Elective and primary angioplasty at hospitals without on-site surgery versus with on-site surgery: results from a national registry

INTRODUCTION: Current European clinical guidelines do not restrict interventional cardiology at centers without on-site surgical backup, but disagreement still exists whether hospitals with cardiac catheterization laboratories, but without on-site cardiac surgery, should develop percutaneous coronary intervention (PCI) programs. Technical improvements in equipment and pharmacologic adjunctive therapy have increased the safety margins of diagnostic and therapeutic cardiac catheterization and more than half of the patients treated by PCI in Portugal are treated at hospitals without on-site cardiac surgery. OBJECTIVES: We set out to compare clinical outcomes of elective and primary PCI for ST-segment elevation myocardial infarction at centers without on-site cardiac surgery with those at centers with on-site cardiac surgery. METHODS: Based on the Portuguese Registry of Interventional Cardiology, we retrospectively reviewed a total of 13,235 PCI procedures performed from January 2002 to June 2006 and compared the results for 7,112 patients treated at hospitals without on-site cardiac surgery with 6,123 patients treated at hospitals with on-site cardiac surgery. RESULTS: Demographic data were similar, with a mean age of 64 (55-72) vs. 63 (54-71) years, 75% vs. 76% male and 25.0% vs. 24.2% with diabetes respectively at centers without and with on-site surgical backup. Hospital mortality at centers without and with on-site surgical backup respectively was: chronic angina: 0.3% vs. 0.3% (NS); acute coronary syndromes: 1.5% vs. 1.0% (NS); acute myocardial infarction with ST elevation and without cardiogenic shock: 4.0% vs. 5.0% (NS); cardiogenic shock: 50.9% vs. 53.4% (NS). CONCLUSIONS: Similar clinical outcomes for interventional cardiology were achieved at hospitals without on-site cardiac surgery and those with on-site cardiac surgery. In the era of coronary stents, adjunctive therapy and experienced operators, elective and primary PCI can safely be performed without on-site surgical backup.     

Long-term results after acute percutaneous transluminal coronary angioplasty in acute myocardial infarction and cardiogenic shock

The aim of this study was to determine the long-term outcome in unselected, consecutive patients after acute percutaneous transluminal angioplasty (PTCA) for acute myocardial infarction (AMI) complicated by cardiogenic shock. This involved a follow-up study from a prospectively conducted patient registry in a tertiary referral center. A total of 59 patients (10 female/49 male; median age 62 years (32-91)) with percutaneous transluminal cardiac interventions in primary cardiogenic shock were identified between January 1995 and January 2000. Twenty-two patients (37%) had been resuscitated successfully before intervention. The in-hospital mortality of shock patients was 36% (n=21, median age 68 (47-84)). The median follow-up of survivors was 18.1 (7-57.3) months, during which three further patients died (8%; two because of sudden cardiac deaths, one because of acute reinfarction). Achievement of thrombolysis in myocardial infarction (TIMI) flow III after acute PTCA (84% in survivors vs. 38% in non-survivors; P<0.001) and the absence of the left main coronary artery (3% survivors vs. 29% non-survivors; P=0.003) as culprit lesion in patients with cardiogenic shock was strongly associated with an improved survival rate. A second cardiac intervention was performed in seven patients (18%). Overall functional capacity of shock survivors was good. At final follow-up, 80% of the survivors were completely asymptomatic. One patient had angina pectoris NYHA II, five patients dyspnoea NYHA class II. Exercise stress-test was performed in 24 of the 38 surviving patients, median exercise capacity was 100% (range 55-113%) of the age adjusted predicted value. In unselected patients with cardiogenic shock due to AMI, treatment with acute PTCA resulted in an in-hospital mortality of 36%, low late mortality and good functional capacity in long-term survivors. TIMI flow grade III after acute PTCA in patients with acute myocardial infarction complicated by cardiogenic shock was strongly associated with an improved survival rate whereas the left main coronary artery as culprit lesion was associated with worse outcome.     

Left thoracoabdominal esophagectomy: results from a single specialist center

The left thoracoabdominal approach to esophagectomy is not widely performed, despite offering excellent exposure to tumors of the esophagogastric junction. Criticisms of the approach have focused on historically high rates of mortality, complications, and positive resection margins. Our aim was to determine whether left thoracoabdominal esophagectomy could combine a radical oncological resection with acceptably low mortality and morbidity. A retrospective cohort study of all left thoracoabdominal esophagectomies was performed at a single specialist center over an 11‐year period. Primary outcomes were in‐hospital mortality, complications, resection margin involvement, and lymph node yield; secondary outcomes were 1‐year and 5‐year survival. Two hundred eleven esophagectomies were performed. In‐hospital mortality was 5.7% (12/211). One hundred one subjects (47.9%) had an uncomplicated recovery; 110 subjects (52.1%) developed at least one complication. There were 15 clinically significant anastomotic leaks (7.1%). Twenty‐four subjects (11.4%) required emergency reoperation, the most common indication being anastomotic leakage. Complete tumor excision (R0 resection) was achieved in 151 of 211 cases (71.6%); median lymph node yield was 24. One‐year and 5‐year survival rates were 70% (147/211) and 21% (24/116), respectively. Left thoracoabdominal esophagectomy can combine a radical oncological resection with acceptably low mortality and morbidity.     

Salvage from cardiogenic shock by atherectomy after failed emergency coronary artery angioplasty

In this case report of a patient undergoing angioplasty for cardiogenic shock during acute myocardial infarction, recurrent occlusion resulted in recurrence of shock. Atherectomy reestablished lasting patency and reversed the patient's hemodynamic collapse. Atherectomy deserves further investigation as a means to salvage vessel patency during unsuccessful coronary angioplasty.     

External ventricular support in primary cardiogenic shock

Primary cardiogenic shock is a common condition with a high mortality rate. In this indication, mechanical assist plays an important part and has improved a lot over the last decade. The authors report their experience with the same assist device in patients with primary cardiogenic shock. Nineteen patients (9 dilated cardiomyopathies, 7 myocardial infarctions, 2 myocardities, 1 undetermined) were treated with an external mechanical ventricular assist device (Thoratec, Berkeley, U.S.). Fourteen patients received a biventricular assist and 5 had a uni-left ventricular assist device. Four of the 19 patients were completely weaned off their ventricular assist after 13, 27, 36 and 94 days, respectively. Ten patients underwent transplantation after an average of 43 days (range 8-95 days). Of the 19 patients, 7 had a portable console allowing autonomous ambulation. Five patients died under mechanical assistance (26.9%) and 3 patients died after transplantation. Three patients required temporary haemodialysis; 4 suffered embolic complications; 4 had mediastinal haemorrhages; 4 had bleeding from other sites, and 6 suffered from late tamponnade. Fourteen patients had at least one infectious episode. The authors conclude that, in patients referred for severe primary cardiogenic shock, the implantation of an external biventricular assist is a reliable option, allowing sequential weaning or being a bridge to transplantation in non-dependent patients, providing they are severely selected.     

Percutaneous transluminal coronary angioplasty in patients with cardiogenic shock.

In cardiogenic shock complicating acute myocardial infarction, percutaneous transluminal coronary angioplasty has been reported to significantly improve the modest survival benefits afforded by emergency surgical revascularization and thrombolytic therapy. The records of all patients who underwent angioplasty for acute myocardial infarction complicated by cardiogenic shock were retrospectively reviewed to determine whether coronary angioplasty improves survival. Of the 45 patients, 28 (group 1, 62%) had successful dilation of the infarct-related artery and 17 (group 2, 38%) had unsuccessful angioplasty. The groups were similar in extent of coronary artery disease, infarct location, incidence of multivessel disease and hemodynamic variables. The overall hospital survival rate was 56% (71% in group 1 and 29% in group 2). Group 1 patients had more left main coronary artery disease, and group 2 patients were older and had a higher incidence of prior myocardial infarction. Multivariate analysis showed that the survival advantage in patients with successful angioplasty was statistically significant (p = 0.014) when these factors were taken into account. At a mean follow-up interval of 2.3 years (range 1 month to 5.6 years), there were five deaths (four cardiac and one noncardiac), for a 2.3-year survival rate of 80% in patients surviving to hospital discharge. During the follow-up period, 36% of hospital survivors had repeat hospitalization for cardiac evaluation, 8% had myocardial infarction, 8% had coronary artery bypass surgery and 24% had angina.     

Elective coronary stent implantation in cardiogenic shock complicating acute myocardial infarction: in-hospital and six-month clinical and angiographic results.

Effective treatment of patients with acute myocardial infarction and cardiogenic shock depends on restoring persistent patency of the infarct-related artery. Coronary stenting, reducing abrupt or delayed closure related to dissection and suboptimal result, may improve PTCA results in cardiogenic shock. Eighteen patients (14 males and 4 females, mean age 59 +/- 7 years), referred to catheterization laboratory for acute myocardial infarction and shock, had elective stent implantation during 14 primary and 4 rescue PTCA. Time delay between shock onset and PTCA was 4.1 +/- 3 hr (range, 30 min to 12 hr). The IRA was LAD in seven patients (38%), LCx in two (11%), and RCA in eight (45%). One patient (5.%) had distal LMCA occlusion. Stent deployment was successful in 100% of patients and resulted in TIMI 3 flow in 13 (72%) patients. In 13 (72%) cases, cardiogenic shock gradually resolved and the patients were discharged alive. Five patients (28%) died because of irreversible hemodynamic deterioration without evidence of reinfarction. At 6-month follow-up, all the discharged patients were alive and no patient had reinfarction or recurrent angina. Heart transplant was required in one patient 5 months after stenting because of refractory congestive heart failure. Angiography demonstrated patency of all the coronary arteries treated, with TIMI 3 flow in all patients. Stent restenosis rate was 30%, and target lesion revascularization with CABG or re-PTCA was not required in any case. LV function improved from 39% +/- 15% to 51% +/- 15% (P < 0.01). Elective coronary stenting is an effective treatment for acute myocardial infarction complicated by cardiogenic shock and may improve acute and long-term survival.     

Effect of early revascularisation in cardiogenic shock complicating acute myocardial infarction. A single center experience

BACKGROUND: Five to 10% of patients with acute myocardial infarction develop cardiogenic shock and the majority of these patients are expected to die within the first few weeks. In this study, we review our recent experience in the management of patients with cardiogenic shock complicating MI and examine the effect of early invasive revascularisation on mortality. METHODS: Thirty-six consecutive patients who developed cardiogenic shock less than 48 h after MI were retrospectively evaluated and divided into two treatment groups. One group received early invasive revascularisation (n=24) and the other group had no early invasive revascularisation, but received similar conventional intensive care medical treatment (n=12). RESULTS: Baseline characteristics and hemodynamic variables were similar in both groups. Apart from invasive revascularisation and the use of intra aortic balloon counterpulsation (IABP), treatment strategies did not differ between the two groups. Thirty-day mortality was 21% in the revascularised group of patients and 58% in the non-revascularised group (P<0.05). CONCLUSIONS: Our data support previous observations suggesting that an aggressive treatment strategy including early invasive revascularisation and IABP is associated with improved short and long-term survival in patients with cardiogenic shock. Since early revascularisation appears safe with a considerable treatment benefit, this approach must be considered in patients with short shock duration early after MI.     

Treatment of primary cardiogenic shock by coronary transluminal angioplasty during the acute phase of myocardial infarction

Cardiogenic shock is a very serious complication of acute myocardial infarction because of its prevalence (10-15% of cases) and the associated mortality of 80 to 90 per cent despite the availability of new inotropic drugs and intra-aortic balloon counterpulsation. The aim of this study was to show that revascularisation by percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction complicated by cardiogenic shock completely changes the prognosis. Between April 1985 and February 1988 emergency PTCA was carried out in 25 patients in cardiogenic shock defined as systolic hypotension (less than 80 mmHg) and clinical signs of peripheral or cerebral hypoperfusion. The patients were 21 men and 4 women with an average age of 62.7 +/- 6.7 years. The average delay before hospital admission was 122 mn (range 30 to 240 mn--40%--). External cardiac massage for ventricular arrhythmias or circulatory arrest was required in 56 per cent of cases and 20 per cent underwent balloon angioplasty during resuscitation. Five patients died in the catheter laboratory and 7 others during the hospital period. Thirteen patients (53%) survived and were discharged home. There have been no late deaths during the 24 month follow-up period; 46 per cent asymptomatic, 38 per cent in Class II and 16 per cent in Class III. Survival was better in the last 15 patients undergoing emergency angioplasty: 66 per cent compared with only 30 per cent in the first 10 patients in whom the decision to perform PTCA was then late, after failure of thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary angioplasty for cardiogenic shock complicating acute myocardial infarction.

To evaluate the role of primary percutaneous transluminal coronary angioplasty in cardiogenic shock, 53 patients admitted with the diagnosis of acute myocardial infarction and cardiogenic shock were studied. Thirty-five (66.0%) patients received intravenous thrombolytic therapy (streptokinase 15 lac units) and 18 (34.0%) underwent primary percutaneous transluminal coronary angioplasty. There was no significant difference in the mean age, risk factor profile, presence of prior myocardial infarction, site of myocardial infarction and cardiac enzyme levels at presentation between the two groups. More male patients were present in the group undergoing primary percutaneous transluminal coronary angioplasty (94.44% vs 68.57%; p = 0.04). The time delay between the onset of symptoms and presentation to the hospital did not differ significantly between the two groups (318.9 vs 320.0 minutes; p = NS). In the primary percutaneous transluminal coronary angioplasty group, 17 patients had a single infarct-related artery and one had both left anterior descending and right coronary artery occlusion. Thus in 18 patients, 19 vessels were attempted. Angiographic success (< 50% residual stenosis) was achieved in 15 (78.94%) vessels of which TIMI III flow was achieved in 10 (52.63%) vessels and TIMI II flow in five (26.31%). Intra-aortic balloon pump was needed in five (27.77%) patients undergoing coronary angioplasty. In-hospital mortality was 27.77 percent in patients undergoing primary percutaneous transluminal coronary angioplasty and 57.14 percent in patients receiving intravenous thrombolytic therapy (p = 0.04). In the thrombolytic therapy group, mortality was higher (85.91%) in patients presenting six hours or later after the onset of symptoms as compared to those presenting in less than six hours of the onset of symptoms (50%). In primary percutaneous transluminal coronary angioplasty group, mortality was 21.42 percent in patients with successful and 50 percent in patients with failed angioplasty. Thus, in patients with acute myocardial infarction and cardiogenic shock, an aggressive invasive strategy with primary percutaneous transluminal coronary angioplasty, as compared to intravenous thrombolytic therapy, is helpful in reducing in-hospital mortality.     

Success rate and incidence of restenosis following coronary excimer laser angioplasty: results of a single center experience

The initial single center experience of percutaneous coronary excimer laser angioplasty is described for the first three series of 147 patients. Sixty patients were treated with a prototype 1.4-mm laser catheter, 40 patients with improved transmission devices, and the third series of 47 patients with an increased pulse width of the laser system allowing improved energy transmission. In 17 patients (12%) laser angioplasty could not be initiated due to inability to cross the lesion with the guidewire or to place the catheter coaxially within the vessel. In 32 patients (58%) of series 1, 11 patients (31%) of series 2, and 17 patients (43%) of series 3, additional balloon dilatation following laser treatment was necessary due to vessel closure (24%) or due to an insufficient angiographic result (35%). There was one death in series 1 (2%) and 2 (3%) each, one perforation in series 2 (3%), two transmural myocardial infarctions in series 1 (4%), and one myocardial infarction in series 2 (3%). During the 6-month follow-up period one patient in series 2 (2%), and one patient in series 3 (3%) died. Angiographic restenosis was found in 22, 12, and 11 patients of series 1 (40%), 2 (34%), and 3 (27%), respectively. No patient developed a transmural myocardial infarction. Thus, percutaneous coronary excimer laser angioplasty can be performed as a safe and feasible procedure in patients with coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Temporary catheter infections in hemodialysis patients: results from a single center in Turkey

In this study, we aimed to determine the frequencies of catheter exit-site infection (CESI), catheter-related bloodstream infection (CR-BSI) and catheter colonization (CC); causative microorganisms; and resistance patterns in patients with temporary hemodialysis catheters. From March 1999 to March 2000, 67 hemodialysis patients (38 males, 29 females; median age: 52, range: 17-84) were evaluated. The CDC criteria were used to diagnose CESI, CR-BSI and CC. The tips of catheters were cultured by Maki's method. At the same time, two different blood cultures, one from peripheral vein and the other through the catheter lumen were drawn. Swab cultures from the catheter exit sites were also performed. The isolation and identification of bacteria were performed by conventional methods and the susceptibility testing by the Kirby-Bauer method. CESI, CR-BSI and CC were found in, respectively, 20 (29.8%), 16 (23.8%) and 11 (16.4%) patients. The etiologic agents in CR-BSI were as follows: Staphylococcus aureus (5), coagulase-negative staphylococci (2), Enterococcus sp. (1), Escherichia coli (1), Acinetobacter sp. (1) and Proteus sp. (1). Methicillin-resistant coagulase-negative staphylococci and methicillin-resistant S. aureus were found in proportions of 45.5% and 63.6% in CESI and CR-BSI+CC. The only risk factor for the development of CR-BSI and CC was intravenous drug use. In our center, the majority of CESI, CR-BSI and CC were due to staphylococci and there was a high rate of methicillin resistance.     

Resuscitation from cardiogenic shock by direct angioplasty and 23-hour balloon inflation using a coronary perfusion balloon

Direct angioplasty is an accepted treatment for acute myocardial infarction and has resulted in stabilization and improvement in the clinical, electrocardiographic, and hemodynamic consequences of acute myocardial infarction. This case demonstrates the effectiveness of coronary perfusion as a method of resuscitation during cardiogenic shock and asystole in a patient with massive acute diaphragmatic and right ventricular infarction. Utilization of prolonged balloon inflation in this case obviated the need for emergency coronary bypass surgery and provided the patient with remarkable and almost complete recovery of left and right ventricular function.     

Multicenter registry of angioplasty therapy of cardiogenic shock: initial and long-term survival

This retrospective multicenter study reviews the role of acute percutaneous transluminal coronary angioplasty in the treatment of cardiogenic shock complicating acute myocardial infarction to determine whether early reperfusion affects in-hospital and long-term survival. From 1982 to 1985, 69 patients were treated with emergency angioplasty to attempt reperfusion of the infarct-related artery. Balloon angioplasty was unsuccessful in 20 patients (group 1) and successful in 49 patients (group 2). Initial clinical and angiographic findings in the groups with unsuccessful and successful angioplasty were similar with respect to age (60.5 +/- 2.3 versus 57 +/- 1.8 years), infarct location (65% versus 65% anterior) and gender (65% versus 67% male). Hemodynamic variables in the two groups, including systolic blood pressure (68 +/- 4.3 versus 73 +/- 1.6 mm Hg), left ventricular end-diastolic pressure (24.4 +/- 2.4 versus 27 +/- 1.0 mm Hg) and initial ejection fraction (28.5 +/- 4% versus 32 +/- 2%), were also similar. Twenty-nine patients received thrombolytic therapy with streptokinase; the overall rate of reperfusion was 34%. Group 1 patients had a short-term survival rate of 20%, compared with 69% in group 2 patients (p less than 0.0005). Thirty-eight patients survived the hospital period and were followed up for 24 to 54 months (mean 32.5 +/- 2.4). Five patients (all in group 2) died during follow-up. The long-term incidence rate of congestive heart failure was 19%, arrhythmia 21%, need for repeat angioplasty 17% and coronary artery bypass grafting 26%. Twenty-four month survival was significantly better in group 2 patients (54%) versus group 1 patients (11%, p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)