Impact of thrombus burden on procedural and mid-term outcomes after primary percutaneous coronary intervention.

OBJECTIVE: Angiographic thrombus burden (TB) can be assessed early and enable a decision on intervention. The aim of this study was to analyze its effect on the incidence of cardiac events after a primary percutaneous coronary intervention. PATIENTS AND METHODS: We carried out a prospective study of 480 consecutive ST-segment elevation myocardial infarction patients treated by systematic primary percutaneous coronary intervention. Large TB was defined as thrombus length at least 2 vessel diameters or as solid thrombus obtained through catheter aspiration. The primary outcome measure was a composite of death, reinfarction, or target vessel revascularization. RESULTS: A total of 205 (47%) patients fulfilled the criteria for large TB. These patients were more frequently treated with abciximab (62.0 vs. 35.8%, P<0.001), showed more angiographic complications (26.6 vs. 13.7%, P=0.001), and had larger infarcts (peak troponin I, 74 vs. 50 ng/ml, P=0.015). During a follow-up of 19 ± 5 months, the rates of primary outcome were similar between groups of small and large TB (16.2 vs. 12.8%, hazard ratio: 0.88, 95% confidence interval: 0.46-1.67, P=0.691). There were no differences in the rates of definite stent thrombosis (0.5 vs. 2.2%, P=0.190). CONCLUSION: Large TB is associated with larger infarct size, but not with worse mid-term outcomes. Selective use of adjuvant therapies according to TB may be an effective approach to reduce thrombotic complications.

Incidence, angiographic features and outcomes of patients presenting with subtle ST-elevation myocardial infarction.

BACKGROUND: Borderline electrocardiograms represent a challenge in ST-segment elevation myocardial infarction (STEMI) management and are associated with inappropriate discharges and delays to intervention. OBJECTIVES: To assess angiographic characteristics and outcomes of patients presenting with subtle ST-elevation (STE) myocardial infarction. METHODS: A total of 504 consecutive patients with suspected STEMI treated by systematic primary percutaneous coronary intervention were prospectively included. Subtle STE was defined as a maximal preinterventional STE of 0.1 to 1 mm. Angiograms were interpreted by investigators unaware of the electrocardiographic data. RESULTS: The proportion of patients with subtle STE was 18.3%, 86% of them presented with Thrombolysis In Myocardial Infarction flow grade 0/1 and 91% underwent percutaneous coronary intervention. Despite having smaller infarcts, subtle STE patients associated more frequent multivessel disease (57% vs 44%, P = .02) and larger delays to reperfusion. During a follow-up of 19.0 ± 4.9 months, the rates of death or reinfarction were similar among groups (10.0% vs 12.6%, P = .467). Subtle STE was not associated with better outcomes neither in univariate nor after adjustment in a multivariate analysis (adjusted hazard ratio 0.79, 95% CI 0.37-1.69, P = .546). CONCLUSIONS: Subtle STEMI is frequent in clinical practice and is usually associated with acute total coronary occlusion. Therefore, it should be diagnosed and treated in the same expeditiously manner as marked STEMI.

[Analysis of mortality in myocardial infarction patients treated with primary angioplasty]. / Análisis de mortalidad en el infarto de miocardio tratado con angioplastia primaria.

BACKGROUND AND OBJECTIVE: Primary angioplasty is an effective method to achieve myocardial reperfusion in ST-elevated myocardial infarction (MI). The objective of this study was to determine the independent factors that could predict mortality in MI patients treated with primary angioplasty and to analyze the prognostic value of tissue reperfusion parameters in those patients. PATIENTS AND METHOD: A prospective observational study was performed in 380 consecutive patients with ST-elevated MI treated with primary angioplasty at a single hospital. RESULTS: Early mortality was 8.9%. Upon univariate analysis, the following variables were associated with significantly higher mortality: age, ejection fraction (EF), multivascular disease, anterior location of MI, lack of resolution of ST segment, flow 0-1 of TIMI, grade 0-1 of blush index and delay time above 4 hours. Multivariate analysis yielded the following independent variables as predictors of mortality: age, degree of heart failure (Killip index) and degree of myocardial perfusion (blush index). CONCLUSIONS: The independent predictive factors of mortality in patients with ST-elevated MI and treated with primary angioplasty are: age, degree of heart failure (Killip index) and degree of myocardial reperfusion (blush index). The resolution of ST segment and blush index represent additional prognostic variables in patients with good epicardial reperfusion.

Análisis de mortalidad en el infarto de miocardio tratado con angioplastia primaria / Analysis of mortality in myocardial infarction patients treated with primary angioplasty

FUNDAMENTO Y OBJETIVO: La angioplastia primaria es el método de reperfusión de elección en el infarto con elevación del segmento ST. El objetivo de nuestro estudio ha sido determinar cuálesson los factores independientes predictores de mortalidad en los pacientes con infarto de miocardio(IM) sometidos a angioplastia primaria y, por otro lado, analizar la implicación pronósticadel estudio de la perfusión tisular en estos pacientes. PACIENTES Y MÉTODO: Se ha realizado un estudio observacional y prospectivo de 380 pacientes tratados con angioplastia primaria, en el contexto de un IM con elevación del segmento ST, en un único centro. RESULTADOS: La mortalidad intrahospitalaria fue del 8,9%. En el estudio univariante, las variables asociadas a una mayor mortalidad fueron: la edad, la fracción de eyección, la enfermedad multivaso, la localización anterior del IM, la falta de resolución del segmento ST, el flujo TIMI0 o 1 en la arteria causante del IM, los grados 0 o 1 del índice de blush y un tiempo de demor superior a 4 h. En el análisis multivariante las variables independientes predictoras de mortalidad fueron la edad, el grado de insuficiencia cardíaca, valorada con la escala Killip, y elgrado de perfusión tisular, valorada con el índice de blush. CONCLUSIONES: Los factores independientes predictores de mortalidad en los pacientes con IM con elevación del segmento ST tratados con angioplastia primaria son la edad, el grado de insuficiencia cardíaca según la escala Killip y el grado de reperfusión miocárdica según el índicede blush. La resolución del segmento ST y el índice de blush poseen un valor pronóstico adicionalen los pacientes con buena reperfusión epicárdica (AU)

BACKGROUND AND OBJECTIVE. Primary angioplasty is an effective method to achieve myocardial reperfusion in ST-elevated myocardial infarction (MI). The objective of this study was to determine the independent factors that could predict mortality in MI patients treated with primary angioplasty and to analyze the prognostic value of tissue reperfusion parameters inthose patients. PATIENTS AND METHOD. A prospective observational study was performed in 380 consecutive patients with ST-elevated MI treated with primary angioplasty at a single hospital. RESULTS. Early mortality was 8,9%. Upon univariate analysis, the following variables were associated with significantly higher mortality: age, ejection fraction (EF), multivascular disease, anterior location of MI, lack of resolution of ST segment, flow 0-1 of TIMI, grade 0-1 of blush indexand delay time above 4 hours. Multivariate analysis yielded the following independent variables as predictors of mortality: age, degree of heart failure (Killip index) and egree of myocardial perfusion (blush index). CONCLUSIONS. The independent predictive factors of mortality in patients with ST-elevated MI and treated with primary angioplasty are: age, degree of heart failure (Killip index) and degreeof myocardial reperfusion (blush index). The resolution of ST segment and blush index represent additional prognostic variables in patients with good epicardial reperfusion (AU)

[Percutaneous intervention for severe aortic stenosis and left main artery disease in a morbidly obese patient]. / Tratamiento percutáneo de estenosis aórtica y lesión de tronco coronario izquierdo severa en paciente con obesidad mórbida.

Obesity increases significantly the rate of postsurgical complications and mortality in patients undergoing major surgery. We present the case of a morbidly obese 65-year-old female with severe aortic stenosis and left main coronary artery disease who underwent successful aortic valvuloplasty and angioplasty, with placement of a stent in the left main coronary artery. After undergoing bariatric surgery and losing 30% of her body weight, the patient was accepted for cardiac surgery to replace the aortic valve and to bypass the left anterior descending coronary artery using the mammary artery. There were no surgical complications.

Tratamiento percutáneo de estenosis aórtica y lesión de tronco coronario izquierdo severa en paciente con obesidad mórbida / Percutaneous intervention for severe aortic stenosis and left main artery disease in a morbidly obese patient

La obesidad es un factor de riesgo para el desarrollo de complicaciones posquirúrgicas e incrementa de forma significativa la tasa de mortalidad intrahospitalaria. Presentamos el caso de una mujer de 65 años con obesidad mórbida, estenosis aórtica severa y enfermedad de tronco que se trató con éxito mediante valvuloplastia aórtica y angioplastia e implantación de stent en tronco coronario izquierdo. Tras una intervención quirúrgica bariátrica y perder el 30% de su peso, la paciente fue aceptada en cirugía cardíaca y se le realizó recambio valvular aórtico y bypass de mamaria a la descendente anterior (DA) sin complicaciones

Obesity increases significantly the rate of postsurgical complications and mortality in patients undergoing major surgery. We present the case of a morbidly obese 65-year-old female with severe aortic stenosis and left main coronary artery disease who underwent successful aortic valvuloplasty and angioplasty, with placement of a stent in the left main coronary artery. After undergoing bariatric surgery and losing 30% of her body weight, the patient was accepted for cardiac surgery to replace the aortic valve and to bypass the left anterior descending coronary artery using the mammary artery. There were no surgical complications