Reasons for reperfusion delay in ST-elevation myocardial infarction and their impact on mortality.

AIMS: The impact of reperfusion delay in ST-elevation myocardial infarction (STEMI) is well known. We aimed to describe the specific reasons for delay to primary percutaneous coronary intervention (pPCI), and their impact on mortality after adjusting for confounders, using the first-medical-contact-to-device (FMCTD) time to measure the delay. METHODS: Between January 2006 and December 2019, 2149 STEMI patients underwent pPCI at our centre. Delayed pPCI was defined as FMCTD > 90 min or > 120 min in the case of inter-hospital transfer. The causes of delay were classified as system-related (related to the network organization) or patient-related (related to the clinical condition of the patient). Primary outcome was 1-year all-cause mortality. RESULTS: The pPCI was timely in 69.9% of patients, delayed for system-related causes in 16.4% or for patient-related causes in 13.7%. Different patient-related causes induced variable median FMCTD time (from 114 min for technically difficult pPCI to 159 min for ECG and/or symptom resolution). By multivariable Cox-regression models, the main independent risk factors for mortality were delay due to comorbidities [hazard ratio (HR) 2.19 (1.22-3.91)], or hemodynamic instability [HR 2.05 (1.25-3.38)], after adjusting for Global Registry of Acute Coronary Events risk score tertiles and angiographic success. The difference in risk of mortality is maintained over the entire spectrum of time from symptom onset. CONCLUSIONS: Different causes of delay had different impacts on mortality, generally more important than the length of the delay. Causes of delay such as hemodynamic instability and comorbidities should prompt specific programs of performance improvement. Timely pPCI maintains prognostic advantages after several hours from symptom onset, mandating prompt reperfusion also in late-presenter patients.

Percutaneous Management of a Coronary Bifurcation Aneurysm with Mesh-Covered Stents and the Simultaneous Kissing Stent Technique.

A 63-year-old man was admitted with a clinical diagnosis of acute coronary syndrome (non-ST-segment elevation), characterized by regional hypokinesia of the left ventricular posterior and lateral walls and by positive cardiac biomarkers. The coronary angiogram showed a 12.5-mm-diameter aneurysm with a mural thrombus and possible distal embolism to the bifurcation of the left circumflex coronary artery and the 2nd marginal branch. The aneurysm was managed percutaneously by implanting 2 mesh-covered stents in accordance with the "simultaneous kissing stent" technique. Follow-up angiography and optical coherence tomography at 5 postprocedural months documented complete sealing of the aneurysm and diffuse in-stent restenosis. No sign of ischemia occurred during the subsequent follow-up.

Switching from femoral to routine radial access site for ST-elevation myocardial infarction: a single center experience.

OBJECTIVES: This study sought to describe the change of first choice access site from transfemoral (TF) to transradial (TR) in primary percutaneous coronary intervention (pPCI) in a single center. BACKGROUND: TR-pPCI, when performed by experienced operators, can reduce bleeding events and improve clinical outcome. However, little is known about the learning curve of TR-pPCI and the results obtained by less experienced operators. METHODS: Time to reperfusion, contrast and radiation doses, and 30-day clinical events were evaluated. The relationship between operator experience and procedural results was assessed. RESULTS: During 6.5 years, 1,045 patients with STEMI underwent pPCI. The rate of TR-pPCI increased gradually from about 40% to 90% and remained stable thereafter. The crossover from TR to TFpPCI occurred in 4.6% of patients and was not related to the operator experience. Patients selected for TR-pPCI had a lower risk profile and lower incidence of 30-day mortality and bleeding events. Time to reperfusion, contrast volume, fluoroscopy time, and angiographic success was not significantly different between the 2 vascular approaches, nor was it associated to the operator experience. At roughly 200 PCIs as operator experience, a slight adjusted reduction in the time form first coronary angiogram to balloon was detected with both vascular approaches. CONCLUSIONS: A progressive transition from TF to TR-pPCI could be implemented over a 4-year period without increasing overall treatment delay. The impact of operator experience on procedural results appeared to be modest and it did not differ in the study access groups.

Comparison of sirolimus-eluting and bare metal stent for treatment of patients with total coronary occlusions: results of the GISSOC II-GISE multicentre randomized trial.

AIMS: Percutaneous coronary intervention with bare metal stent (BMS) in chronic total coronary occlusions (CTOs) is associated with a higher rate of angiographic restenosis and reocclusion than that observed in subtotal stenoses. Preliminary reports have suggested a better performance of drug-eluting stents in CTO. In this multicentre, randomized trial, we compared the mid-term angiographic and clinical outcome of sirolimus-eluting stent (SES) or BMS implantation after successful recanalization of CTO. METHODS AND RESULTS: Patients with CTO older than 1 month, after successful recanalization, were randomized to implantation of SES (78 patients) or BMS (74 patients) in 13 Italian centres. Clopidogrel therapy was prescribed for 6 months. The primary endpoint was in-segment minimal luminal diameter (MLD) at 8-month follow-up. Secondary clinical endpoints included death, myocardial infarction (MI), target lesion revascularization (TLR), and target vessel revascularization (TVR) at 24 months. Patients treated with SES showed, at in-segment analysis, a larger MLD (1.98 +/- 0.57 vs. 0.98 +/- 0.80 mm, P < 0.001), a lower late luminal loss (-0.06 +/- 0.49 vs. 1.11 +/- 0.79 mm, P < 0.001), and lower restenosis (9.8 vs. 67.7%, P < 0.001) and reocclusion (0 vs. 17%, P = 0.001) rates. At 24-month follow-up, patients in the SES group experienced fewer major adverse cardiac events (50.0 vs. 17.6%, P < 0.001) mainly due to a lower rate of both TLR (44.9 vs. 8.1%, P < 0.001) and TVR (44.9 vs. 14.9%, P < 0.001). CONCLUSION: In CTO, SES is markedly superior to BMS in terms of restenosis and reocclusion rate, and incidence of repeat revascularization at 24 months. Clinicaltrials.gov identifier: NCT00220558.