Cardiac events after low osmolar ionic or isosmolar nonionic contrast media utilization in the current era of coronary angioplasty.

OBJECTIVES: Our study aimed to compare the isosmolar nonionic dimer iodixanol and the low osmolar ionic agent ioxaglate in the current era of percutaneous coronary intervention (PCI), using clopidogrel, enoxaparine, direct stenting, and drug eluting stent. BACKGROUND: Previous studies have suggested an association between thrombus-related events and type of contrast media. METHODS: Our prospective single-center study included 498 consecutive patients who were assigned to receive either iodixanol (n = 231) or ioxaglate (n = 267). The primary endpoint was the cumulative rate of in-hospital major adverse clinical events (MACE). A secondary endpoint was the rate of angiographic or procedural complications. RESULTS: Clinical and angiographic baseline characteristics and procedural data were similar in the 2 groups. A peak anti-Xa > 0.5 IU/ml was obtained in 97% in both groups. Glycoprotein IIb/IIIa inhibitors were used in 42% of patients. Coronary stenting was performed in 91% of patients, with direct stenting in 70%, and drug-eluting stent in 28% of patients. In-hospital MACE was more frequent in patients receiving iodixanol compared with those receiving ioxaglate (4.8% vs. 0.3%, P < 0.005). This difference was mainly related to the appearance of a large thrombus during PCI (6% with iodixanol vs. 0.3% with ioxaglate, P < 0.0001). In multivariate analysis, independent predictors of in-hospital MACE were use of iodixanol (P < 0.01), the higher number of stent used (P < 0.008), bifurcation/ostial lesion (P < 0.01), and balloon dilation before stenting (p < 0.001). CONCLUSIONS: In our study reflecting the current era of PCI, thrombus-related events are more frequent with the isosmolar nonionic dimer iodixanol than with the low osmolar ionic agent ioxaglate.

Predictive factors of cardiac events after implantation of sirolimus-eluting stents for treatment of in-stent restenosis.

BACKGROUND: The factors associated with recurrent restenosis after SES implantation for in-stent restenosis are unknown. This study aimed to assess the clinical outcome and to analyse predictive factors of cardiac events in patients with in-stent restenosis treated with Sirolimus-eluting stent (SES). METHODS: In 3 centers, consecutive patients (n = 100) with elective indication to percutaneous coronary intervention (PCI) for in-stent restenosis (n = 110) were treated with SES: 28 lesions were focal, 40 diffuse, 17 proliferative, and 15 showed total occlusion. RESULTS: SES implantation was successful in all patients, without complication during the first hospital stay. The mean follow-up was 15 (10-24) months. A cardiac event related to the target vessel occurred in 24 (24%) patients, and was associated with dialysis status (p < 0.05), lower ejection fraction (p < 0.05) and revascularization without SES in another site (p < 0.0001). A cardiac event related to the SES occurred in 11 (11%) patients, secondary to an acute or sub-acute thrombosis of the SES (2%), to a late occlusion of the target vessel (4%) or to a non-occlusive restenosis of the SES (5%), and was associated with unstable angina (p < 0.01), multivessel disease (p < 0.03) and revascularization without SES in another site (p < 0.03). No cardiac event related to the SES occurred in patients with direct stenting. Target lesion revascularization for in-SES restenosis or occlusion of the target vessel was performed in 7 (7%) patients, and was associated with unstable angina (p < 0.01) and revascularization without SES in another site (p < 0.01). Target vessel revascularization was needed in 20 patients (20%), related to dialysis status (p < 0.01) and a revascularization without SES in another site (p < .0001). CONCLUSIONS: SESs are effective in the treatment of high risk patients with complex in-stent restenosis. Most of cardiac events during follow-up are related to a revascularization without SES in another site.

Myocardial infarction after endomyocardial biopsy in a heart transplant patient.

In a heart transplant patient who had undergone several endomyocardial biopsies, ultrasound examination revealed severe left ventricular dysfunction after a stroke. Coronary angiography showed a distal left anterior descending artery fistula to the right ventricle. Left ventricular angiogram showed apical dyskinesia. The electrocardiogram and angiographic changes were thought to be due to a myocardial infarction secondary to a postendomyocardial biopsy hematoma, which should be added to the list of possible complications involved in endomyocardial biopsy.