Feasibility of transradial coronary angiography and intervention using a single Ikari left guiding catheter for ST elevation myocardial infarction.

BACKGROUND: Transradial coronary intervention (TRI) has been widely adopted in ST elevation myocardial infarction (STEMI) patients but there is limited literature on the use of a single catheter for both diagnostic angiography and intervention. We aim to evaluate the feasibility and outcomes of TRI with a single Ikari left (IL) guiding catheter in STEMI patients. METHODS: This is a retrospective study of 362 consecutive STEMI patients from August 2007 to December 2008. We assessed the feasibility of TRI with a single IL and compared this strategy with conventional transfemoral intervention (TFI) on the following outcomes: (1) door to perfusion time, (2) total procedural duration, (3) total fluoroscopy duration, and (4) major adverse cardiac events (MACE) by intention to treat analysis. RESULTS: TRI was attempted in 185 patients. There were no failed radial cannulations. Overall success rate of primary TRI with a single IL was 96.9% and there were only 2 failures that required conversion to TFI. Compared to TFI, TRI with IL tended to a shorter median door to perfusion time, 90 (IQR 76.0 - 119.5) versus 98 (IQR 80.8 - 120.5) minutes (P = 0.07) and a shorter median procedure duration of 34 (IQR 27.0 - 45.0) versus 37 (IQR 28.0 - 49.3) minutes (P = 0.06). The median fluoroscopy duration was longer in the TRI group. MACE were comparable between the 2 groups. CONCLUSION: In experienced centers, TRI with a single IL catheter for STEMI is a feasible and effective approach and outcomes are comparable to conventional TFI.

Three-year experience of primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction in a hospital without on-site cardiac surgery.

INTRODUCTION: Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in hospitals without on-site cardiac surgery capability, despite receiving only a class IIb recommendation in the ACC/AHA practice guidelines, can be performed effectively and safely. We reviewed the fi rst 3 years of our experience. MATERIALS AND METHODS: This is a retrospective single centre review of all patients receiving primary PCI for STEMI between 2003 and 2005. Demographic, procedural and outcome data were analysed. RESULTS: There were 259 patients who underwent primary PCI. The mean age was 55.3 +/- 12.3 years. Median door-to-balloon time was 97.5 minutes and 45.2% and 52.9% had anterior and inferior STEMI, respectively. The majority of patients presented with Killip class I (87.6%); however, 5.8% were in Killip class IV. Single vessel disease was found in 47.1%. Angiographic PCI success (defined as residual stenosis <50% with TIMI 3 fl ow) was achieved in 89.1%. Usage of stents, distal protection and aspiration devices were 97.2%, 27.8% and 34.1 %, respectively; 9.3% required intra-aortic balloon pump insertion. No patients required transfer for emergency coronary bypass surgery as a result of PCI complications. Post-PCI ST resolution >50% was achieved in 80.6%. The mean post-infarct left ventricular ejection fraction was 44.1%. In-hospital, 30-day, 6-month and 1-year mortality rates were 2%, 2.8%, 4.0% and 4.8%, respectively. Clinically driven target lesion revascularisation rate was 2.8% at 1 year. CONCLUSIONS: Our results are comparable to those from on-site surgical centres. This supports the feasibility and safety of primary PCI in cardiac centres without on-site cardiac surgery.

Percutaneous coronary intervention with stenting of left main coronary artery with drug-eluting stent in the setting of acute ST elevation myocardial infarction.

AIM: Primary angioplasty of the left main coronary is not a common procedure. We present 16 cases of angioplasty of left main coronary artery with drug-eluting stent (DES) implantation in the setting of acute ST elevation myocardial infarction. METHOD: Between December 2003 and November 2005, sixteen patients presented with acute ST elevation myocardial infarction where the left main coronary artery was shown to be involved with or without the left anterior descending or left circumflex arteries. Primary angioplasties were performed on the unprotected left main coronary artery. Five patients received direct stenting while the rest had pre-dilatation. Only one patient received Taxus(R) while the rest received Cypher(R) stents. RESULTS: Of the sixteen patients, eleven developed cardiogenic shock necessitating intra-venous inotropic and intra-aortic balloon counter-pulsation support. Seven perished in hospital (46%); four within the first day while one had a complicated course and perished on the 42nd day of hospitalization. There was no difference in clinical history (hypertension, diabetes, age, and previous coronary intervention) or hemodynamic features (presenting blood pressure, duration of infarct, stent length, and maximum balloon size or pressure) between the two groups. However, the use of inotropes and intra-aortic balloon counter-pulsation (100% vs. 44% p=0.034) was significantly more common in the group which perished. Patient with cardiogenic shock had increased mortality of 63%. Of the nine survivors, one required repeat intervention for subacute stent thrombosis at sixteenth day and one underwent coronary bypass surgery at three months. All remained well up to mean follow up of 420 days. CONCLUSION: Left main coronary artery infarct especially in the setting of cardiogenic shock has a very high mortality rate. Percutaneous intervention can be performed on these patients with minimal delay. In our series, we have shown that primary intervention of the unprotected left main coronary artery with a drug-eluting stent carries an acceptable level of major adverse coronary event. In those who survived the initial event, there is a low rate of mortality or morbidity.

Sirolimus-eluting stent implantation for treatment of proximal left anterior descending coronary artery lesions: long-term outcome and predictors of adverse cardiac events.

OBJECTIVES: Acute and long-term results after sirolimus-eluting stent (SES) implantation of proximal left anterior descending coronary artery (LAD) disease were evaluated. BACKGROUND: Although SES has been used increasingly for the treatment of LAD disease, data regarding their safety and efficacy in a real-world population are limited. METHODS: We investigate the short- and long-term results in 966 patients who underwent SES implantation for stenosis of proximal LAD. RESULTS: The procedural success rate was 97.6%, and procedural non-Q-wave myocardial infarction (MI) rate was 14.5%. In-hospital major complications occurred in five patients (0.5%), including three deaths and two Q-wave MIs. During follow-up (20.4 +/- 8.9 months), there were 16 deaths (1.7%; 10 cardiac, 6 noncardiac), 2 Q-wave MIs, and 22 target lesion revascularizations (2.3%). Late stent thrombosis occurred in two patients (0.2%), 14 and 23 months after the procedure. The event-free survival rates for cardiac death/Q-wave MI were 98.6% +/- 0.4% at 1 year and 97.8% +/- 0.6% at 2 years. The cumulative probabilities of survival without major adverse cardiac events (MACE) were 96.7% +/- 0.6% at 1 year and 95.4% +/- 0.8% at 2 years. In multivariate analysis, stented length (HR 1.04, 95%CI 1.01-1.07, P = 0.009) and infarct-related artery (HR 5.18, 95%CI 1.09-24.64, P = 0.039) were independently related to cardiac death/Q-wave MI. In addition, stented length (HR 1.04, 95%CI 1.02-1.06, P < 0.001) and left ventricular dysfunction (HR 2.66, 95%CI 1.07-6.63, P = 0.036) were significant independent predictors of MACE. CONCLUSIONS: SES implantation for proximal LAD disease appears safe and effective in a real-world population, and the independent predictors of MACE included stented length and left ventricular dysfunction.

Presumed dapsone-induced drug hypersensitivity syndrome causing reversible hypersensitivity myocarditis and thyrotoxicosis.

INTRODUCTION: A 22-year-old Malay soldier developed dapsone hypersensitivity syndrome 12 weeks after taking maloprim (dapsone 100 mg/pyrimethamine 12.5 mg) for anti-malarial prophylaxis. CLINICAL PICTURE: He presented with fever, rash, lymphadenopathy and multiple-organ involvement including serositis, hepatitis and thyroiditis. Subsequently, he developed congestive heart failure with a reduction in ejection fraction on echocardiogram, and serum cardiac enzyme elevation consistent with a hypersensitivity myocarditis. TREATMENT: Maloprim was discontinued and he was treated with steroids, diuretics and an angiotensin-converting-enzyme inhibitor. OUTCOME: He has made a complete recovery with resolution of thyroiditis and a return to normal ejection fraction 10 months after admission. CONCLUSION: In summary, we report a case of dapsone hypersensitivity syndrome with classical symptoms of fever, rash and multi-organ involvement including a rare manifestation of myocarditis. To our knowledge, this is the first case of dapsone-related hypersensitivity myocarditis not diagnosed in a post-mortem setting. As maloprim is widely used for malaria prophylaxis, clinicians need to be aware of this unusual but potentially serious association.