Early myocardial surgical revascularization after ST-segment elevation myocardial infarction in multivessel coronary disease: bridge therapy is the solution?

BACKGROUND: Many ST-segment elevation myocardial infarction (STEMI) patients have a multivessel disease that initially require percutaneous coronary intervention (PCI) of the culprit vessel but subsequently may require coronary artery bypass graft (CABG) of nonculprit vessels. Evidence supports staged revascularization, but the identification of optimal strategies (percutaneous or surgical), the timing and the management of antiplatelet therapy after recent PCI with stenting are matters of great controversies. METHODS: In our retrospective registry, we have enrolled 21 patients presenting with STEMI and multivessel disease, who underwent PCI of the culprit vessel only and then CABG of nonculprit vessels. Demographic, clinical, echocardiographic, angiographic findings, preoperative score, surgical data and postoperative complications were collected. At 21.6 ±â€Š15.6 months follow-up death, reinfarction and/or cardiovascular and noncardiovascular events were recorded. RESULTS: Patients were 62 ±â€Š9 years old and had in the most cases a good ejection fraction. At angiography, the culprit lesion was right coronary artery in 16 patients (76%). Angiographic characteristics excluded a staged PCI (SYNTAX score = 31.6 ±â€Š7.4) and European System for Cardiac Operative Risk Evaluation II resulted low (1.46 ±â€Š1.01). Following the indication to cardiac surgery after Heart Team discussion, the withdrawal of oral P2Y12 inhibitor was planned and tirofiban intravenous was started. Off-pump CABG was performed after 7.2 ±â€Š3.2 days. No death, reinfarction and/or cardiovascular and noncardiovascular events occurred at follow-up. CONCLUSION: We can conclude that a careful preoperative selection is mandatory for a good postoperative course and long-term survival and that early-staged CABG can, however, be performed using bridge therapy, also after STEMI.

Prognostic value of clinical, echocardiographic and angiographic indicators in patients with large anterior ST-segment elevation myocardial infarction as a first acute coronary event.

BACKGROUND: The risk of death in patients affected by ST-elevation segment myocardial infarction (STEMI) is well known, but more data are required to define the in-hospital mortality in special subsets. We sought to assess the prognostic value of indicators in patients with large anterior STEMI as a first acute coronary event, undergoing percutaneous coronary intervention (PCI) and intra-aortic balloon pump (IABP). METHODS AND RESULTS: We evaluated 48 consecutive large anterior STEMI patients admitted as first acute coronary event, undergoing in acute phase both PCI and IABP. Patient demographics, clinical, noninvasive and invasive findings, together with in-hospital complications, were collected. Moreover, findings obtained after a 24-month follow-up were reported. The primary endpoint was in-hospital mortality, whereas the secondary endpoints were out of hospital mortality, rehospitalization for heart failure or reinfarction, and New York Heart Association (NYHA) class at least 2 at follow-up visit. The univariate analysis showed a significant association with symptom to balloon, left anterior descending coronary artery, myocardial blush grade, and wall motion score index. Results of the multivariable analysis revealed the strongest predictive power for in-hospital mortality of proximal left anterior descending coronary artery (odds ratio: 6.9; 95% confidence interval: 1.1-67.7) and of myocardial blush grade 0-1 (odds ratio: 5.5; 95% confidence interval: 1.0-38.8). In-hospital death occurred in 13 patients (27% of total cases), whereas, at follow-up, the mean of survival was 66.7 ±â€Š7.0%. CONCLUSION: The patients with large anterior STEMI as a first acute coronary event, undergoing PCI and IABP, had a very high in-hospital mortality, whereas the mortality rate over the follow-up period was lower. The involvement of a large territory at risk and the ineffective treatment in terms of myocardial reperfusion were the main predictors of in-hospital mortality.

Coronary vasomotion dysfunction after everolimus-eluting stent implantation.

First generation drug-eluting stent can cause a paradoxical "in-segment" coronary vasoconstriction. This phenomenon was seen with sirolimus, paclitaxel, and, more recently, also with zotarolimus-eluting stent. For the first time, we describe a case of coronary-induced vasoconstriction by everolimus-eluting stents (EES).