A randomized study of prourokinase during primary percutaneous coronary intervention in acute ST‐segment elevation myocardial infarction

Objectives

To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions (PCI) in patients with acute ST‐segment elevation myocardial infarction (STEMI).

Methods

Acute STEMI patients underwent primary PCI were randomly divided into two groups: intracoronary prourokinase (IP) group (n = 118) and control group (n = 112). During primary PCI, prourokinase or saline were injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and MACE occurred in the 6‐months follow up were recorded.

Results

No significant differences were observed between two groups with respect to baseline demographic, clinical, and angiographic characteristics (P > 0.05). In IP group, more patients had complete ST segment resolution (>70%) compared with control group (P < 0.05). Patients in IP group showed lower levels of serum CK, CK‐MB and TnI, and a much higher myocardial blood flow (MBF) than those in control group (P < 0.05). No significant differences of TIMI major or minor bleeding complications were observed between the two groups (P > 0.05). At 6‐months follow‐up, there was a trend that patients in the IP group had a less chance to have MACE, though it was not statistically different (8.5% vs 12.5%, P > 0.05).

Conclusions

Intracoronary administration of prourokinase via balloon catheter during primary PCI effectively improved myocardial perfusion in STEMI patients.     

The ratio of contrast volume to glomerular filtration rate predicts outcomes after percutaneous coronary intervention for ST‐segment elevation acute myocardial infarction

Objective: To assess the value of the ratio between contrast medium volume and glomerular filtration rate (CMGFRr) for prediction of development of contrast‐induced nephropathy (CIN) and mortality in patients with ST‐segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Background: Renal function is a strong predictor of outcome in patients with STEMI. CIN may complicate the course of primary PCI in these patients. Methods: The study population included all 871 consecutive patients with STEMI without cardiogenic shock who underwent primary PCI at our center from January 1, 2001, to October 30, 2006. CIN was defined as an absolute increase in serum creatinine > 0.5 mg/dL or a relative increase >25% within 48 hr after PCI. Results: In‐hospital CIN developed in 72 (8.3%) patients. On linear regression analysis, the following variables were independently associated with CIN: male sex (odds ratio [OR] = 0.42, 95% confidence interval [CI], 0.18–0.97, P = 0.04), GFR < 60 (OR = 3.6, 95% CI, 2.79–4.78, P < 0.0001), multivessel coronary artery disease (OR = 1.67, 95% CI, 1.08–2.58, P = 0.02), CMGFRr (OR = 1.53, 95% CI, 1.01–2.31, P = 0.04, for upper tertile vs. lower two tertiles), and Killip class > 1 (OR = 1.35, 95% CI, 1.03–1.76, P = 0.03). CMGFRr > 3.7 was a strong independent predictor of CIN (OR = 3.87, 95% CI, 1.72–8.68, P = 0.001). Twenty‐six (2.9%) patients died at 1 month after PCI. The following variables were independently predictive of 1‐month mortality: CMGFRr > 3.7 (OR = 3.3, 95% CI, 1.22–9.04, P = 0.018) and multivessel coronary artery disease (OR = 2.3, 95% CI, 1.28–4.07, P = 0.005). Conclusion: The contrast medium‐to‐GFR ratio is a strong predictor of CIN and of 1‐month mortality in patients undergoing primary PCI for STEMI. © 2010 Wiley‐Liss, Inc.     

Thrombus aspiration alone during primary percutanous coronary intervention as definitive treatment in acute ST‐elevation myocardial infarction

Background : In some patients with ST‐segment elevation myocardial infarction (STEMI) who underwent primary percutanous coronary intervention (pPCI) with thrombus aspiration, residual stenosis after thrombus aspiration is non‐significant and additional balloon dilatation or stent placement may be unnecessary. We investigated the angiographic, procedural, and clinical outcomes of these patients in our single center pPCI‐database. In addition, to gain insight in the pathological mechanisms of coronary thrombosis in these patients, we established the histopathological characteristics and age of the aspirated material. Methods : This study consists of STEMI patients who underwent pPCI with thrombus aspiration alone in our institution. Thrombus material was collected and processed and the sections were analyzed for the presence of fresh (<1 day) or older thrombus (>1 day) and plaque components. One year clinical follow‐up was obtained and vital status was assessed up to March 2010. Results : We identified 16 STEMI patients who underwent thrombus aspiration alone as the definitive treatment during pPCI. Acceptable flow with minimal non‐significant residual stenosis immediately after thrombus aspiration was present in 14 patients (88%). In four patients (25%) repeat angiography was performed after several days and disappearance of the residual thrombus could be confirmed in three patients. During follow‐up, repeat target lesion revascularization was performed in one patient at 53 days. No recurrent myocardial infarction was observed. Two patients died 1,166 and 1,228 days after the index‐event from non‐cardiac causes. Conclusions : In selected STEMI patients undergoing pPCI, thrombus aspiration alone is feasible and safe on the short‐term and there appears to be no high risk of recurrent ischemic events during follow‐up. Our results suggest that additional balloon inflation or stent implantation may be unnecessary in selected patients, when there is no significant residual stenosis after thrombus aspiration. © 2011 Wiley Periodicals, Inc.     

ST‐segment elevation on intracoronary electrocardiogram after percutaneous coronary intervention is associated with worse outcome in patients with non‐ST‐segment elevation myocardial infarction

The AMPLATZER^TM Vascular Plug 4 (AVP4) is a self‐expandable, replaceable occluder made of Nitinol wire mesh, which allows the safe and effective interventional occlusion of medium size vessels. This report describes an infant diagnosed with pulmonary atresia, ventricular septal defect, and multifocal collateral lung perfusion through four major aortopulmonary collateral arteries (MAPCAs). A central aorto‐pulmonary shunt was performed at 4 months of age. Because of postoperative pulmonary hyperperfusion, one of the MAPCAs was closed interventionally using a 5 mm AVP4. This MAPCA originated from the descending aorta (DAO) near the fifth thoracic vertebra and ran behind the esophagus to the lower lobe of the right lung. The MAPCA was closed near its origin from the DAO. Four weeks later, the patient presented with severe gastrointestinal bleeding, caused by perforation of the AVP4 into the esophagus. The occluder was extracted surgically, the MAPCA was clipped and the esophageal injury was sutured. To date, there have been no reports describing esophageal perforation due to an AVP4. The perforation in this patient may have been due to implantation of the AVP4 near the aorta in a MAPCA segment located directly in front of the spine and behind the esophagus. Another possible factor may have been the requirement for a gastrointestinal feeding tube. Although the occluder is soft and flexible, the spindle‐shaped ends may cause trauma if they are located close to other structures. © 2016 Wiley Periodicals, Inc.     

Histopathology of aspirated thrombus and its association with ST‐segment recovery in patients undergoing primary percutaneous coronary intervention with routine thrombus aspiration

Background : In patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with thrombus aspiration, the histopathology of aspirated thrombus was previously related to long‐term mortality. In this study, we sought to investigate the association between histopathology of aspirated thrombus and ST‐segment recovery, a marker of microvascular dysfunction, immediately at the end of the PCI procedure. Methods : We included 892 STEMI patients who underwent primary PCI with routine thrombus aspiration and for whom combined data on histopathology of aspirated thrombus and ST‐segment recovery were available. Patients were categorized according to histopathology of aspirated thrombus: fresh only (<1 day), older (>1 day), or no material aspirated. ST‐segment recovery was defined as incomplete if <50%. Results : Incomplete ST‐segment recovery occurred in 134 of 363 patients (37%) with fresh thrombus, in 104 of 238 patients (44%) with older thrombus, and in 142 of 291 patients (49%) with no material. Unadjusted odds ratios for incomplete ST‐segment recovery of patients with older thrombus and no material, when compared with patients with fresh thrombus, were 1.33 (95% CI, 0.95–1.85; P = 0.097) and 1.63 (95% CI 1.19–2.23; P = 0.002), respectively. Both associations were unchanged after multivariable adjustment for clinical predictors of ST‐segment recovery. ST‐segment recovery was a strong predictor of long‐term mortality, independent of the histopathology of aspirated thrombus. Conclusions : This study shows that ST‐segment recovery immediately at the end of the PCI procedure was a significant prognosticator, independent of the histopathology of aspirated thrombus. We found that the histopathology of aspirated thrombus (fresh, older, no material) was associated with ST‐segment recovery in STEMI patients undergoing primary PCI with thrombus aspiration. © 2010 Wiley‐Liss, Inc.     

A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals

BACKGROUND:

Historically, access to primary percutaneous coronary intervention (PCI) for the treatment of patients with ST segment elevation myocardial infarction (STEMI) has been limited in Canada. Recent studies have identified innovative strategies to improve timely access and reduce reperfusion time. Accordingly, the contemporary use of primary PCI treatment in Canada was ascertained.

METHODS:

A cross-sectional survey of all 38 Canadian hospitals that were capable of performing PCI procedures was conducted from June 2007 to November 2007. The survey focused on the practice of primary PCI for patients with STEMI and whether the hospitals had implemented internal strategies to reduce ‘door-to-balloon’ times. Analyses were performed at the level of geographical regions.

RESULTS:

Overall, 71% of PCI hospitals (27 of 38) provided around-the-clock primary PCI for patients with STEMI, but the proportion of PCI hospitals offering this service varied widely, from 33% to 100% across regions. All Canadian PCI hospitals provided around-the-clock rescue PCI treatment to STEMI patients who had failed fibrinolytic therapy. In terms of strategies that are associated with reduced reperfusion time, it was observed that only 42% of PCI hospitals (16 of 38) provided feedback on door-to-balloon time to the emergency department and to the cardiac catheterization laboratories within one week of the primary PCI procedure. Overall, 24% of the hospitals had not adopted any of the four identified strategies to improve door-to-balloon time.

CONCLUSION:

Although the majority of Canadian hospitals with PCI capability provide around-the-clock primary PCI for patients with STEMI, significant variations in this practice exist across the country. Canadian PCI hospitals have not consistently adopted strategies that are associated with improved door-to-balloon time.     

急性ST段抬高性心肌梗死直接经皮穿刺冠状动脉成形术后早期ST段变化的意义

目的探讨急性ST段抬高性心肌梗死(STEMI)直接经皮穿刺冠状动脉成形术(PCI)术后梗死相关动脉(IRA)完全开通、前向血流恢复后,早期ST段变化的临床意义。方法回顾性分析2001-01~12北京朝阳医院心脏中心收治的216例直接PCI后、IRA完全开通、前向血流恢复正常病人的临床、冠脉造影和心电图资料。直接PCI术后,ST段抬高指数≥50%的病人41例,为病例组。从其余175例ST段抬高指数<50%的病人中随机抽取50例,为对照组。结果两组病人的ST段抬高指数、Q波计数、室壁运动积分和平均肌酸激酶值差异有显著性意义(P<0·05);术后2周,ST段早期恢复较ST段持续抬高病人的室壁运动改善,左室射血分数(LVEF)、心排指数(CI)、每搏指数(SVI)增加(P<0·05)。ST段早期恢复合并心功能不全的病人,术后2周室壁运动增强,LVEF、CI、SVI增加(P<0·05),左室舒张末容积、左室收缩末容积减少(P<0·01)。结论STEMI直接PCI后IRA完全开通、前向血流恢复正常而ST段持续抬高病人的梗死范围扩大,左室舒缩功能不全严重,可能与心肌组织没有有效地恢复血流灌注或无复流有关。     

Primary percutaneous coronary intervention for inferior ST‐segment elevation myocardial infarction in a patient supported by the HeartWare left ventricular assist device

A 63‐year‐old man with an ischaemic cardiomyopathy, supported by the HeartWare left ventricular assist device (LVAD), presented with ventricular tachycardia and inferior ST‐elevation myocardial infarction (STEMI) with associated acute right ventricular (RV) dysfunction. He underwent primary percutaneous coronary intervention with balloon angioplasty and placement of three drug‐eluting stents in the proximal‐to‐mid right coronary artery. Post‐procedure, ventricular arrhythmias abated, RV systolic dysfunction resolved and RV size normalised. Percutaneous coronary intervention (PCI) facilitated by the use of miniaturised percutaneous LVAD has become an increasingly available treatment option for high‐risk patients. PCI in patients on established full mechanical circulatory support is not a common occurrence. Indeed, to our knowledge, this is the first case of primary percutaneous coronary intervention on an LVAD‐supported heart reported in the medical literature. The case raises several specific issues that are of peculiar interest to clinicians involved in the care of patients supported by mechanical assist devices who experience an acute coronary syndrome requiring emergent revascularisation.     

Clinical impact of complete atrioventricular block in patients with ST‐segment elevation myocardial infarction

Complete atrioventricular block (CAVB) is a common complication of ST‐segment elevation myocardial infarction (STEMI). Although STEMI patients complicated with CAVB had a higher mortality in the thrombolytic era, little is known about the impact of CAVB on STEMI patients who underwent primary percutaneous coronary intervention (PCI). The study aimed at evaluating the clinical impact of CAVB on STEMI patients in the primary PCI era. We consecutively enrolled 1295 STEMI patients undergoing primary PCI within 24 hours from onset. Patients were divided into two groups according to the infarct location: anterior STEMI (n = 640) and nonanterior STEMI (n = 655). The outcomes were all‐cause death and major adverse cardiocerebrovascular events (MACCE) with a median follow‐up period of 3.8 (1.7–6.6) years. Eighty‐one patients (6.3%) developed CAVB. The incidence of CAVB was lower in anterior STEMI patients than in nonanterior STEMI (1.7% vs 10.7%, p < .05). Anterior STEMI patients with CAVB had a higher incidence of all‐cause deaths (82% vs 20%, p < .05) and MACCE (82% vs 25%, p < .05) than those without CAVB. Although higher incidence of all‐cause deaths was found more in nonanterior STEMI patients with CAVB compared with those without CAVB (30% vs 18%, p < .05), there was no significant difference in the incidence of MACCE (24% vs 19%). Multivariate analysis showed that CAVB was an independent predictor for all‐cause mortality and MACCE in anterior STEMI patients, but not in nonanterior STEMI. CAVB is rare in anterior STEMI patients, but remains a poor prognostic complication even in the primary PCI era.