Borderline trend towards long-term mortality benefit from drug eluting stents implantation in ST-elevation myocardial infarction patients in Poland-data from NRDES registry.

OBJECTIVES: To analyze long-term outcome of ST-Elevation Myocardial Infarction (STEMI) and non-STEMI (NSTEMI) patients treated with Drug Eluting Stents (DES) stents with regard to mortality and stent thrombosis rates based on the national Polish PCI registry database. BACKGROUND: Only a few studies suggested potential trend towards lower mortality in STEMI patients treated with DES. Current European Society of Cardiology STEMI guidelines recommend DES use only with one restriction to suspected patient poor compliance or contraindication to dual antiplatelet therapy. METHODS: Thirteen high-volume interventional cardiology centers in Poland enrolled patients in National Registry of Drug Eluting Stents (NRDES) Registry from October 2010 till October 2011. RESULTS: There were 2686 patients enrolled in NRDES Registry. Eighty five patients (3%) had both DES and BMS implanted at index PCI procedure and were excluded from further analysis. A subpopulation of STEMI (1709; 66%) and NSTEMI (892; 34%) patients was selected for BMS vs DES comparison. A significant difference in favor of DES group for 1-year mortality was found in STEMI subgroup (P < 0.0001-unadjusted and P = 0.0497 after propensity score adjustment). No such differences were noticed for NSTEMI subgroup or stent thrombosis comparisons. CONCLUSIONS: A strong selection bias for DES stents was observed with regard to demographic and angiographic characteristics in both STEMI and NSTEMI. DES implantation was associated with similar ischemic outcome to BMS at 1-year follow-up. STEMI patients with DES presented a trend towards lower long-term mortality at 1 year in comparison to BMS.

Long-term follow-up of mesh-covered stent implantation in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The MGuard stent (a bare-metal stent wrapped externally in a polymer mesh sleeve) was introduced to reduce the risk of distal embolisation and no-reflow phenomenon during percutaneous coronary intervention (PCI) in thrombus containing lesions, including ST-segment elevation myocardial infarction (STEMI). However, data on the long-term performance of the MGuard stent is limited. AIM: To assess the long-term safety and efficacy of MGuard stent implantation during primary PCI for STEMI. METHODS AND RESULTS: In this multicentre study, a total of 60 patients with STEMI ≤12 h treated with the MGuard stent were enrolled. Angiographic success of PCI was achieved in 96.7%, with the final TIMI grade 3 flow in 90.0% of patients. At six months, the overall rate of major adverse cardiac and cerebrovascular events (MACCE; composite of cardiac death, nonfatal target vessel reinfarction, target lesion revascularisation, and stroke) was 1.7%. A long-term follow-up of the study was successfully performed in 57 patients (mean follow-up of 38.7 ± 3.1 months). The long-term cardiac mortality was 7.0%, with a MACCE rate of 8.8%. There was no decrease in the left ventricular ejection fraction and no enlargement of the left ventriclebetween index and long-term follow-up echocardiogram. CONCLUSIONS: The early safety and efficacy of the MGuard stent was maintained during the long-term follow-up. However, comparative data from ongoing randomised clinical trials are still required to confirm the long-term efficacy of MGuard stent implantation in patients with STEMI.

A clinical evaluation of the ProNOVA XR polymer-free sirolimus eluting coronary stent system in the treatment of patients with de novo coronary artery lesions (EURONOVA XR I study).

AIMS: Evaluation of safety and efficacy of ProNOVA XR, a new generation of polymer-free sirolimus eluting stents (SES), utilizing a pharmaceutical excipient for timed release of sirolimus from the XR platform. METHODS AND RESULTS: Safety and efficacy of ProNOVA XR coronary stent system was examined in EURONOVA prospective, single arm, multi-center registry of 50 patients with de novo native coronary lesions up to 28 mm in length in arteries between 2.25 and 4 mm. At 6-month, in-stent late lumen loss by QCA was 0.45 ± 0.41 mm and in-stent neointimal volume obstruction in the IVUS sub-study was 14 ± 11%. One-year clinical follow-up revealed a favorable safety profile, with 2% of in-hospital MACE and 6.4% of MACE from hospital discharge up to 12 months (including 1 cardiac death >30 days after stent implantation and 2 TLRs). According to the ARC definition, there was no definite or probable stent thrombosis and 1 possible stent thrombosis (2%) up to 12 months of clinical follow-up. CONCLUSIONS: In this preliminary evaluation, ProNOVA XR polymer-free sirolimus eluting stent system appeared safe with an early promise of adequate effectiveness in the treatment of de novo coronary lesions in up to 12 months of clinical, angiographic and IVUS follow-up.

[Pseudo-Wellens syndrome in a patient with vasospastic angina]. / Rzekomy zespól Wellensa u pacjenta z dlawica naczyniowo−skurczowa.

Wellens syndrome is characterised by negative or biphasic T waves in V2-V4 leads and critical stenosis of proximal part of the left descending coronary artery. These ECG changes without atherosclerotic changes in coronary angiography, i.e. coronary artery spasm are called pseudo-Wellens syndrome. We describe a patient with acute coronary syndrome and pseudo-Wellens syndrome as a cause of vasospastic angina. These ECG abnormalities need differentiation with acute pulmonary embolism.

Mesh covered stent in ST-segment elevation myocardial infarction.

AIMS: The MGuard stent (bare metal stent wrapped externally with a polymer mesh sleeve) is designed to prevent distal embolisation by reducing thrombus and plaque fragments released during and post percutaneous coronary intervention (PCI). The aim of this study was to confirm the clinical feasibility, safety and performance of the MGuard stent during primary PCI for ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS: The present study was a multicentre, prospective, single arm study in which 60 patients with STEMI <12 hours were enrolled. Predilatation was performed in 61.7% of the cases and thrombus aspiration in 18.3%. In one (1.7%) patient the stent could not cross the lesion. Final TIMI grade 3 flow was observed in 90.0% of patients, with myocardial blush grade 3 in 73.3% of patients and complete (>70%) ST-segment resolution 60 minutes after PCI in 61.4% of patients. In 5.0% of cases distal embolisation occurred. The total major adverse cardiac events rate during the 6-month follow-up was 1.7%. CONCLUSIONS: Based on this experience, the MGuard stent implantation in STEMI patients is safe and highly effective. A larger randomised trial is warranted to confirm the clinical endpoints.

Intracoronary ultrasound-guided angioplasty for coronary chronic total occlusion.

BACKGROUND: Recanalisation for coronary chronic total occlusion (CTO) is associated with high rates of restenosis and reocclusion. The use of intracoronary ultrasound (ICUS) may improve immediate and long-term outcomes following recanalisation. To our knowledge, no study has examined the use of ICUS-guided balloon angioplasty in CTO. AIM: To compare the results of ICUS-guided balloon angioplasty and ICUS-guided angioplasty with stent implantation in patients with CTO. METHODS: The study involved 51 CTO patients in whom optimal balloon angioplasty results were achieved according to quantitative coronary angiography (QCA). These patients then underwent ICUS-guided balloon angioplasty with the goal of achieving a minimal luminal cross-sectional area (MLCSA) of > 6.0 mm2 and a residual plaque burden (RPB) of < 65%. Of the 51 patients, the ICUS criteria defining optimal balloon angioplasty were achieved in 23 patients and 7 patients did not undergo stent implantation due to calcification and/or small vessel diameters (group A--30 patients). In 21 patients, the failure to achieve optimal ICUS parameters resulted in stent implantation with the goal of achieving in stent MLCSA > 9 mm2 and > 55% of average total cross-sectional area of the vessel according to distal and proximal reference segments (group B). The two groups were similar in terms of clinical and angiographic characteristics. RESULTS: Balloon angioplasty which was regarded as optimal by QCA, was shown to be non-optimal by ICUS in 41 patients (80.4%). The MLCSA was smaller in group A than group B (6.5 +/- 1.5 vs. 8.9 +/- 2.0 mm2; p < 0.001). Restenosis was found in 8 (26.6%) group A patients and 4 group B patients (19%) (p > 0.05). The restenosis rate in 23 group A patients with optimal ICUS parameters was 8.6% (2 patients). Consecutive ICUS measurements showed a gradual increase in the total vessel area during the PCI procedure and at the 6-month follow-up (p < 0.05). CONCLUSIONS: (1) Achieving an optimal balloon angioplasty result in CTO patients requires confirmation using ICUS. (2) In some patients immediate and long-term outcomes following ICUS-guided optimised balloon angioplasty are comparable to those of ICUS-guided stent implantation. (3) Direct measurement of a chronically occluded coronary artery at pre-intervention, during the intervention and at long-term follow-up may argue in favour of using ICUS in recanalisation of CTO. (4) ICUS-guided balloon angioplasty for CTO could be a method of choice in patients in whom long-term dual antiplatelet therapy is associated with a high probability of bleeding complications.

Dissection of the right coronary ostium and sinus of Valsalva during right coronary artery angioplasty.

We describe a case of dissection of the coronary ostium and sinus of Valsalva during a recanalization procedure to address chronic total occlusion of the right coronary artery (RCA). The patient was treated conservatively, and 1 month later, underwent angioplasty of the RCA and marginal branch. Based on a review of the incidence of, management strategies for, and causes of dissection of the RCA and ascending aorta, we conclude that the frequency of this condition may be underestimated and, in view of the increasing number of elderly patients, will rise over time.

[Polymorphic ventricular tachycardia in acute myocardial infarction without ST elevation in a patient with thrombocytopenia]. / Wieloksztaltny czestoskurcz komorowy i dlugi odstep QT u chorej z zawalem serca bez uniesienia odcinka ST i z maloplytkowoscia--zlozony aspekt arytmii.

67-year-old woman with thrombocytopenia (treated with prednisolon and azathiopryn) was admitted because of acute myocardial infarction without ST segment elevation (NSTEMI). From the 2nd day we observed increasing QTc interval from 461 ms with normal potassium level. Suddenly on the 6th day of the so far uncomplicated AMI ventricular fibrillation developed and was successfully treated with DC shock, and amiodarone (150 mg i.v.) was administered because of recurrent NSVT. Potassium level was 2.9 mmol/l. Within the next 2 days in the morning hours we observed episodes of recurrent polymorphic ventricular tachycardia (PMVT), always progressing into ventricular fibrillation (VF). The ECG showed QT interval--520 ms, QTc--602 ms. The patient was given an increasing dose of beta-blocker and lidokaine in i.v. infusion. After this regimen PMVT/VF did not recur and QT was normalized. Additionally successful PCI of LAD with 80% stenosis was performed. The paper discusses the problem of PMVT in the settings of AMI.

Fractional diastolic and systolic pressure in the ascending aorta are related to the extent of coronary artery disease.

BACKGROUND: Ascending aortic fractional pulse pressure and fractional systolic pressure (FSP) were demonstrated to differentiate patients with and without coronary artery disease. However, no study so far has analyzed the relationship between FSP and fractional diastolic pressure (FDP) and the extent of coronary artery disease. Therefore, we investigated the relationship between ascending aortic FSP and FDP and the extent of coronary atherosclerosis in unselected patients with angiographically confirmed coronary artery disease. METHODS: The study group consisted of 445 patients (350 men and 95 women, mean age 58.5 +/- 9.7 years) with angiographically confirmed coronary artery disease and ejection fraction > 55%. Invasive ascending aortic blood pressure during catheterization and conventional sphygmomanometer measurements were taken. RESULTS: Pulse pressure (PP), FSP, and FDP derived from intraaortic measurements differentiated patients with one-, two-, and three-vessel coronary artery disease (PP, 62.8 +/- 15.8 v 64.8 +/- 17.9 v 71.7 +/- 19.1 [P < .0001]; FSP, 1.45 +/- 0.09 v 1.46 +/- 0.10 v 1.51 +/- 0.12 [P < .0001]; FDP 0.77 +/- 0.05 v 0.77 +/- 0.05 v 0.75 +/-0.06 [P < .0001]). After multivariate stepwise adjustment, the odds ratio (OR) and confidence interval (CI) of having three-vessel disease was as follows: PP per 10 mm Hg, OR = 1.15, 95% CI = 1.01 to 1.30; FSP per 0.1, OR = 1.28, 95% CI = 1.03 to 1.60; and FDP per 0.1, OR = 0.61, 95% CI = 0.39 to 0.95. None of the brachial pressure indices was independently related to the extent of coronary atherosclerosis. CONCLUSIONS: Pulse pressure (PP), FSP, and FDP of the ascending aorta are related to the risk of three-vessel disease in patients with coronary artery disease and preserved left ventricular function.

[Primary percutaneous coronary interventions in acute myocardial infraction with ST-segment elevation. Experience in a heart catheterization unit without surgical backup]. / Pierwotna angioplastyka wiencowa w swiezym zawale serca. Doswiadczenia pracowni odleglej od osrodka kardiochirurgicznego.

BACKGROUND: Primary percutaneous coronary intervention (PCI) in patients (pts) with ST-segment elevation myocardial infarction is regarded as treatment superior to thrombolysis. Coronary stents and GP IIb/IIIa receptor inhibitors improved safety and clinical outcome of interventional procedures. Safety of primary PCI procedure in catheterisation laboratories which do not have on-site surgical backup is still under evaluation. METHODS: In a cohort of 249 consecutive patients we analysed short and long-term clinical outcome of primary PCI performed in catheterisation laboratory which is located several kilometres from a cardiac surgery department, with an effective transfer time < 30 minutes. RESULTS: Coronary stents were implanted in 43% pts. GP IIb/IIIa receptor inhibitors were used in 54.2% pts. Cardiogenic shock on admission was diagnosed in 7.2% pts. Intra-aortic balloon counterpulsation usage was necessary in 6.4% pts. In-hospital mortality was 6% (3.5% in non-shock pts). In two pts (0.8%) during hospitalization repeat PCI was performed--in one case due to reinfarction. No urgent cardiosurgery intervention was necessary. Mortality and myocardial infarction rate after hospital discharge during 6 month follow up was 2.4% and 2.8% respectively. In 4% pts repeated PCI was performed due to restensosis. Cumulative event free survival was 84%. CONCLUSION: Primary PCI procedure for acute myocardial infarction seems to be feasible and safe in catheterisation laboratories without on-site surgical backup provided usage of stents, GPIIb/IIIa receptor inhibitors and intraaortic balloon counterpulsation and cooperation with a nearby cardiosurgery department with short transfer time.

[Intracoronary thrombolysis combined with platelet receptor IIb/IIIa inhibitor and followed by percutaneous coronary intervention for the treatment of acute myocardial infarction: two case reports]. / Ostry zawal serca. Dowiencowe zastosowanie skojarzonej terapii trombolitycznej z blokerem plytkowego receptora IIb/IIIa Opis dwóch przypadków.

By using classical thrombolytic treatment in acute myocardial infarction, reperfusion can be obtained in 60-80% of patients. However, in only 30-55% of cases TIMI grade 3 flow is achieved. Primary percutaneous coronary intervention (PCI) offers the potential for a higher rate of reperfusion and a lower rate of bleeding events. Recently, advances in platelet inhibition and PCI procedures have led to the combination of all the approaches. Facilitated PCI or the use of elective PCI after pharmacological reperfusion therapy can combine the best aspects of thrombolysis and mechanical revascularization in acute myocardial infarction. We report two cases with acute myocardial infarction successfully treated with PCI following thrombolytic treatment combined with platelet receptor IIb/IIIa inhibitor.

[Percutaneous coronary angioplasty in acute myocardial infarction in elderly patients]. / Przezskórna angioplastyka wiencowa w swiezym zawale serca u chorych w podeszlym wieku.

BACKGROUND: Over 1/3 of all patients treated for acute myocardial infarction are elderly (over 70 years of age). Blood flow restoration in the infarct-related artery is a fundamental therapeutic strategy, however reperfusion therapy is rarely used in the elderly as compared with younger groups. Mortality and complication rates are much higher in the elderly than in younger patients irrespective of the type of reperfusion therapy. Elderly patients are modestly represented in studies undertaken to analyze the efficacy of various types of reperfusion therapy. For this reason the choice of an optimal therapy in acute myocardial infarction in the elderly remains an open question. METHODS: In the I Department of Cardiology PCI has been the strategy of choice in the treatment of acute myocardial infarction. This is a retrospective analysis of early and late outcomes of primary coronary angioplasty in elderly patients with myocardial infarction. Between June 2001 and December 2003 four hundred and five (405) consecutive patients were admitted to our centre due to acute myocardial infarction. A group of 352 patients treated by primary coronary angioplasty was analyzed. Patients were divided into two subgroups one subgroup--over 70 years of age (84 patients) and the second one--below 70 years of age (268 patients) serving as controls. Early (in-hospital) and late (at 30 days, 6 and 12 months) outcomes were assessed. RESULTS: The most important observation was that elderly patients with myocardial infarction may be safely and effectively treated with primary coronary angioplasty. In-hospital mortality (5.9% vs. 2.2%, p < 0.05) and the number of bleeding complications (9.5% vs. 4.1%, p < 0.05) were higher in the elderly than in younger patients, but still lower than in the studies where fibrinolysis was used as a reperfusion strategy. Another important fact was the relatively frequent use of a platelet glycoprotein IIb/IIIa inhibitor (abciximab) in the elderly group (46.4% patients). CONCLUSIONS: Our results prove that these agents may also be safely administered in elderly patients with myocardial infarction. It is probable that the relatively frequent use of platelet glycoprotein IIb/IIIa inhibitors in our elderly patients was one of the reasons for lower early mortality as compared with the findings of other investigators.

[Assessment of myocardial reperfusion in patients with acute myocardial infarction treated with combination of fibrinolysis and IIb/IIIa platelet inhibitor]. / Angiograficzna ocena reperfuzji miokardium u chorych ze swiezym zawalem serca leczonych kombinacja leków fibrynolitycznych oraz blokerów plytkowego receptora IIb/IIIa.

UNLABELLED: Facilitated percutaneous coronary intervention (facilitated PCI) in acute myocardial infarction--the use of planned PCI after pharmacological reperfusion therapy, can fuse the best aspects of thrombolysis and primary angioplasty. The aim of the study was to assess microvacular reperfusion in patients with acute myocardial infarction treated with half dose of alteplase and full dose of abciximab followed by primary PCI. METHODS: The study enrolled 100 patients with myocardial infarction within 12 hrs of chest pain onset in hospitals with at least 90 minutes of transportation time to interventional center. All patients received intravenous boluses of 60 U/kg heparin, 15 mg alteplase (r-tPA) and 0.25 mg/kg abciximab, and then infusions of: alteplase (35 mg/60 min) and abciximab (0.125 micrograms/kg/min for 12 hours) before transportation to interventional facility RESULTS: Coronary angiography was performed at a mean 123 +/- 38 minutes after lytic therapy administration. In baseline angiography 73% of patients had TIMI 3 flow in infarct related artery. In 88 patients (90%) there was TIMI 2 + 3 flow. In 82 patients PCI was performed immediately after diagnostic catheterization, with angiographic procedural success rate of 92% (TIMI 3). Corrected TIMI frame count was 29.8 +/- 25.9 before and 17.2 +/- 9.5 after PCI. TIMI Myocardial Perfusion Grade 3 and 2 (MPG 3 + 2) was present in 77% of patients before and in 72% after PCI. CONCLUSIONS: Combination of abciximab and half dose of alteplase was a very effective strategy in restoring flow in infarct related artery and achieving microvascular reperfusion. This model of pharmacological treatment could be utilized as pre-treatment for patients referred for primary PCI from remote hospitals.

[The influence of percutaneous coronary recanalization of total coronary occlusions on the heart rate variability ]. / Wplyw udroznienia przewlekle zamknietych tetnic wiencowych na zmiennosc rytmu serca.

In patients following a myocardial infarction, heart rate variability is an important prognostic factor. Decreased heart rate variability is associated with a higher mortality rate. This study evaluated the influence of recanalisation by percutaneous coronary intervention (PCI) in totally occluded coronary arteries on the heart rate variability in patients with myocardial akinesis in the recanalised artery area. The study group included 22 men (average age 52.8 +/- 7.7) after successful PCI recanalization of the totally occluded artery. All patients had akinesis in the recanalised artery area. All patients underwent 24-hour continuous electrocardiographic Holter monitoring with HRV analysis and echocardiographic dobutamine tests both before the PCI and 6 months afterwards. The population was divided into two groups: group A (10 patients) had contractility adjustments in echocardiographic tests that were performed 6 months after the PCI. Group B (12 patients) did not have contractility adjustments. Before the PCI, there were no differences in the wall motion score index (WMI) or the time-domain HRV parameters between the two groups. After 6 months, there was a significant increase in the WMI value in group A, whereas this index remained unchanged in group B. In group A the time-domain HRV parameters had improved 6 months after the PCI, whereas they remained unchanged in group B. Successful percutaneous revascularization of the totally occluded coronary artery in patients with myocardial akinesis in the occluded artery area leads to an increase in HRV parameters. This improvement occurred only in patients that had a contractility adjustment after the PCI in previous akinetic segments of myocardium.

[Acute myocardial infarction complicated by cardiogenic shock treated with angioplasty of left main stenosis - two case reports]. / Zawal serca powiklany wstrzasem. Angioplastyka pnia lewej tetnicy wiencowej.

Two patients with acute myocardial infarction (MI) complicated by cardiogenic shock are described. Coronary angiography revealed subtotal left main stenosis. Both patients underwent successful primary coronary angioplasty. The role of coronary angioplasty in patients with acute MI complicated by cardiogenic shock is discussed.