV‐infected individuals undergoing PCI for AMI in the United States.

     

High risk of stent thrombosis in the first 6 months after coronary stenting

Objectives

To estimate the incidence of stent thrombosis (ST) after early discontinuation of clopidogrel.

Background

Premature discontinuation of clopidogrel is the strongest risk factor for ST. In contrast, recent studies suggest that shorter dual antiplatelet therapy (DAPT) can be discontinued as soon as 3 months after stenting. However, these studies included very few ACS patients and were not powered for ST. Hence, little is known about the occurrence of ST in high‐risk populations when DAPT is discontinued early.

Methods

This is a subanalysis of The Dutch ST Registry 437 ST cases (mainly first‐generation DES and BMS). Acute coronary syndrome was the indication for index‐PCI in 74% of the patients. Clopidogrel discontinuation rates in ST patients and matched controls were used to calculate the absolute incidence of ST after early clopidogrel discontinuation.

Results

The overall rate of ST after cessation of clopidogrel was 4.6% (95%CI: 3.9‐5.4%), as compared to 1.7% (95%CI: 1.5‐1.9%) in patients who did not discontinue clopidogrel. The incidence of ST was 35.4% when clopidogrel was discontinued in the first 30 days after index‐PCI declining to 11.7% when clopidogrel was discontinued in the first 180 days.

Conclusions

This dedicated ST registry shows that ST rates were very high when clopidogrel was discontinued before 6 months after index‐PCI and therefore suggests that clopidogrel discontinuation in the first 6 months after ACS should be avoided.

     

Recurrent Myocardial Infarction After Primary Percutaneous Coronary Intervention in Multivessel Coronary Disease Is Primarily Related to Stent Failure

Objectives

Our aim was to investigate the risk of events related to non‐culprit lesions after primary percutaneous coronary intervention (PCI) in patients with multivessel coronary disease (MVD).

Background

In patients undergoing primary PCI for ST‐elevation myocardial infarction (STEMI) who are diagnosed with MVD, the optimal treatment strategy is currently under debate. Although observational data exposed an increased risk of multivessel PCI in the acute phase of STEMI, 2 recently published randomized controlled trials showed a reduction of death or recurrent myocardial infarction (MI) after preventive PCI of non‐culprit lesions when compared with culprit‐lesion PCI only.

Methods

We performed a post‐hoc analysis of 279 patients with MVD included in the Paclitaxel‐Eluting Stent versus Conventional Stent in Myocardial Infarction with ST‐Segment Elevation (PASSION) trial. We analyzed the incidence and cause of recurrent MI. Recurrent MI due to stent failure was assumed in the event of definite or probable stent thrombosis.

Results

After 5 years, 14 patients (5.7%) with MVD had a recurrent MI versus 17 (5.4%) patients with 1‐vessel disease (HR 1.06, 95%CI 0.52–2.15, P = 0.87). The majority of events was attributable to stent failure, while of the remaining 6 events, only 1 was proven to originate from a lesion that was judged significant at enrolment.

Conclusions

In this post‐hoc analysis of the PASSION trial, recurrent MI in patients with MVD was mainly related to stent failure rather than a new event originating from a significant stenosis in a non‐culprit coronary artery. (J Interven Cardiol 2015;28:523–530)

     

Femoral Access PCI in a Default Radial Center Identifies High‐Risk Patients With Poor Outcomes

Background

Increasingly the trans‐radial route (TRR) is preferred over the trans‐femoral route (TFR) for PCI. However, even in high volume default TRR centers a cohort of patients undergo TFR PCI. We examined the demographics, procedural characteristics, and outcomes of patients undergoing PCI via the TF.

Methods

The patient demographics, procedural data, and outcomes of 5,379 consecutive patients undergoing PCI at a default radial center between 2009 and 2012 were examined. Major bleeding (MB) was classified by ACUITY and BARC definitions.

Results

A total of 559 (10.4%) patients underwent PCI via the TFR and 4,820 patients via the TRR (89.6%). Baseline variables associated with TFR were shock, previous CABG, chronic total occlusion intervention, rotablation/laser use, female sex, and renal failure. Sixty‐five patients of the TFR cohort (11.6%) experienced MB with 27 (41.5%) being access site related. MB was significantly more frequent than in the radial cohort. The variables independently associated with MB in the TFR cohort were renal failure, acute presentation, shock, and age. In the TFR, patients with MB mortality was high at 30 days (17.2% vs 2.6% for no MB, P < 0.0001) and at 1 year (37.6% vs 5.0%, P < 0.0001). Shock and MB were highly predictive of 30 day and 12 month mortality.

Conclusion

In a default radial PCI center 10% of patients undergo PCI via the femoral artery. These patients have high baseline bleeding risk and undergo complex interventions. As a result the incidence of major bleeding, transfusion and death are high. Alternative strategies are required to optimize outcomes in this select group. (J Interven Cardiol 2015;28:485–492)

     

Impella 2.5 initiated prior to unprotected left main PCI in acute myocardial infarction complicated by cardiogenic shock improves early survival

Objectives

To assess post‐procedural outcomes when Impella 2.5 percutaneous left ventricular assist device (pLVAD) support is initiated either prior to or after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULMCA) culprit lesion in the context of acute myocardial infarction cardiogenic shock (AMICS).

Background

Initiation of Impella 2.5 pLVAD prior to PCI is associated with significant survival benefit in the setting of AMICS. Outcomes of those presenting with a ULMCA culprit lesion in this setting have not been well characterized.

Methods

Thirty‐six consecutive patients in the cVAD Registry supported with Impella 2.5 pLVAD for AMICS who underwent PCI on ULMCA culprit lesion were included in our multicenter study.

Results

The average age was 69.8 ± 14.2 years, 77.8% were male, 72.7% were in CS at admission, 44.4% sustained one or multiple cardiac arrests, and 30.6% had anoxic brain injury. Baseline characteristics were comparable between the Pre‐PCI group (n = 20) and Post‐PCI group (n = 16). Non‐ST segment elevation myocardial infarction and greater coronary disease burden were significantly more frequent in the Pre‐PCI group but they had significantly better survival to discharge (55.0% vs 18.8%, P = 0.041). Kaplan‐Meier 30‐day survival analysis showed very poor survival in Post‐PCI group (48.1% vs 12.5%, Log‐Rank P = 0.004).

Conclusions

Initiation of Impella 2.5 pLVAD prior to as compared with after PCI of ULMCA for AMICS culprit lesion is associated with significant early survival. As previously described, patients supported after PCI appear to have very poor survival at 30 days.

     

Efficacy and Safety of Local Intracoronary Drug Delivery in Treatment of No‐Reflow Phenomenon: A Pilot Study

Background

Successful reopening of epicardial coronary artery does not always mean optimal myocardial reperfusion in a sizable portion of patients, mostly because of no‐reflow phenomenon.

Objectives

We investigated whether local injection of adrenaline ± verapamil in the distal coronary bed is more effective than their intracoronary (IC) injection through the guiding catheter in the treatment of no‐reflow phenomenon following percutaneous coronary intervention (PCI).

Methods

A total of 40 patients with no‐reflow following PCI were randomized into two groups. Group 1 received IC adrenaline ± verapamil through a well‐cannulated guiding catheter while Group 2 received the above‐mentioned drugs in the distal coronary bed through a perfusion balloon or selective microcatheter. The primary end points were the achievement of TIMI III flow with MBG II or III. Secondary end points were the occurrence of hypotension, arrhythmias, and major adverse cardiac events (MACEs) during hospital stay.

Results

After drug injection, the percentage of patients achieving Thrombolysis in Myocardial Infarction (TIMI) III flow in Group 1 was 40% versus 80% in Group 2, P = 0.032. MBG II and III was significantly lower in Group 1; 10% and 25% versus 15% and 65% in Group 2, respectively, P = 0.033. Primary end points were achieved in only 35% of patients in Group 1 and in 80% of patients in Group 2 (odds ratio, 7.43, 95% confidence interval 1.78–31.04, P < 0.01). Secondary end points were not different between both groups.

Conclusion

Local intra‐coronary delivery of adrenaline ± verapamil is a safe and effective method for the treatment of no‐reflow phenomenon complicating PCI.

     

Short‐term Effect of Upstream Administration in Comparison to Deferred Injection of Tirofiban on Patients with Acute ST‐Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background

High bolus dose tirofiban has been demonstrated to provide greater inhibition of platelet aggregation, but the most appropriate timing of its administration remains unknown.

Objectives

To evaluate the efficacy of upstream vs. deferred administration of tirofiban in patients with acute ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) on clinical outcomes.

Methods

The 660 patients with acute ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention were divided into upstream (n = 330, administration of tirofiban to all patients in emergency room) and deferred groups (n = 330, treatment of patients with large thrombus burden or no‐reflow phenomenon in cardiac catheterization laboratory during PCI). The primary end‐points were death, nonfatal myocardial infarction (MI), stent thrombosis (ST), revascularization of targeted vessels (TVR) or major adverse cardiac events (MACE) at 1 month and 6 months following PCI, with safety end‐point at 7 days.

Results

Compared with that of the deferred group, there was a significant increase of left ventricular ejection fraction (LVEF) in the upstream group within 7 days (55.5 ± 6.6% vs. 54.6 ± 7.9%, P = 0.011). The rates of 7‐day and 1‐month MACE in the upstream group were lower than those in the deferred group (1.5% vs. 4.2%, 3.3% vs. 7.0%, P = 0.037 and 0.034, respectively). However, there were higher tendencies for major and minor bleedings in the upstream group (1.8% vs. 0.9%, 2.7% vs. 1.5%, P = 0.315 and 0.280, respectively).

Conclusion

To the Chinese patients with acute myocardial infarction undergoing primary PCI, upstream administration of tirofiban was slightly superior to deferred injection for short‐term clinical outcomes.

     

Platelet function monitoring for stent thrombosis in critically III patients with an acute Coronary syndrome

Background

Patients after cardiac arrest or in cardiogenic shock due to acute coronary syndrome (ACS) are at high risk for stent thrombosis (ST) and recurrent cardiovascular events after primary percutaneous coronary intervention (PCI). High post‐interventional platelet reactivity (HPR) might be an additional risk factor for ST in these critically ill patients.

Methods

Between 2006 and 2016, 401 critically ill patients from a cardiologic intensive care unit underwent platelet function testing after primary PCI using whole blood impedance aggregometry. After exclusion of patients with an abnormal platelet count, 357 patients have been included into the final analysis of this retrospective observational study.

Results

The incidence of definite early ST was 19.2% in patients with HPR to P2Y12 antagonists and 1.2% in patients without HPR. Likewise, the incidence of early ST in patients with HPR to acetylsalicylic acid (ASA) was 21.4% versus 1.8% in patients without HPR. In contrast, the incidence of late ST or recurrent myocardial infarction in untreated lesions was not associated with HPR to ASA or P2Y12 antagonists.

Conclusions

Platelet function testing in critically ill ACS patients identified patients at high risk for early ST and might be beneficial for risk stratification.

     

Rotational Atherectomy for Left Main Coronary Artery Disease in Octogenarians: Transradial Approach in a Tertiary Center and Literature Review

Objectives

The aim of this study was to appreciate the safety and effectiveness of transradial percutaneous coronary intervention (PCI) with rotational atherectomy for highly calcified left main coronary artery (LMCA) disease in octogenarians.

Background

Conventional surgery is still considered the preferred management for LMCA disease; but, when the lesion is severely calcified, and the patient is unsuitable for surgery, the interventional cardiologist faces a complex PCI traditionally approached by femoral access.

Methods

Between June 2004 and December 2010, octogenarians with calcified LMCA disease who were primary denied for surgical revascularization were enrolled. Procedural success and major adverse cerebral and cardiovascular events (MACCE) including death, nonfatal myocardial infarction, target lesion revascularization (TLR), or stroke during long‐term follow‐up were evaluated.

Results

Forty‐two consecutive patients≥80 years had undergone stenting for calcified LMCA disease (13 with rotational atherectomy, the “Rota” group, and 29 without rotational atherectomy, the “without Rota” group). Procedural success was good (92.3% vs. 96.6%, respectively, p = NS). Mean follow‐up time was 25.7 ± 21.4 and 28 ± 32.3 months, respectively. There was a TLR in 25% and 11.1%, respectively; p = NS. No difference was detected in terms of overall in‐hospital or long‐term mortality or MACCE.

Conclusion

Rotational atherectomy followed by stent implantation by transradial approach, when applied to heavily calcified lesions, appeared to be a safe and effective strategy for the treatment of LMCA disease in octogenarians who were refused for surgery. (J Interven Cardiol 2013;26:173–182)

     

Effectiveness of the proximal optimization technique for longitudinal stent elongation caused by post‐balloon dilatation

Objectives

To evaluate the effectiveness of the proximal optimization technique (POT) to prevent longitudinal stent elongation.

Background

The mechanism of stent elongation, which occurs after post‐balloon dilation, is still unclear.

Methods

A total of 103 lesions treated with optical coherence tomography guided coronary intervention between May 2013 and November 2017 were retrospectively analyzed. Lesions were divided according to the circumferential degree of malapposition at the stent edge immediately after deployment into well‐apposed group (<180°) and malapposed group (≥180°). Post‐dilation was performed from distal to proximal within the stent until August 2016 (non‐POT cohort), and POT was applied thereafter (POT cohort). In the POT cohort, post‐dilation was done at the proximal portion of the stent with sufficiently large balloon to minimize malapposition followed by distal dilatations. Stent elongation length was defined as the change in stent length from stent deployment to after post‐dilatation.

Results

In the non‐POT cohort, 72 lesions, including 54 lesions in the well‐apposed group and 18 in the malapposed group were analyzed. Stent elongation length was significantly longer in the malapposed group than in the well‐apposed group (1.51 ± 1.34 mm vs 0.13 ± 0.84 mm, P < 0.01). In the POT cohort, 31 lesions including 21 in the well‐apposed group and 10 in the malapposed group were analyzed. Stent elongation length was not significantly different between the groups (?0.09 ± 0.91 mm vs 0.30 ± 0.99 mm, P = 0.29).

Conclusions

Malapposition of the stent edge is responsible for longitudinal stent elongation caused by post‐dilatation. POT appeared to effectively prevent longitudinal stent elongation.

     

Complications with Angio‐Seal™ Vascular Closure Devices Compared with Manual Compression after Diagnostic Cardiac Catheterization and Percutaneous Coronary Intervention

Objectives

This study assessed and compared vascular complications in CATHs and PCIs using an Angio‐Seal? vascular closure device (VCD) versus manual compression (MC).

Methods

Secondary data analysis of a population‐based multiyear cohort database was conducted to compare femoral access‐related vascular outcomes in cardiac procedures using VCD and MC between May 1, 2006 and December 31, 2010. The primary outcome was any vascular complication. Propensity score adjusted analysis was conducted to reduce bias associated with covariate imbalance between the groups compared.

Results

Of the 11,897 procedures, 7,063 (59.4%) used a VCD. Vascular complications occurred in 174/8,796 (2.0%) of CATHs and 82/3,004 (2.7%) of PCIs. In the CATH sample, the odds of vascular complication were 57% lower if a VCD was used (OR = 0.43, 95% CI 0.31–0.60). For the PCI sample, the risk was 49% lower if a VCD was used (OR = 0.51, 95% CI 0.31–0.81).

Conclusions

A low incidence of vascular complications was observed with the use of an Angio‐Seal VCD relative to MC for both procedures.

     

Factors Associated With Ineligibility for PCI Differ Between Inpatient and Outpatient ST‐Elevation Myocardial Infarction

Objectives

Without early revascularization, both inpatient and outpatient STEMIs have poor outcomes. Reasons for denying PCI for STEMI, however, remain uncertain. This single‐center retrospective cohort study compares factors and outcomes associated with ineligibility for PCI between inpatients and outpatients following ST‐elevation myocardial infarction (STEMI).

Methods

A total of 1,759 STEMI patients between June 2009 and January 2015 were assessed. Individual medical records were reviewed to obtain reasons for PCI ineligibility for STEMI patients who did not receive reperfusion therapy.

Results

Compared to outpatients with STEMI (n = 1,688), inpatients (n = 71) were less likely to receive coronary angiography (60.6% vs 95.9%; P < 0.001) or PCI (50.7% vs 80.9%; P < 0.001), with longer ECG/door to first device activation times (97 [78, 131] vs 63 [49, 78] minutes; P < 0.001). When coronary angiography was performed, however, similar rates of PCI and procedural success were seen in both groups. Principal contraindication for PCI was risk of bleeding within the inpatient population and complex coronary artery disease within the outpatient population. Total in‐hospital mortality was higher in inpatient STEMIs compared to outpatients (42.2% vs 10.0%; P < 0.001), but lower for patients eligible for PCI in both groups.

Conclusions

Reasons for PCI ineligibility differ between inpatient and outpatient STEMIs. Inpatients have increased risks of bleeding, lower coronary angiography and PCI use, and higher in‐hospital mortality. Especially for inpatients, specific PCI STEMI protocols that anticipate and overcome types of ineligibility and delay for cardiac catheterization may improve outcomes.