OCT联合冠状动脉造影指导与单纯冠状动脉造影指导对STEMI患者介入治疗临床结果影响

目的探讨光学相干断层成像技术(OCT)联合冠脉造影指导下对急性ST段抬高心肌梗死(STEMI)急诊经皮冠状动脉介入治疗(PCI)的临床疗效。方法入选2016年1月至2017年5月于首都医科大学附属北京潞河医院和2019年1月至6月于首都医科大学附属北京友谊医院住院的急性STEMI患者。OCT组选择接受急诊PCI并行OCT检查的STEMI患者100例,应用OCT检查明确心肌梗死(心梗)病因,决定介入方案,在OCT指导下行介入治疗;冠脉造影组患者选择在同期内未行OCT的行急诊PCI的STEMI患者,按照梗死相关冠状动脉(冠脉)相同、性别相同、年龄相差±5岁的条件,两组按照1:1进行匹配。主要观察终点是术后30 d主要心脏不良事件(MACE)发生率;次要观察终点包括支架和球囊选择是否存在差异及术后冠脉TIMI分级、心功能和生化指标的差异。结果本研究OCT发现STEMI患者斑块破裂、斑块侵蚀、钙化结节发生率分别为54%、22%、2%、2%。OCT组共用球囊184个,植入药物洗脱支架113枚,冠脉造影组共用球囊186个,共置入支架122枚,两组均无统计学差异(P0.05)。两组术后TIMI血流、肌酸激酶同工酶(CKMB)峰值、左室射血分数均无明显差异(P0.05)。两组术后30 d MACE事件发生率两组无差异(P0.05)。OCT发现支架术后即刻支架贴壁不良率、支架边缘夹层、组织脱垂、支架膨胀不全发生率分别为23%、16%、18%、1%。结论斑块破裂是STEMI的主要发病原因,其次是斑块侵蚀,OCT指导的介入治疗可以明确STEMI的发病机制及时发现介入并发症,指导临床处理,未增加MACE事件。     

自发性冠状动脉夹层所致急性冠状动脉综合征的临床与预后研究

目的:分析自发性冠状动脉夹层(SCAD)所致急性冠状动脉综合征(ACS)患者的临床资料,以积累该病的诊疗经验。方法:选择经冠状动脉造影(CAG)或冠状动脉影像学检查明确诊断为SCAD所致的ACS患者为研究对象,分析其病历资料和CAG资料,对其临床特征、冠状动脉影像学特征、治疗策略和随访结果进行分析。结果:共入选18例患者,其中ST段抬高型心肌梗死(STEMI)5例(27.7%),非ST段抬高型心肌梗死(NSTEMI)3例(16.7%),不稳定性心绞痛10例(55.6%);患者平均年龄(47.5±12.3)岁,其中女性13例(72.2%),合并2种以上冠心病危险因素的患者仅7例(38.9%);冠状动脉夹层的分型以1型病变10例(55.6%)为主,18例患者共发现23处夹层病变,5例(27.7%)合并多支冠状动脉夹层病变,其中12处(52.2%)病变累及前降支(LAD),7处(30.4%)病变累及旋支(LCX),4处(17.4%)病变累及右冠状动脉(RCA);患者治疗策略以药物保守治疗13例(72.2%)为主,经过12个月的随访,血运重建2例(11.1%),再次心肌梗死1例(5.6%),其余15例在随访中无任何严重主要不良心脑血管(MACCE)事件发生。结论:SCAD所致的ACS患者多为年轻女性,且合并冠心病危险因素较少,患者经药物保守治疗后近期预后良好。     

血管内超声指导冠状动脉中重度钙化病变介入治疗的效果

目的:评价血管内超声(IVUS)对冠状动脉中-重度钙化病变介入治疗的指导作用及对预后的影响。方法:2009年1月~2013年1月冠状动脉中-重度钙化病变患者219例接受冠状动脉介入治疗,其中95例患者术中应用血管内超声指导,124例患者在单纯冠状动脉造影(CAG)指导下完成介入治疗。结果:两组患者的临床基线特征、靶血管部位、病变类型、置入支架数目、长度、直径;冠状动脉旋磨和切割球囊应用等方面,差异均无统计学意义。两组患者住院期间及术后30 d临床终点事件,包括主要不良心血管事件(MACE)事件、支架内血栓发生率的差异均无统计学意义。随访12个月时,IVUS组MACE事件发生率显著低于CAG组(8.4%vs.17.7%,P0.05),IVUS组靶血管重建发生率显著低于CAG组(3.2%vs.10.5%,P0.05)。IVUS组与CAG组在支架内血栓发生率方面差异无统计学意义(3.2%vs.3.2%)。结论:IVUS指导中-重度冠状动脉钙化病变术后即刻和短期临床效果并不优于CAG,但应用IVUS指导能够显著降低术后1年靶血管重建发生率。     

光学相干断层成像对ST段抬高型心肌梗死患者急诊经皮冠状动脉介入治疗策略的影响

目的探讨光学相干断层成像(OCT)指导下对急性ST段抬高型心肌梗死(STEMI)急诊经皮冠状动脉介入治疗(PCI)策略的影响。方法纳入2016年1月至2017年5月接受急诊PCI并行OCT检查的STEMI患者100例,利用OCT检查明确STEMI发病机制,评价PCI即刻效果,随访12个月观察预后。结果 17例(17.0%)患者因OCT图像欠清晰未能明确心肌梗死发病机制,其中15例置入支架;其余83例患者中斑块破裂54例(65.1%,54/83)、斑块侵蚀22例(26.5%,22/83)、钙化结节2例(2.4%,2/83)、支架贴壁不良致晚期支架内血栓形成2例(2.4%,2/83)、亚急性支架内血栓形成1例(1.2%,1/83)、冠状动脉痉挛2例(2.4%,2/83),其中68例置入支架。83例置入支架、造影成功的患者中,OCT发现支架术后造影不易识别的支架贴壁不良、组织脱垂、支架膨胀不全患者18例(21.7%,18/83);支架边缘夹层16例(19.3%,16/83),其中血流受限需要干预的支架近端夹层2例(2.4%,2/83)。17例未置入支架患者中冠状动脉痉挛2例、血栓负荷重1例,其余14例(斑块破裂7例、斑块侵蚀4例、晚期支架内血栓形成2例及亚急性支架内血栓形成1例)因OCT检查残余狭窄70%、TIMI血流Ⅲ级未置入支架。随访(11.0±4.0)个月,除1例院内死于心源性休克和1例亚急性支架内血栓形成患者外,所有出院患者均未发生主要不良心血管事件。结论 OCT可以检测出约1/4 STEMI患者冠状动脉支架置入术后多种不良特征并进行治疗。     

冠状动脉造影与血流储备分数指导下边支介入治疗对冠状动脉分叉病变患者影响的对比研究

目的比较冠状动脉造影(CAG)与血流储备分数(FFR)指导下边支介入治疗对冠状动脉分叉病变患者的影响。方法选取2013年4月—2014年9月在东莞市第三人民医院就诊的冠状动脉分叉病变患者86例,随机分为A组和B组,每组43例。A组患者在CAG指导下进行边支介入治疗,而B组患者在FFR指导下进行边支介入治疗。比较B组患者手术前后FFR,两组患者行支架置入术者所占比例、置入支架数量、支架长度、手术时间及住院时间;记录随访6个月、12个月及2年不良心血管事件发生情况。结果 B组患者术后FFR高于术前(P0.05)。B组患者行支架置入术者所占比例低于A组,置入支架数量少于A组,支架长度短于A组(P0.05),而两组患者手术时间及住院时间比较,差异无统计学意义(P0.05)。随访6、12个月时两组患者病死率及支架内血栓形成、心肌梗死、心绞痛发生率比较,差异无统计学意义(P0.05);随访2年时两组患者病死率及心肌梗死、心绞痛发生率比较,差异无统计学意义(P0.05),而B组患者支架内血栓形成发生率低于A组(P0.05)。结论与CAG指导下边支介入治疗相比,FFR指导下边支介入治疗能更好地降低冠状动脉分叉病变患者行支架置入术必要性、减少置入支架数量、缩短支架长度,且有利于降低长期支架内血栓形成发生率。     

血管内超声指导对于冠状动脉真性分叉病变介入治疗长期预后的影响

目的研究血管内超声（intravascular ultrasound,IVUS）指导对于冠状动脉真性分叉病变植入药物洗脱支架（drug eluting stent,DES）长期预后的影响。方法通过分析2005年10月至2010年3月DK—Crush系列随机对照研究入选735例原位冠状动脉真性分叉病变植入DES患者,应用倾向评分匹配临床和造影特征,165例IVUS指导和165例冠状动脉造影指导患者纳入研究,比较两组患者的长期预后。结果两组临床基线资料和造影特征比较,差异无统计学意义（P〉0．05）。IVUS指导组更常见选择双支架策略（P=0．007）,IVUS指导组主支血管（MV）和分支血管（SB）的最大支架直径和支架总长度以及分支血管支架个数显著超过常规造影指导组;介入治疗后QCA分析显示,IVUS指导组分支血管参考血管直径（RVD）和即刻获得以及主支血管近端和分支血管最小管腔直径（MLD）显著超过造影指导组。12个月随访发现两组心脏死亡、靶病变重建（TLR）和主要心血管事件（MACE）比较,差异无统计学意义（P〉0．05）。然而,IVUS指导组晚期支架内血栓和急性心肌梗死发生率显著低于造影指导组,差异有统计学意义（0．6％ vs.4．8％。P=0．04;1．8％ vs.6．7％,P=0．03）。结论IVUS指导冠状动脉真性分叉病变植入DES可以显著减低晚期支架内血栓和由此引起急性sT段抬高心肌梗死发生率而改善长期预后。     

冠状动脉造影和血管内超声引导药物洗脱支架植入治疗冠状动脉慢性闭塞病变远期效果的对比研究

目的:随机对比研究冠状动脉造影(CAG)引导和血管内超声(IVUS)引导药物洗脱支架(DES)植入治疗冠状动脉慢性闭塞病变(CTO)12个月的临床效果。方法:230例CTO病变患者,成功介入开通CTO病变后随机入选CAG引导组(115例)和IVUS引导组(115例)。主要终点为术后12个月复查CAG时CTO血管晚期管腔丢失值(LLL),次要终点为术后12个月的主要心脏不良事件(MACE),包括心源性死亡、靶病变血运重建(TLR)、靶血管血运重建(TVR)、心肌梗死(MI)、支架内血栓(ST)。结果:12个月CAG复查时IVUS引导组LLL显著低于CAG引导组(P0.05)。临床随访12个月时,IVUS引导组累计MACE发生率与CAG引导组无显著性差异;心源性死亡、TLR、TVR、MI两组无显著性差异,但ST有降低趋势(P=0.052)。结论:IVUS引导DES植入治疗CTO病变显著降低12个月的LLL;随访12个月,IVUS引导组ST有降低趋势,其他MACE无显著性下降。     

心肌血流储备分数指导下药物治疗冠状动脉临界病变患者的远期疗效

目的研究心肌血流储备分数(FFR)指导下药物治疗冠状动脉临界病变患者的安全性。方法 2010年4月至2011年9月武汉亚洲心脏病医院介入中心行冠状动脉造影提示临界病变同时行冠状动脉内压力导丝测定FFR≥0.8的连续15例患者,规范冠心病二级预防药物治疗。随访≥1年,包括主要不良事件(包括死亡、心肌梗死、再次靶病变血运重建术、卒中)及再发心绞痛、再次住院、出血发生情况。结果 15例患者平均(61±7.49)岁。其中男性7例(46.7%),冠状动脉造影病变平均(1.2±0.5)支。15例患者冠状动脉造影提示19处临界病变:左前降支15处、回旋支3处,右冠状动脉1处;其中单支病变者11例(73.3%),双支病变者4例(26.7%),均合并前降支病变;FFRmyo均值(0.88±0.06)。15例患者平均随访(23.6±5.67)个月,其中1例(6.7%)失访。2例(13.3%)不稳定型心绞痛患者随访期间出现心绞痛,症状较前无明显加重,含服硝酸甘油可缓解,余心肌梗死、再次靶病变血运重建术、卒中、全因死亡、再次住院率、出血等不良事件无发生。对入选患者心绞痛发生情况采用Kaplan-Meier法做生存分析,FFR术后平均再发心绞痛时间为术后(29.12±0.67)个月。结论初步验证了FFR指导下药物治疗冠状动脉临界病变患者是可行的。     

不同时间窗干预非ST段抬高型急性冠状动脉综合征疗效观察

目的 比较非ST段抬高型急性冠状动脉综合征患者早期干预和延迟干预的有效性和安全性.方法 本试验为多中心随机研究,将入选的非ST段抬高型急性冠状动脉综合征患者分配至早期组(24 h内接受冠状动脉造影)和延迟组(36 h后接受冠状动脉造影),接受介入治疗或冠状动脉旁路移植术.主要终点是180 d随访时死亡、心肌梗死、卒中的复合终点,次要终点是180 d随访时死亡、心肌梗死、难治性缺血、卒中、再次血运重建.结果 共有815例患者入选,主要终点事件发生率早期组为9.0%,延迟组为14.6%(P=0.01).次要终点事件(180 d死亡、心肌梗死或难治性缺血复合终点)的发生率早期组为14.6%,延迟组为22.0%(P=0.01).180 d心肌梗死发生率延迟组高于早期组(10.8%比5.2%,P=0.00).另一个次要终点事件(180 d死亡、心肌梗死、难治性缺血、卒中或再次血运重建复合终点)的发生率早期组为26.7%,延迟组为30.4%(P=0.25).结论 早期干预可以减少非ST段抬高型急性冠状动脉综合征患者再发心肌梗死的发生率.     

光学相干断层成像和血管内超声在冠状动脉介入手术中的应用

目的 应用光学相干断层成像(OCT)及血管内超声(IVUS)检测技术评价冠状动脉内粥样硬化斑块的稳定性,并指导支架置入,检测血管对置入支架后即刻和中远期的反应.方法 选择2008年2-7月间的27例患者,进行冠状动脉造影、OCT及IVUS检查,共检查了30支血管,其中8处为药物支架植入术后血管,并对19处病变进行了支架置入.结果 除外支架置入的8例(置入6个月～4年)外,其余22例病变行OCT及IVUS检查,发现稳定性斑块5例,不稳定斑块17例,其中OCT检出内膜小撕裂4例(IVUS未检出,P＞0.05),冠状动脉撕裂伴夹层病变5例(IVUS检出1例,P＞0.05),血栓形成5例(IVUS检出1例,P＞0.05),偏心斑块伴薄纤维帽12例(IVUS检出2例,P＜0.01).8例曾经进行支架治疗的患者,造影、OCT和IVUS发现2例再狭窄;OCT显示支架内膜覆盖良好,IVUS小能精确看到内膜;OCT检测出1例患者有支架后瘤样扩张.对17例不稳定性斑块及2例支架再狭窄病例行支架置入术,术后支架膨胀不良发生率26.0%,OCT及IVUS检出率相同;支架贴壁不良发生率63.2%,IVUS榆出率低于OCT(10.5%比63.2%,P＜0.01);支架近远端撕裂10.5%,IVUS均不能检出;内膜脱垂发生率52.6%,IVUS检出率低于OCT(10.5%比52.6%,P＜0.05).结论 OCT与IVUS相比,在不稳定性斑块检测准确度方面明显优于IVUS,更能精确指导冠状动脉支架置人.IVUS在操作简便性及反映斑块负荷方面要优于OCT.     

紫杉醇微孔载药支架与进口雷帕霉素药物洗脱支架治疗冠心病的临床效果比较

目的:比较紫杉醇微孔载药支架和进口雷帕霉素药物洗脱支架在经皮冠状动脉介入治疗中的临床疗效。方法: 筛选73例行经皮冠状动脉介入治疗术的冠心病患者,随机分为两组,紫杉醇微孔载药支架组（紫杉醇组,35例）和进口雷帕霉素药物洗脱支架组（雷帕霉素组,38例）。支架植入术后6个月复查冠状动脉造影（CAG）。随访6个月,对比两组支架内血栓形成、主要心血管不良事件（包括心源性死亡、非致死性心肌梗死、靶病变血运重建）和支架内再狭窄发生率。结果: 随访6个月,两组均未出现急性、亚急性和晚期支架内血栓形成、非致死性心肌梗死和心源性死亡。心绞痛、支架内再狭窄和靶病变血运重建发生率均无统计学差异。结论: 紫杉醇微孔载药支架与进口雷帕霉素药物洗脱支架在治疗冠状动脉简单病变时具有相同的近、中期临床疗效和安全性。     

Outcomes of drug-eluting stents compared to bare-metal stents in ST-segment elevation acute myocardial infarction

IntroductionPrimary percutaneous coronary intervention (PPCI) has become the treatment of choice in patients with ST-segment elevation myocardial infarction (STEMI). Drug-eluting stents (DES) reduce restenosis compared to bare-metal stents (BMS) but there is conflicting data concerning their use in the setting of STEMI. We aimed to evaluate the influence of the type of stent on the outcomes of PPCI.MethodsThis was a single-center longitudinal study including 213 consecutive patients (76% men, mean age 60±12 years) with STEMI undergoing PPCI between 2003 and 2007, divided into two groups: BMS (43.7%) and DES (56.3%). We assessed clinical and demographic features as well as angiographic and electrocardiographic signs of myocardial reperfusion. The composite outcome of death, myocardial infarction (MI) or target-lesion revascularization (TLR) was evaluated.ResultsAt a median follow-up of 26 months there were no differences in the composite outcome of death/MI/TLR (BMS 18.3% vs DES 15.8%) or in the incidence of stent thrombosis. Angiographic results of the procedure were also similar. Independent predictors of the composite outcome were age (HR=1.06, 95% CI [1.02-1.11], left anterior descending artery as infarct-related vessel (HR=2.69, 95% CI [1.17-6.19]) and use of glycoprotein IIb/IIIa inhibitors (HR=0.33, 95% CI [0.13-0.83]).ConclusionsThere was no benefit in angiographic outcomes or major cardiac events after treatment with drug-eluting stents compared to bare-metal stents in this group of patients with STEMI.     

Thrombus aspiration during primary percutaneous coronary intervention for acute myocardial infarction: A review of clinical evidence and guidelines

Acute ST segment elevation myocardial infarction (STEMI) is characterized by complete thrombotic occlusion of a major coronary artery. Early recanalization of the infarct-related artery is most efficiently delivered by primary percutaneous coronary intervention (PPCI), however this does not always restore normal myocardial perfusion, mainly due to distal embolization of the thrombus and microvascular obstruction. Early evidence for manual thrombus aspiration during PPCI was promising and this was once considered an important aspect of the procedure, especially in patients with a high thrombus burden. However, a large body of evidence from recent major randomized controlled trials (notably TASTE and TOTAL) does not support the routine use of manual thrombus aspiration in patients with STEMI undergoing PPCI.     

Management of multivessel coronary disease after ST elevation myocardial infarction treated by primary angioplasty

BACKGROUND: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but available data failed to consistently show a benefit in long-term clinical outcomes. METHODS: We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were defined as a composite of death, periprocedural myocardial infarction after staged, elective PCI, stroke, stent thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death, stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome. RESULTS: Group 1 patients underwent staged PCI 5.9 +/- 3.5 days after primary angioplasty. The mean length of follow-up was 13 months (392 +/- 236 days). The incidence of in-hospital MACE was 20.3% in Group 1 and 10.8% in Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037). In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure, which occurred in 15.6% of patients. CONCLUSIONS: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural myocardial infarction during the elective procedure.     

Effect of delayed vs immediate stent implantation on myocardial perfusion and cardiac function in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous intervention with thrombus aspiration

Background

Optimizing microcirculation in STEMI patients with thrombus-containing lesion undergoing percutaneous coronary intervention (PCI) remains challenging. Our objective was to compare the effects on myocardial perfusion and cardiac function of delayed vs immediate stent implantation after thrombus aspiration in STEMI patients undergoing PCI.

Methods

Eighty-seven STEMI patients with thrombus-containing lesion undergoing PCI were enrolled. After thrombus aspiration was performed, subjects were divided into 2 groups according to residual thrombus score (TS): immediate stent implantation (ISI) group (n = 47, residual TS < 2; stenting was performed immediately), and delayed stent implantation (DSI) group (n = 40, residual TS ≥ 2; stenting was performed 7 days later). Corrected thrombolysis in myocardial infarction frame count and myocardial blush grade were analyzed immediately after PCI. The wall motion score index was assessed on admission and at 6-month follow-up.

Results

At the end of the PCI procedure, the corrected thrombolysis in myocardial infarction frame count was significantly shorter and the myocardial blush grade 3 was more frequent in the DSI group than in the ISI group. Compared with the ISI group, the DSI group had a lower incidence of thrombus-related angiographic events, including distal embolization and no reflow. A significantly greater improvement in wall motion score index from baseline to 6-month follow-up was observed in the DSI group compared with the ISI group.

Conclusions

In STEMI patients presenting with thrombus containing lesion undergoing PCI, delayed stent implantation after thrombus aspiration leads to better myocardial perfusion and cardiac functional recovery in comparison with immediate stent implantation.     

冠心病患者介入治疗失败后行急诊冠状动脉旁路移植术的预后

目的 探讨冠心病患者经皮冠状动脉介入治疗失败后行急诊冠状动脉旁路移植术(CABG)的预后.方法回顾性分析2002年1月至2010年12月阜外心血管病医院11例经皮冠状动脉介入治疗失败后行急诊CABG患者的临床资料,并进行随访.院内随访内容包括心脏性死亡、Q波心肌梗死、肾功能不全、神经系统事件;院外随访的研究终点为主要心血管不良事件,包括死亡、心肌梗死和靶病变血管重建.结果 患者年龄(61±5)岁.冠状动脉造影显示三支病变患者5例(45.5％).在介入治疗的靶血管病变中,9例(81.8％)位于左前降支,中、重度钙化、慢性完全闭塞及弥漫性长病变分别为3例(27.3％)、4例(36.4％)和4例(36.4％).11例患者均有行急诊CABG的指征,其中冠状动脉夹层5例(45.5％)、冠状动脉穿孔 3例(27.3％)、病变无法充分扩张1例(9.1％)、血管急性闭塞1例(9.1％)和支架脱载1例(9.1％).CABG术后随访(47±33)个月.院内随访期间,发生心脏性死亡1例(9.1％),Q波心肌梗死2例(18.2％).院外随访期间,1例(9.1％)患者死于肾功能衰竭,无因心原性事件再次住院的患者.结论经皮冠状动脉介入治疗失败后行急诊CABG多见于复杂冠状动脉病变,术后患者的长期预后良好.     

Prognostic significance of postprocedural sustained ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention (from the HORIZONS-AMI Trial)

The prognostic significance of postprocedure sustained ventricular tachycardia or ventricular fibrillation (VT/VF) in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) has rarely been studied, although a previous study has suggested that its occurrence portends decreased survival. We examined outcomes from the prospective large-scale multicenter randomized HORIZONS-AMI trial to evaluate the incidence, clinical correlates, and outcomes of in-hospital sustained VT/VF after PPCI. Of 3,485 patients undergoing PPCI in whom VT/VF did not occur before or during the procedure, 181 patients (5.2%) developed VT/VF after PPCI. Most postprocedural VT/VF episodes (85%) occurred in the first 48 hours. Patients with postprocedural VT/VF were more likely men with Killip class > I on presentation but had a lower prevalence of hypertension and diabetes. Patients with postprocedural VT/VF were also less frequently taking β blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at admission. Mean door-to-balloon time was shorter and Thrombolysis In Myocardial Infarction grade 0 flow before PPCI was more common in patients with VT/VF, although Thrombolysis In Myocardial Infarction grade 3 flow rates after PPCI did not vary. There were no significant differences in adjusted 3-year rates of mortality (hazard ratio 0.73, 95% confidence interval 0.30 to 1.79) or composite major adverse clinical events (death, myocardial infarction, target vessel revascularization, or stroke; hazard ratio 0.71, 95% confidence interval 0.44 to 1.15) in patients with versus without postprocedural sustained VT/VF. In conclusion, sustained VT/VF after PPCI in the HORIZONS-AMI trial was not significantly associated with 3-year mortality or major adverse clinical events. Further studies are required to address the prognostic significance of VT/VF in patients with STEMI undergoing PPCI.     

Association of serum cystatin C levels with myocardial perfusion and cardiac functional recovery in patients with anterior wall ST elevation myocardial infarction treated with primary coronary intervention

This study sought to investigate the association of baseline serum cystatin C levels with myocardial perfusion and cardiac functional recovery in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). 108 patients with a first anterior STEMI who underwent PPCI were enrolled. Serum cystatin C was measured by immunoturbidimetric method. Patients were divided into two groups according to the median cystatin C levels on admission: group 1 (≥median, n = 54) and group 2 (<median, n = 54). Myocardial perfusion was assessed by angiographic criteria, ST-segment resolution, and the index of microcirculatory resistance (IMR). Echocardiographic wall motion score index was analyzed on admission and at 6-month follow-up. Patients with angiographically, electrocardiographically no-reflow had significantly higher cystatin C levels on admission. Patients with an IMR ≥33.7 U also had significantly higher cystatin C levels. The WMSI showed a greater improvement in group 2 than in group 1 and there was a significant negative correlation between improvement of WMSI and the cystatin C levels. There was no significant difference in MACEs between the 2 groups. However, congestive heart failure (CHF) was observed significantly more frequent in group 1 than in group 2 (18.5 vs. 5.6 %, p = 0.022). Multivariate logistic regression analysis demonstrated that cystatin C levels at admission were a significant independent predictor of angiographic no-reflow and the development of CHF at 6-month follow-up. Elevated cystatin C levels at admission were independently associated with impaired myocardial perfusion, poor cardiac functional recovery and development of CHF in patients with anterior STEMI undergoing PPCI.     

Adjunctive stent implantation following directional coronary atherectomy in patients with coronary artery disease

Objectives. This prospective case-control study evaluated the acute and long-term results of stent implantation preceded by debulking of the plaque by means of directional coronary atherectomy.

Background. In comparison with balloon angioplasty, intracoronary stenting produces a larger luminal diameter, maintains artery patency and reduces the incidence of restenosis. Optimal stent deployment is a pivotal factor for achieving the best results, but the bulk of the atherosclerotic plaque opposes stent expansion and may limit the success of the procedure. Debulking of the plaque may provide a better milieu for optimal stent deployment.

Methods. Directional coronary atherectomy followed by a single Palmaz-Schatz stent implantation was attempted in 100 patients. The successes, complications and angiographic results of the combined procedure were evaluated both acutely and during follow-up. Matched patients undergoing successful Palmaz-Schatz stent implantation alone during the same period served as controls.

Results. Atherectomy followed by stent implantation was performed in 94 patients with 98 lesions; periprocedural complications were observed in four cases. The stenosis diameter decreased from 76 ± 9% at baseline to 30 ± 13% after atherectomy (p < 0.0001), and 5 ± 9% after stent implantation (p < 0.0001); it increased to 27 ± 15% at 6-month angiography (p < 0.0001). During the 14 ± 10 months of follow-up, none of the patients died or experienced myocardial infarction, but three patients underwent target lesion revascularization. The patients undergoing stent implantation alone achieved smaller acute gains, tended to have a higher late lumen loss, had a higher restenosis rate (30.5% vs. 6.8%, p < 0.0001) and showed a greater incidence of clinical events during follow-up (p < 0.0001).

Conclusions. Debulking atherosclerotic lesions by means of directional coronary atherectomy before stent implantation is a safe procedure with a high success rate and a low incidence of restenosis at follow-up.     

Thrombus aspiration in acute myocardial infarction:Rationale and indication

Reperfusion of myocardial tissue is the main goal of primary percutaneous coronary intervention(PPCI) with stent implantation in the treatment of acute ST-segment elevation myocardial infarction(STEMI). Although PPCI has contributed to a dramatic reduction in cardiovascular mortality over three decades, normal myocardial perfusion is not restored in approximately one-third of these patients. Several mechanisms may contribute to myocardial reperfusion failure, in particular distal embolization of the thrombus and plaque fragments. In fact, this is a possible complication during PPCI, resulting in microvascular obstruction and no-reflow phenomenon. The presence of a visible thrombus at the time of PPCI in patients with STEMI is associated with poor procedural and clinical outcomes. Aspiration thrombectomy during PPCI has been proposed to prevent embolization in order to improve these outcomes. In fact, the most recent guidelines suggest the routine use of manual aspiration thrombectomy during PPCI(class Ⅱa) to reduce the risk of distal embolization. Even though numerous international studies have been reported, there are conflicting results on the clinical impact of aspiration thrombectomy during PPCI. In particular, data on long-term clinical outcomes are still inconsistent. In this review, we have carefully analyzed literature data on thrombectomy during PPCI, taking into account the most recent studies and meta-analyses.