ABSTRACT
Thrombolytic therapy continues to be the common treatment in acute ST elevation myocardial infarction in the majority of heart centers worldwide. However, thrombolytic therapy is associated with high re-occlusion and re-infarction rates. So, most patients now undergo early diagnostic angiography and possibly angioplasty of the culprit artery but the controversy about the timing of angiography after thrombolysis continues to remain unresolved. In this prospective cohort study, we compared the outcome of early invasive strategy versus delayed invasive approach in ST-elevation MI patients who had received successful thrombolytic therapy. Primary endpoint of the study was Major Adverse Cardiovascular Events or MACE [the combined rate of death, re-infarction, major bleeding and cerebrovasular events. Secondary endpoints were re-infarction and re-hospitalization rate. The study comprised 142 patients of which 87 had a routine angiography in less than 10 days of acute event and 55 underwent ischemia-guided angiography after 10 days of index event. Stenting of the culprit vessel was done in 60% of the routine angiography group and 63% of the ischemia-guided group. The patients were followed for 8.8 +/- 2.8 months after the index event. The primary endpoint occurred in 6.9% of routine angiography patients and 10.9% of the control group [P= 0.4]. The rate of re-infarction was significantly higher in the delayed invasive arm than routine early invasive arm [10.9% vs. 1.1, P:0.01],and mostly occurring before angiography. Routine angiography as soon as possible after thrombolysis can reduce re-infarction and was not associated with any increased risk of adverse events in our study
Subject(s)
Humans , Female , Male , Adult , Middle Aged , Aged , Aged, 80 and over , Thrombolytic Therapy , Myocardial Infarction , Prospective Studies , Cohort Studies , Treatment OutcomeABSTRACT
Chronic thromboembolic pulmonary hypertension [CTEPH] is a serious and underdiagnosed disorder with significant morbidity and mortality. It is thought to result from single or recurrent pulmonary thromboemboli arising from the sites of venous thrombosis, often from the lower limbs. Surgical correction of anatomical obstructions [endarterectomy of pulmonary artery] is the treatment of choice in these patients, and the patients outcomes are good. The mortality rate in some centers is about 5%, but in others it is up to 30%. We started pulmonary endarterectomy in Shaheed Rajaie Heart Center [RHC] in Iran four years ago. Pulmonary thromboendarterectomy is performed under hypothermia and total circulatory arrest with cardiopulmonary bypass. All patients are evaluated in our hospital for known risk factors of deep vein thrombosis and pulmonary emboli. Right heart catheterization and measurement of pulmonary artery pressure and vascular resistance are performed in some of the patients and left heart catheterization in those who are over 45 years of age. CT angiography of the pulmonary artery with multi-slice CT scan is done in all patients before and after endarterectomy. Patient selection for successful endarterectomy is based on CT angiography and perfusion lung scan with consideration of pulmonary vascular resistance in some cases. During a 4-year period, 15 patients [5 female and 10 male] underwent this type of surgery in RHC. Their mean age was 35.87 [min. 18, max. 55] years old. The mean pulmonary artery systolic pressure by echocardiography was 87.60 mmHg [min. 55mmHg, max. 140 mmHg, SD 23.26 mmHg] and the mean pulmonary artery pressure was 46.43mmHg [min. 23 mmHg, max. 60 mmHg, SD 11.70 mmHg]. Mean surgery time was 5.33 hours [min. 4hrs, max. 14 hrs, SD. 2.46 hrs], mean bypass time was 138 minutes [min. 84, max. 220, SD=43.28 minutes], mean intubation time was 49.88 hours [min. 7 hrs, max. 216 hrs, SD 61.66 hrs], and intensive care unit stay time was 5.43 days [min. 3, max. 9, SD=1.98]. Two fatalities occurred due to bleeding and shock. The mortality rate was 20%. IVC filters were placed in a minority of the patients who had clear-cut evidence of lower extremity deep vein thrombus as a cause of pulmonary thromboembolic events. Pulmonary endarterectomy is the treatment of choice in CTEPH with an acceptable mortality rate and a good prognosis. It is possible to perform this procedure without recourse to more sophisticated evaluations with an acceptable mortality rate in patients who have segmental lobar or main pulmonary artery organized clot