Feasibility limits of transradial primary percutaneous coronary intervention in acute myocardial infarction in the real life (TRAP-AMI).

BACKGROUND: There is growing evidence that transradial (TRI) as compared to transfemoral (TFI) percutaneous coronary intervention (PCI) is associated with improved clinical outcome driven by less hemorrhagic complications, in particular in STEMI patients receiving aggressive antithrombotic treatment. Feasibility rate of TRI in STEMI patients has not yet been evaluated. METHODS/RESULTS: Four-hundred seventy-five consecutive STEMI patients (<12h) without cardiogenic shock were prospectively screened for this all-comer single-centre registry between January 2008 and August 2010. Nine patients were excluded for a priori ineligibility for TRI (forearm shunt for dialysis, prior TRI failure). In the 466 patients enrolled, the operator's opinion about ease of radial puncture was assessed in 4 categories, based on radial pulse quality. Operators were advised not to attempt TRI if ease of puncture was judged "probably difficult/impossible". In case of puncture failure the operator switched immediately to TFI. The mean age of patients was 61 ± 14 (range 27-94) years. Seventy-three percent were men, 17% had diabetes. Nine percent had previous PCI. Glycoprotein inhibitors were used in 70%, and thrombectomy was performed in 70% of patients. PCI was performed using 6F and 5F guiding catheters. Procedural success rate was 98.2% (TIMI flow ≥ 2). In 4.1% (n=19) of patients the operator judged ease of radial puncture "probably difficult/impossible" and no TRI attempt was performed (primary TFI). In the 447 patients with TRI attempt, TRI failure requiring switch to TFI (secondary TFI) was necessary in 22 patients (4.7% of total) following radial puncture failure (n=15), dissection of the radial artery (n=1), prohibitive tortuosities or stenosis of the upper limb axis (n=2), or non-selective position or lack of stability of the guiding catheter (n=2). After the start of the angioplasty procedure, switch from TR to TF was not necessary in any patient. In total, the overall feasibility rate of TRI was 91.2%. Independent predictors of final TFI were age ≥ 80 years (adjusted OR: 2.37; 95% CI:1.05-5.34, p=0.037), body weight<60 kg (adjusted OR: 2.84; 95% CI:1.22-6.59, p=0.015); and previous PCI (adjusted OR: 3.42; 95% CI:1.40-8.37, p=0.007); female gender was borderline significant (adjusted OR:2.10; 95% CI:0.97-4.54, p=0.059). CONCLUSION: In STEMI patients without cardiogenic shock and without a priori indication for TFI, PCI can be performed via the radial artery in more than 90% of cases with high procedural success rate. Operator's judgement of eligibility for TRI based on radial pulse quality is predictive of successful TRI in 95% of cases. TR failure is significantly more common in the elderly and in patients with low body weight.

Native valve infective endocarditis in a tertiary care center in a developing country (Tunisia).

The aim of the study was to describe the epidemiological and clinical aspects of native valve infective endocarditis (IE) in a Tunisian high-volume tertiary care center and to identify the predictors of outcome. Demographic, clinical, laboratory, and echocardiographic characteristics were examined in 134 patients who fulfilled the modified Duke criteria for native valve IE between January 1997 and December 2006. Logistic regression analysis was used to identify prognostic factors for death. Mean age was 34.22 years. Diagnosis was definite in 93% of cases. Median time to diagnosis was 21 days. Rheumatic heart disease (RHD) was the predominant (45%) underlying heart condition. One or more vegetations were detected in more than 93% of cases. The median size of vegetation was >15 mm in 28% of cases. In 66 cases (49%), cultures remained negative. Serology was positive in 15 cases, and in 4 cases leaflet culture identified the agent. The infective agent was identified in 87 cases (65%), causative microorganisms were mainly Staphylococci (n = 30, including 6 coagulase-negative Staphylococcus), and Streptococci (n = 32). Overall mortality was 19%. On multivariate analysis, congestive heart failure (hazard ratio = 5.34, 95% confidence interval 1.67 to 17.15, p = 0.005) and large vegetations (>15 mm; hazard ratio = 5.78, 95% confidence interval 1.84 to 18.32, p = 0.002) were predictive of in-hospital mortality but not neurological complications or staphylococcus IE. In conclusion, IE remains a serious disease affecting a young population in Tunisia, with RHD as still the most common underlying heart disease, and it is associated with a high mortality.