impact of transradial versus transfemoral approach for percutaneous coronary intervention on the outcome of patients presenting with acute coronary syndrome

Background: The transfemoral approach [TFA] has been until presently the main-stay for arterial access PCI in the setting of acute STEMI, while the transradial approach [TRA] is gaining ground in elective as well as primary procedures

Objectives: to assess the impact of transradial versus transfemoral approach for PCI on the outcome of patients presenting with acute coronary syndrome

Patients and Methods: prospective study was conducted on 100 patients presenting to Ain Shams University Hospitals Coronary Care Unit [CCU] with recent onset acute coronary syndrome [whether unstable angina [UA]/non-ST-segment-elevation MI [NSTEMI] or ST-segment-elevation MI [STEMI]] undergoing revascularization via percutaneous coronary intervention [PCI]. Patients were randomized into 2 equal groups, for the first group PCI was performed via TFA while for the second group via TRA

Results: Our study found that, with TRA we get less bleeding, less local vascular complications [8 [16%] vs 2 [4%], p=0.045] and less amount of dye used [169.60 +/- 21.28 versus 187.00 +/- 37.65 ml, p=0.006] without significant increase in fluoroscopy time [10.86 +/-4.88 versus 9.76 +/-4.74 mins, p=0.256] or radiation exposure. Although there was no significant difference in mortality and morbidity, TRA offers the patient a more simple procedure with less hospital stay [3.4 +/-0.948 versus 3.86 +/-0.808 days, p<0.01]

Conclusion: Radial artery access is a safe and effective approach for management of ACS. If performed by experienced operators, TRA should be the standard access in managing ACS specifically in STEMI

Study of the fate of detectable left atrial thrombi at repeated tranesophagealechocardiography in patients with mitral stenosis

Previous studies did not encourage balloon mitral valvuloplasty [BMV] when left atrial and /or LAA thrombi are present. Patients with LA and/or LAA thrombi are considered at high risk for thromboembolic events. So it is considered a major cause of morbidity and mortality in patients with mitral stnosis. To investigate the fate and stability of LA and/or LAA thrombi under the effect of oral anticoagulation this study included thirty patients with mitral stenosis having LA and/or LAA thrombi detected by TEE. They were subjected to full anticoagulation therapy controlled by INR of 2-3. Repeated TEE were done three and six months later. According to the results of this study the patients were grouped into two main groups: Group 1: included sixteen patients who had dissolved LA or LAA thrombi after anticoagulation therapy. It represented [53.33%] of all cases included in this study. In thirteen patients out of all the total sixteen patients representing group I, the thrombi were dissolved after three months therapy as they had clear LA and LAA in the second TEE study. They represented [81.25%] of group I and [43.33%] of all patients included in this study. In three patients the thrombi were dissolved after six month anticoagulation therapy, they represented [18.75%] of group I and [10%] of the whole patients included in this study. Group II: which included eleven patients [36.66%] all of them had non dissolved thrombi in LA and LAA in spite of six months anticoagulation therapy, three patients were excluded from the study. In conclusion: Complete resolution of LA and/or LAA thrombi occurs in a considerable number of patients [53.33%]. Age of the patients, size of the left atrium and size of LAA or LAA thrombi are considered the only significant factors influencing thrombus resolution. No other clinical or echocardiographic parameters could influence thrombus resolution. Majority of LA andyor LAA thrombi dissolve in the first three months with less incidence of resolution in the next months

IV Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention

The rapid progress in the field of interventional cardiology in the last few years necessitates a continuous search for the most safe and effective methods to gain an optimum results, either equipments or drugs. to examine the use of enoxaparin as an anticoagulant in elective PCI, and compare it with unfractionated heparin regarding the acute procedural complications and the immediate 24-hour post-PCI events. The study was conducted on 84 patients who were classified independently into 2 groups. 50 patients represent group [A], received IV single bolus of enoxaparin in a dose of 0.5mg/kg at the start of the procedure and 34 patients represent group [B], received the usual traditional dose of unfractionated heparin [10000-15000 units].All patients were prepared by clopidogrel or ticlopidin before PCI in addition to aspirin 150 mg daily.Follow up was done for all patients during the immediate 24 hours after PCI for death, myocardial infarction, myocardial ischemia requiring urget coronary intervention and cerobrovascular stroke. There was no statistical significant difference between the two groups regarding the type of vessels treated or number of stents placed. None of the patients of both groups experienced any of the following complications during the procedure or 24 hours after: major bleeding, myocardial infarction, myocardial ischemia requiring urgent surgical or repeat percutaneous coronary revascularization or death. The major difference between the two groups was the immediate sheath removal in the enoxaparin group, without sheath site complication [minor haematoma] which was observed in 9% of the UFH group. Angiographic complications were coronary artery dissection [in one patient in group A [2%] and 3 patients in group B [9%]] and acute closure of the culprit vessel [occurred in one patient in group A [2%] and none in group B. The results were quite encouraging, with no statistical differences between the two arms of the study regarding the acute complications and the clinical outcome. The use of enoxaparin in this reduced dose is feasible in elective PCI with adequate level of anticoagulation without need for monitoring its anticoagulant effect. The early sheath removal in group A necessitates further studies to assess its impact on the duration of hospital stay and the possibility of early discharge of the patients

Relation of papillary muscle traction to autonomic nervous system dysfunction as evaluated by head-up-tilt-test in mitral valve prolapse

Mitral valve prolapse [MVP] is one of the commonest valvular abnormalities and is characterized by systolic superior leaflet displacement. This results in abnormal tension on the papillary muscles which may lead to, or is associated with alteration in the autonomic functions. The aim of this work is to detect and assess papillary muscle traction [PMT] in patients with idiopathic MVP in a trial to correlate it with any autonomic dysfunction as evaluated by head-up-tilt test [HUTT]. Thirty symptomatic MVP patients and a control group of 15 persons [cardiologically free], aged 15-35 years, were enrolled in the study. They were all thoroughly evaluated clinically, radiologically, electrocardiographically and by ECHO-Doppler. Patients with secondary causes for MVP were excluded. PMT was measured by 2-dimentional ECHO in all patients and controls who were subsequently subjected to HUTT. The obtained results showed both groups to be comparable. The MVP patients showed mitral regurgitation [MR] in 13 cases [43.3%]. Seventeen patients [56.7%] had MVP with no MR. PMT was greater in patients than in controls [5.7+/-3 versus 0.85+/-0.7mm], p value <0.001. Leaflet displacement as well as PMT index were also significantly higher in patients than in controls [p<0.001]. HUTT was positive [provoking syncope or presyncope associated with hypotension, bradycardia, or both] in six MVP patients [20%] and in none of the controls. HUTT appeared to be predictable by four of the studied parameters, namely, leaflet displacement, PMT, traction index and MR. Ten patients had PMT >/=6mm and 20 patients had it <6mm as shown by ECHO. Six out of the 10 patients who had PMT of >/=6mm had abnormal response to HUTT, while none of the 20 patients with PMT <6mm, and none of the controls had an abnormal response to HUTT. A statistically derived predictor value of >/=6mm PMT should be considered as an indicator to perform HUTT to MVP patients in a trial to detect asymptomatic patients prone to syncope. We recommend that PMT be a part of routine ECHO examination of MVP patients. Those with MR or PMT of 6 mm or more should be evaluated by HUTT for the occurrence of syncope or other manifestations of autonomic dysfunction aiming at avoidance or decrease of morbidity in this group of patients