Percutaneous coronary intervention in acute myocardial infarction with cardiogenic shock: immediate and late outcomes.

BACKGROUND: Acute myocardial infarction (AMI) with cardiogenic shock carries a high mortality rate. Early revascularization shows better results than conservative medical treatment. OBJECTIVE: To determine short and long term results of patients with cardiogenic shock from AMI who underwent percutaneous coronary intervention (PCI). METHODS: Patients were identified from the PCI registry from 1993 to 1999. Follow-up data were collected from medical records and/or phone calls. RESULTS: From 1993 to 1999, there were 1211 PCI procedures performed at King Chulalongkorn Memorial Hospital. Seventeen of these cases (M9, F8) had cardiogenic shock. Mean age was 59 +/- 14 yrs. Fourteen patients had AMI. The other 3 cases developed shock more than 24 hours after AMI. Primary PCI was done in 11 cases. Thirteen patients (76.5%) needed intra-aortic balloon pump support. Average peak CPK and CK-MB were 5393 and 580 u/l, respectively. Five patients (29.4%) died in hospital, 3 of whom died on the first day due to pump failure. Twelve patients were followed for a mean duration of 412 days (range 12 - 1,464). One patient died 6 months after PTCA because of in-stent restenosis of the left main coronary artery. CONCLUSION: AMI with cardiogenic shock has a high mortality rate. However, in this group of patients who had early revascularization by PCI, mortality seemed to be lower than previously reported. If PCI is available, the procedure should be offered for this subset of AMI patients.

Initial outcomes of coronary angioplasty in diabetic patients.

Diabetes is one of the controllable risk factors of coronary artery disease. Many reports have shown that diabetes is a poor prognostic indicator for coronary events and revascularization among patients who undergo PTCA or coronary artery bypass surgery. The present work, the first prospective study in Thailand, was conducted to compare the demographic data and initial outcomes of diabetic patients (DM) with those of non-diabetic ones (non-DM) who underwent percutaneous coronary angioplasty (PTCA). Data between January 1993 and December 1998 were prospectively collected after each procedure and before discharge. During the 6-year period, 812 patients (DM-280, non-DM-532) were enrolled. The DM group had significantly more female patients (45.4 vs 21.1%, p < 0.0001), older age (62.5 +/- 8.2 vs 60.5 +/- 10.8 y, p < 0.007), less smoking (21.8 vs 43.2%, p < 0.0001), more dyslipidemia (56.8 vs 41.9%, p < 0.0001) and a higher incidence of hypertension (51.8 vs 42.5%, p = 0.01). The left ventricular ejection fraction, indication for PTCA, size of attempted vessel, and number of diseased vessels were similar in both groups. The case success rate was 93.9 per cent in the DM group and 92.3 per cent in the non-DM group (P=NS). Two patients (0.7%) in the DM and three cases (0.6%) in the non-DM group died during hospitalization. Overall major adverse cardiac events were not different between both groups (1.4 vs 1.9%, P =NS). In conclusion, there were some demographic differences in DM compared with non-DM patients who undergo PTCA; but initial outcomes, major adverse cardiac events, and mortality rates were not significantly different.

Safety and acceptable initial outcomes of reused balloon catheters for percutaneous transluminal coronary angioplasty.

OBJECTIVES: This study was conducted to compare the safety and initial outcomes applying reused balloon (RB) catheters with those of attained new balloon (NB) catheters when performing percutaneous transluminal coronary angioplasty. BACKGROUND: Recently, PTCA procedures have been used increasingly for the treatment of patients with coronary heart disease. In the era of national economic constraint, reused balloon catheters will reduce the cost of expensive, imported coronary angioplasty devices. Hence, data concerning the safety and success rate of RB catheters compared with NB catheters are urgently required. METHODS: Prospective comparative study between reused and new balloon catheters for coronary angioplasty. Data forms were completed after each procedure and before the patient was discharged after an 18-month period. RESULTS: From July 1996 to December 1997, 221 cases (121-RB, 100-NB) were enrolled. Mean age, ejection fraction, diseased vessel and lesion characteristics were similar in both groups. The number of lesions was much higher performed in the RB than in the NB group (1.7 +/- 0.9 vs 1.4 +/- 0.8, p = 0.02). The RB group had more cases of acute myocardial infarction than the NB group (7.4% vs 1%, p = 0.003), however, the angiographic and case success rate were the same (99.5% vs 97.9% and 98.3% vs 97% respectively). Major adverse cardiac events in RB amounted to 1.7 per cent and for NB to 1.0 per cent (p = ns). The total amount of balloons used in RB was much higher than in the NB group (1.5 +/- 0.6 vs 1.1 +/- 0.3, p = <0.0001). There were neither infection nor positive blood cultures in either group. CONCLUSIONS: Reused balloon catheters can be safely used for percutaneous transluminal coronary angioplasty with a high success rate. The total cost of angioplasty can be reduced without a decline in efficacy.

Percutaneous transluminal coronary angioplasty in King Chulalongkorn Memorial Hospital: a four-year experience.

From January 1993 to December 1996, 461 cases (743 lesions) of percutaneous transluminal coronary angioplasty (PTCA) were performed at King Chulalongkorn Memorial Hospital. Seventy eight per cent of the patients were male. Mean age was 61.1 +/- 9.6 yrs and mean ejection fraction was 0.59 +/- 0.18. The indications for PTCA were chronic stable angina (53%), post myocardial infarction (MI) angina (26.6%), unstable angina (17.4%) and acute MI (3%). Emergency PTCA was performed on 15 cases with 5 patients in cardiogenic shock. Fifty four per cent of the cases were performed in single vessel disease, 33 per cent in double vessel disease and 13 per cent in tripple vessel disease. The vessels dilated were the left anterior descending artery (44.2%), right coronary artery (27.8%), left circumflex artery (26.7%), left main (0.9%) and saphenous vein graft (0.4%). Mean balloon size was 2.48 mm. The overall success rate of PTCA, defined as residual diameter stenosis less than 50 per cent, was 91.5 per cent. In addition to PTCA, 123 stent implantations with mean stent size 2.98 mm and 15 rotational athrectomy were done in 114 cases. Complications of PTCA occurred in 32 cases (6.9%). Ten patients (2.2%) had abrupt closure, 1 of these needed emergency coronary bypass graft surgery (CABG). One patient (0.2%) had cerebral embolism with minor residual neurological deficit. One patient (0.2%) had toe gangrene which eventually needed amputation. One patient (0.2%) who presented with acute extensive anterior wall MI and failure of thrombolytic therapy died 8 hours after successful PTCA due to refractory cardiogenic shock. In the patients who also had stent implantation, there were 6 stent misplacements: 3 in the right femoral artery without any complication, 2 were misplacements in the coronary system and 1 dislodged in LM necessitating emergency CABG. CONCLUSION: PTCA is the coronary interventional procedure that can be performed with a high success rate and minimal complications.

The first 100 cases of intracoronary stent implantation in cardiac center, King Chulalongkorn Memorial Hospital.

At King Chulalongkorn Memorial Hospital from July 1994 to December 1996, 123 stents were implanted in 75 males and 25 females. Average age of the patients was 61.3 +/- 9.6 years. Fifty-five per cent of the cases were performed in stable angina, 26 per cent in post myocardial infarction angina. 17 per cent in unstable angina and 2 per cent in acute myocardial infarction. Seventy stents were implanted in the left anterior descending artery, 25 in the left circumflex artery, 27 in the right coronary artery and one stent in the left main. The indications for stent implantation were abrupt closure in thirteen sites, mild dissection in 58, suboptimal dilatation in 19, restenosis in 23 and de novo in 10. Mean size of the stents was 2.99 +/- 0.49 mm and mean inflation pressure was 11.9 atmosphere. Palmaz-Schatz stent was the most commonly used (53.6%) followed by AVE Microstent II (42.3%). There were 3 stents loss in the right femoral artery without any complications. Two stents were misplaced, one stent dislodged in the left main and needed emergency coronary bypass graft surgery. Two patients developed acute stent thrombosis and were successfully reopened with intracoronary urokinase. No patient had major bleeding complication, subacute thrombosis, acute myocardial infarction or death. CONCLUSION: Stent implantation can be performed rather safely with a high success rate and minimal complications.

Echocardiographic features in patients with beta thalassemia/hemoglobin E: a combining effect of anemia and iron load.

Hemoglobin concentration, iron parameters and cardiac status of 25 patients with beta thalassemia/hemoglobin E disease were measured. Two-dimensional echocardiography was employed to evaluate chamber size, ejection fraction and muscle fiber shortening. The seventeen patients who had a mean hemoglobin concentration of less than 7.7 g/dl were found to have significantly larger cardiac chambers and higher cardiac output than the patients with higher hemoglobin concentrations. A statistically significant difference in ejection fraction and per cent of fractional shortening of cardiac muscle fibers was not found. A comparison of subjects with ferritin concentrations above and below 1,500 micrograms/L showed no significant difference in chamber sizes, ejection fraction and in per cent fractional shortening. However, a comparison of 14 patients with transferrin saturation > or = 80 per cent with those less than 80 per cent showed a significant decrease in both ejection fraction and fiber fractional shortening in the more highly saturated subjects. By using stepwise multiple regression analysis, the hemoglobin level was shown to significantly determine cardiac enlargement, while ejection fraction and percentage fractional shortening were significantly associated with transferrin-iron saturation. Thus, anemia leads to chamber enlargement, while high transferrin iron saturation is associated with cardiac muscle dysfunction. The findings in the individual patient reflect the integration of these two effects.