Risk-scoring model to predict one-year major adverse cardiac events after percutaneous coronary intervention

Background: The aim of the present study was to develop a scoring system for predicting 1-year major adverse cardiac events [MACE], including mortality, target vessel or target lesion revascularization, coronary artery bypass graft surgery, and non-fatal myocardial infarction after percutaneous coronary intervention [PCI]

Methods: The data were extracted from a single center PCI registry. The score was created based on the clinical, procedural, and laboratory characteristics of 8206 patients who underwent PCI between April 2004 and October 2009. Consecutive patients undergoing PCI between November 2009 and February 2011 [n= 2875] were included as a validation data set

Results: Diabetes mellitus, increase in the creatinine level, decrease in the left ventricular ejection fraction, presentation with the acute coronary syndrome, number of diseased vessels, primary PCI, PCI on the left anterior descending artery and saphenous vein graft, and stent type and diameter were identified as the predictors of the outcome and used to develop the score [R[²] = 0.795]. The models had adequate goodness of fit [Hosmer-Lemeshow statistic; p value = 0.601] and acceptable ability of discrimination [c-statistics = 0.63]. The score categorized the individual patients as low-, moderate-, and high-risk for the occurrence of MACE. The validation of the model indicated a good agreement between the observed and expected risks

Conclusion: An individual risk-scoring system based on both clinical and procedural variables can be used conveniently to predict 1-year MACE after PCI. Risk classification based on this score can assist physicians in decision-making and postprocedural health care

Mid-term follow-up of drug-eluting stenting for in-stent restenosis: bare-metal stents versus drug-eluting stents

Despite major advances in percutaneous coronary intervention [PCI], in-stent restenosis [ISR] remains a therapeutic challenge. We sought to compare the mid-term clinical outcomes after treatment with repeat drug-eluting stent [DES] implantation [[DES sandwich] technique] with DES placement in the bare-metal stent [DES-in-BMS] in a [real world] setting. We retrospectively identified and analyzed clinical and angiographic data on 194 patients previously treated with the DES who underwent repeat PCI for ISR with a DES or a BMS. ISR was defined, by visual assessment, as a luminal stenosis greater than 50% within the stent or within 5 mm of its edges. We recorded the occurrence of major adverse cardiac events [MACE], defined as cardiac death, non-fatal myocardial infarction, and the need for target vessel revascularization [TVR]. Of the 194 study participants, 130 were men [67.0%] and the mean +/- SD of age was 5 7.0 +/- 10.4 years, ranging from 37 to 80 years. In-hospital events [death and Q-wave myocardial infarction] occurred at a similar frequency in both groups. Outcomes at twelve months were also similar between the groups with cumulative clinical MACE at one-year follow-up of 9.6% and 11.3% in the DES-in-BMS and the DES-in-DES groups, respectively [p value = 0.702]. Although not significant, there was a trend toward a higher TVR rate in the intra-DES ISR group as compared to the intra-BMS ISR group [0.9% BMS vs. 5.2% DES; pvalue = 0.16]. Our study suggests that the outcome of the patients presenting with ISR did not seem to be different between the two groups of DES-in-DES and DES-in-BMS at one-year follow-up, except for a trend toward more frequent TVR in the DES-in-DES group. Repeat DES implantation for DES restenosis could be feasible and safe with a relatively low incidence of MACE at mid-term follow-up

Impact of side-branch flow in coronary bifurcation intervention

The optimal strategy in percutaneous coronary intervention [PCI] for coronary artery bifurcation lesions has yet to be agreed upon. We compared a strategy for stenting the main vessel to provide a complete perfusion flow in the side branch, namely thrombolysis in myocardial infarction [TIMI] - III, with a strategy for intervention in both the main vessel and the side branch [MV + SB]. This retrospective study utilized data on 258 consecutive patients with bifurcation lesions scheduled for PCI at Tehran Heart Center between March 2003 and March 2008. The patients were followed up for 12 months, and the primary end point was a major adverse cardiac event [MACE], i.e. cardiac death, myocardial infarction, target-vessel revascularization, and target-lesion revascularization during the 12-month follow-up period. A total of 52.7% of the patients underwent PCI on the main vessel of the bifurcation lesions [MV group] and 47.3% with a similar lesion type received a percutaneous intervention on both the main vessel and the side branch [MV + SB group]. The total rate of MACE during the follow-up was 4.3% [11 patients]; the rate was not significantly different between the MV and MV + SB groups [3.7% vs. 4.9%, respectively; p value = 0.622]. There was no association between MACE in performing a simple or complex interventional strategy to treat coronary bifurcation lesions when drawing the TIMI- III flow as a goal in a simple technique.

Effectiveness of two-year versus one-year use of dual antiplatelet therapy in reducing the risk of very late stent thrombosis after drug-eluting stent implantation

Impact of 12 months' versus 24 months' use of dual antiplatelet therapy on the prevalence of stent thrombosis in patients undergoing percutaneous coronary intervention [PCI] with the drug-eluting stent [DES] is not clear. As a result, duration of dual antiplatelet therapy is still under debate among interventionists. From March 2007 until August 2008, all consecutive patients with successful PCI who received at least one DES and were treated with dual antiplatelet therapy [Clopidogrel + Aspirin] were included. All the patients were followed up for more than 24 months [mean = 35.27 +/- 6.91 months] and surveyed for very late stent thrombosis and major cardiovascular events. From 961 patients eligible for the study, 399 [42%] discontinued Clopidogrel after 12 months and 562 [58%] continued Clopidogrel for 24 months. The clinical and procedural variables were compared between the two groups. In the 12 months' use group, two cases of definite thrombosis occurred at 18 and 13 months post PCI. In the 24 months' use group, 2 cases of definite thrombosis occurred at 14 and 28 months post PCI, one of them with stenting in a bifurcation lesion. Five cases of probable stent thrombosis were detected at 21, 28, 32, 33, and 34 months after the procedure. It is of note that amongst the 10 cases of stent thrombosis, only 1[10%] thrombosis occurred when the patient was on Clopidogrel and Aspirin and all the other 9 [90%] cases of thrombosis appeared after the discontinuation of the dual antiplatelet therapy. Extended use of dual antiplatelet therapy [for more than 12 months] was not significantly more effective than Aspirin monotherapy in reducing the risk of myocardial infarction or stent thrombosis, death from cardiac cause, and stroke

One-year clinical outcomes of ultra long apollo polymer-based paclitaxel-eluting stents in patients with complex, long coronary artery lesions

For all the wealth of research comparing the efficacy of the different types of the drug-eluting stent [DES] such as sirolimus-, paclitaxel-, and zotarolimus-eluting stents, there is still a dearth of data on the different brands of each DES type. We aimed to investigate the one-year clinical outcomes, including major adverse cardiac events [MACE], of the use of the ultra long Apollo paclitaxel-eluting stent in patients with long atherosclerotic coronary artery lesions. According to a retrospective review of the Tehran Heart Center Registry of Interventional Cardiology, a single-center nonrandomized computerized data registry in which all adult patients who undergo single or multi-vessel percutaneous coronary intervention [PCI] are enrolled without any specific exclusion criteria, the mixed use of long Apollo paclitaxel-eluting stents and other types of the DES as well as myocardial infarction within forty-eight hours prior to the procedure was excluded. In total, 122 patients were enrolled in the study, and their baseline clinical, angiographic, and procedural characteristics were obtained. In addition, the patients' follow-up data and, most importantly, MACE during a one-year period after intervention were recorded. The mean follow-up duration was 14.1 +/- 3.8 months. The one-year clinical follow-up data were obtained in 95.9% of all the patients. The incidence of MACE was 5.7% during the entire study period. There was 1 death, which occurred during the initial days after PCI. The incidence of non-fatal myocardial infarction was 2.5% [3 cases], including one patient who underwent target vessel revascularization seven months later. Also, 3 patients with single-vessel disease and in-stent restenosis underwent coronary artery bypass grafting between five to ten months later. Our results showed that the Apollo paclitaxel-eluting stent might be regarded as a safe and effective treatment for long coronary lesions

Outcomes of percutaneous coronary intervention on saphenous vein graft and native coronary vessels

The optimal target for revascularization in patients with history of coronary artery bypass graft surgery [CABG] is unclear. This study was designed to compare the outcome of percutaneous coronary intervention [PCI] on saphenous vein grafts [SVG] and that on native vessels in patients with previous CABG in terms of major adverse cardiac events [MACE]. The study drew upon data on consecutive patients hospitalized for PCI and MACE rate during a nine-month follow- up period. The patients were divided according to the target vessel for PCI into two groups: SVG and native vessel. Between 2003 and 2007, 226 patients underwent PCI 6.57 +/- 4.55 years after CABG. Their mean age was 59.52 +/- 9.38 years, and 176 [77.9%] were male. PCI was performed on the SVG in 63 [27.9%] patients and on the native coronary artery in the rest. During a nine-month follow-up period, 9 [4%] patients suffered MACE; the prevalence of MACE was not significantly different between the SVG group [4.8%] and the native vessel group [4.9%], [p value = 0.999]. PCI on grafted and native vessels did not affect MACE in patients undergoing PCI after CABG

Return to work following cardiac rehabilitation in patients undergoing cardiac procedures with an approach to patient's viewpoints and attitude

To estimate the rate of return to work [RTW] after cardiac rehabilitation and determine the relationship between RTW and clinical and socio-demographic factors with an approach to patient's attitude. Prospective follow-up study. Tehran Heart Center, Iran. Two hundred and forty six consecutive patients undergoing different types of cardiac procedures between May and September 2007 were studied. A checklist was completed for patients according to medical history and physical examination recorded in medical files. A complementary interview was also carried out by phone. Rate of RTW after cardiac rehabilitation and the relationship between RTW and clinical and socio-demographic factors. Two groups were matched for gender, age, occupation type and the type of cardiac procedures. Rehabilitated patients in comparison with control group had higher rates of RTW three month [55.4 Vs 26.2%] and eight months [94.7 Vs 81.0%] after the time of cardiac rehabilitation. Positive attitude toward RTW was observed more in rehabilitated patients three month and eight months after cardiac procedures. Cardiac rehabilitation programs [OR: 3.507, p = 0.027], preoperative functional class [OR: 6.541, p < 0.001], experience of regular physical activity at home before RTW [OR: 3.836, p = 0.004] and job support programs [OR: 4.050, p = 0.022] were main predictors for RTW eight months after cardiac procedures. Patients undergoing cardiac procedures benefit from cardiac rehabilitation to preserve work status. The need for appropriate supportive protocols can guarantee RTW after cardiac rehabilitation and improve patients' attitude toward continuing their jobs

Comparison of short-term clinical outcome of non-ST elevation versus ST elevation myocardial infarction

Studies on the prognosis of ST elevation myocardial infarction [STEMI] versus non-ST elevation myocardial infarction [non-STEMI] have shown different results. The present study was designed to compare the early outcome and left ventricular systolic function of patients with ST and non-ST elevation myocardial infarction. The patients' information was derived from 10,065 consecutive patients hospitalized in Tehran Heart Center with acute MI [2007 patients with STEMI and 8058 with non-STEMI]. The baseline clinical characteristics, post-MI complications, left ventricular systolic functions, and 30-day mortality rates were compared. A history of current cigarette smoking, opium addiction, and brain stroke was more frequent in the STEMI patients, whereas hyperlipidemia, hypertension, and obesity were found more in the non-STEMI group. Ejection fraction was higher in the non-STEMI patients than that in the STEMI group, and anterior wall infarction was detected more frequently in the STEMI cases. A history of coronary artery bypass grafting and also percutaneous coronary intervention was observed more in the non-STEMI group. Amongst the in-hospital complications, ventricular arrhythmias [1.4 vs. 0.5, P<0.001] and pulmonary edema [0.4 vs. 0.1, P=0.002] were more prevalent in the STEMI cases. The 30-day mortality rate in the STEMI group was higher than that in the non-STEMI group [5.5 vs. 2.4, P<0.001]. Early mortality in both groups was dependant on advanced age, diabetes mellitus, post-MI bradycardia, and atrioventricular block. Also, female gender and pulmonary edema in the STEMI group and family history of MI in the non-STEMI patients could predict 30-day mortality. There were several differences in the baseline characteristics and early outcome between the two types of STEMI and non-STEMI. The 30-day mortality rate was higher in the STEMI group than that in the non-STEMI group

Short and Long-Term Outcomes of Percutaneous Coronary Intervention in Patients with Low; Intermediate and High Ejection Fraction : Cardiovascular Topics

Reduced ejection fraction (EF) has previously been shown to be a risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention (PCI). However; with the advent of stents; procedural complications and restenosis rates have reduced dramatically. The aim of this study was to assess the association between left ventricular (LV) ejection fraction and in-hospital and longterm outcomes using a prospective registry. Methods : After exclusion of patients with acute myocardial infarction (MI) and those with missing data on left ventricular ejection fraction; 2 030 patients undergoing PCI between March 2002 and 2004 remained in our prospective registry. Patients were divided into three categories: group 1: EF 40(n = 293); group 2: EF = 41-49(n = 268) and group 3: EF 50(n = 1 469). The frequency of in-hospital and follow-up outcomes between groups was compared using appropriate statistical methods. Results: Stents were used for over 85of the patients in each group. The mean EF + SD in the lowest to highest EF groups was 35.8 + 5.4; 45.5 + 1.6and 57 + 5.7; respectively. The angiographic and procedural success rates were 91.8; 92.1 and 94.1; (p = 0.16); and 91.1; 90.3 and 92.9; (p = 0.09); respectively. The respective cumulative major adverse cardiac events (MACE) and cardiac death rates at follow-up were 5.8; 2.2 and 3.3(p = 0.04) and 2; 0.4 and 0.3(p = 0.02); respectively. The hazards ratio (95CI) for MACE and cardiac death in the lowest versus highest EF groups were 2.07 (1.03-4.16) and 5.49 (1.29-23.3). Conclusion : Patients with significant left ventricular dysfunction had higher long-term major adverse cardiac events and cardiac death rates. Even the use of newer techniques such as stenting did not compensate for this

In-Hospital and Mid-Term Adverse Clinical Outcomes of a Direct Stenting Strategy Versus Stenting after Predilatation for the Treatment of Coronary Artery Lesions : Cardiovascular Topic

Background : Direct stenting without balloon dilatation may reduce procedural costs and duration; and hypothetically; the restenosis rate. This study was designed to compare the in-hospital and long-term outcomes of direct stenting (DS) versus stenting after pre-dilatation (PS) in our routine clinical practice. Methods : The 1 603 patients treated with stenting for single coronary lesions were enrolled into a prospective registry. Patients with acute myocardial infarction (MI) within the preceding 48 hours; and those with highly calcified lesions; total occlusions; or a lesion in a saphenous graft were excluded. The baseline; angiographic and procedural data; in-hospital outcomes and follow-up data were recorded in our database and analysed with appropriate statistical methods. Results : Eight hundred and fifty-seven patients (53.5) were treated with DS and 746 (46.5) underwent PS. In the DS group; lesions were shorter in length; larger in diameter and had lower pre-procedural diameter stenosis. Type C and diffuse lesions and drug-eluting stents were found less often (p 0.001). With univariate analysis; dissection and non-Q-wave MI occurred less frequently in this group (0.2 and 0.6vs 3.9 and 2.1; p 0.001 and p ; p = 0.79). With multivariate analysis; direct stenting reduced the risk of dissection (OR = 0.07; 95CI: 0.01-0.33; but neither the cumulative endpoint of MACE (OR = 1.1; 95CI = 0.58-2.11; p = 0.7) nor its constructing components were different between the groups. Conclusions : Direct stenting in the real world has at least similar long-term outcomes in patients treated with stenting after pre-dilatation; and is associated with lower dissection rates

Short- term outcomes and mid-term follow-up after coronary angioplasty in patients younger than 40 years of age

Stenting is currently the standard of care in percutaneous coronary intervention [PCI]. Whether young patients remain at increased risk after PCI in the present stent era has not been investigated widely. We evaluated angiographic characteristics and short- and mid-term outcomes in patients younger than 40 years of age who underwent PCI. From April 2003 to March 2005, prospective data were collected in 118 consecutive patients, who were less than 40 years of age and underwent PCI at our referral center. The PCI outcomes in these patients were compared to those in 354 patients, randomly selected from 2493 patients older than 40 years of age in our database. Follow-up was scheduled at 1 month, 5 months, and 9 months through clinic visits, telephone interviews, and reviewing hospital records. Patients<40 years of age were more often male [91.5% vs. 71.8%, P<0.001], current smokers [33.9% vs. 15.2%, P<0.001], and had more family history of coronary artery disease [38.1% vs. 21.8%, P<0.001] and myocardial infarction [44.1 vs. 31.1, p=0.01], while diabetes mellitus [6.8% vs. 22.1%, P<0.001], hypertension [13.6% vs. 35.3%, P<0.001], and hyperlipidemia [34.7% vs. 44.8%, P=0.055] were less common in these patients. There were no significant differences between the two groups regarding vessel involvement, reference vessel diameter, stenosis rate [before and after procedure], and lesion characteristics, with an exception that angulated lesions were more common in the patients. 40 years of age [P<0.05]. The young patients, who underwent PCI, presented more frequently with single-vessel disease [61% vs. 46%, P=0.01].The vessel and lesion sites of PCI and clinical success rates were similar in these age groups. Usage of stent was high and similar, and drug- eluting stent use was not significantly different between the two groups. With a high procedural success [94.9% vs. 91.8%], intra-hospital and late complications were very low and similar in both groups. Percutaneous coronary intervention is a safe and effective procedure for young patients, and major adverse cardiac events are similar in young and older patients

Free wall rupture and ventricular septal defect post acute anterior myocardial infarction

Myocardial free wall rupture is a catastrophic complication of acute myocardial infarction, and prognosis will depend on the prompt diagnosis by echocardiography, extension of infarct size, and prompt surgical treatment. Free wall rupture concomitant with ventricular septal defect [VSD] may be more complicated for management. A case of a 69-year-old man with myocardial free wall rupture and VSD following acute anterior myocardial infarction is presented

Main Pulmonary Artery Hydatidosis with Seconday Involvement of the Lungs: a Shepherd Boy's Story

Cardiac hydatid cyst [CHC] is a rare disease that was endemic in some regions especially in sheep-raising areas. The most commonly accepted theory for the routes of heart involvement in hydatid cyst was infestation by the hexacanthus embryo through coronary arteries.Here, we describe a case with the primitive cardiac hydatid cyst located around the pulmonary valve [PV] and main pulmonary artery [mPA] extended to right and left pulmonary arteries and metastasized to both lungs. Could it be possible for the embryo to adhere PV and mPA directly

Predictors of Long-term Outcome in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: a single center registry [THCR]

This study sought to access differences in long-term [9 months] outcomes between Acute Coronary Syndrome [ACS] patients who undergo early intervention compared to Percutaneous Coronary Intervention [PCI] in stable and refractory conditions. Data originated from Tehran Heart Center Registry- interventional cardiology [THCR-IC] and consisted of 1267 patients divided into two categories; 227 patients had features corresponding to acute coronary syndromes [17.9%] and 1040 patients suffered from stable angina [82.1%]. They were admitted between April 3, 2003 and April 25, 2004. The clinical success rate of PCI was higher in ACS [97% vs. 94%; P=0.037], while In-hospital complications was similar in both groups. During the follow-up period, clinical restenosis was not significantly different and the overall number of re-interventions caused by restenosis or progression was not more frequent in ACS patients. Also, 1.3% of ACS and 0.4% of SA patients died, but the difference was not statistically significant [P=0.16]. Finally, Major Adverse Cardiac Events [MACE] showed no significant difference [5.2% vs. 3.9%; P=0.42]. Multivariate analysis showed that female sex [OR=25.6; P=0.003] and previous history of PCI [OR=8.4; P=0.016] were the only strong independent risk factors for major adverse cardiac events. Analyzing ACS patient outcomes using Mantel-Hanzel analysis showed that the female sex was the only factor which strongly increased the incidence of MACE. Both ACS and SA patients who underwent coronary intervention had similar in-hospital and composite major adverse cardiac events, nevertheless female gender must be considered as an independent risk factor for major adverse cardiac events especially in patients with acute coronary syndrome who undergo PCI

Interventional Closure of Patent Foramen Ovale [PFO] with Amplatzer PFO Occluder in Patients with Paradoxical Cerebral Embolism

Percutaneous transcatheter closure has been proposed as an alternative to surgical closure or long-term anticoagulation in patients with presumed paradoxical embolism and patent foramen ovale [PFO]. There were two symptomatic patients [29 and 47 years old] who underwent percutaneous transcatheter closure of PFO after at least two events of cerebral ischemia; one embolic event had occurred under anti-platelet therapy. For both patients, Amplatzer PFO occluder measuring 25 mm in diameter were used. In both cases, complete occlusion by color Doppler and transesophageal contrast echocardiography investigation was achieved after the procedure and lasted at least up to 3 months after implantation as determined by our follow up. Mean fluoroscopy time was 16.7 minutes. Percutaneous transcatheter closure was technically successful in both patients [100%]. No residual shunt was seen at the end of the procedure or in follow-ups. In-hospital follow-up was uneventful. At a mean follow-up of 3 months, no recurrent embolic neurological events were observed. Transcatheter closure of PFO with Amplatzer PFO occluder devices is a safe and effective therapy for patients with previous paradoxical embolism PFO. Percutaneous closure is associated with a high success rate, low incidence of hospital complications, and freedom of cerebral ischemic events