Long term clinical outcomes in DES implantation for unprotected left main disease.

AIM: Generate a long term follow-up and evaluate the impact of clinical and procedural characteristics on long term events in percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation for unprotected left main coronary artery (ULMCA) disease. METHODS: Ninety-seven consecutive patients who underwent PCI with DES, either sirolimus (SES) or paclitaxel-eluting stent (PES), for de novo lesions in ULMCA were analyzed. No patients were excluded. Mean follow-up was 3 years (range 1-6.7 years). RESULTS: Technical and procedural success rate were 100% and 95.9%. According to the Academic Research Consortium definitions, cardiac death occurred in 6.1% of patients, reinfarction, target vessel revascularization (TVR) and target lesion revascularization (TLR) occurred in 6.1%, 17.5% and 4.2% of patients respectively. Definite stent thrombosis (ST) incidence was 1%, whereas possible ST occurred in 4.2% of patients. Postdilation was performed in 49.5% of patients and was, among all clinical and procedural characteristics, the only factor at multivariate analysis significantly related to lower MACE (25% vs. 46.9%, P=0.024, CI: 0.202 to 0.889) and TVR (8.3% vs. 26.5%, P=0.03 CI: 0.096-0.895). CONCLUSION: Long term follow-up in PCI of ULMCA disease shows favorable clinical results. Stent postdilation seems to have a protective role in DES PCI for ULMCA disease.

Effects of EPC capture stent and CD34+ mobilization in acute myocardial infarction.

AIM: Percutaneous coronary intervention (PCI) is the gold standard for the treatment of acute myocardial infarction (AMI), with the main limitation of in-stent restenosis for BMS and late stent thrombosis (ST) for both BMS and DES. Endothelial progenitor cells (EPC) CD34+ capture stents, promoting vascular healing, may be advantageous in preventing ST. Aim of the study is to evaluate the outcomes of AMI patients treated with EPC CD34+ capture stent and describe the mobilization kinetics of CD34+ and their clinical correlation. METHODS: Fifty AMI patients underwent primary PCI with EPC CD34+ capture stent. Serial assays of CD34+ were performed by flow-cytometric analysis. RESULTS: Procedural success rate was 100%. At six-months follow-up cardiac death, myocardial infarction, target lesion revascularization (TLR) and target vessel revascularization (TVR) occurred respectively in 2%, 4%, 10% and 12% of patients. No case of ST was observed. The MACE-free survival was 81,2%. The mean peak value of plasmatic CD34+ was 4.69±3.76 cells/µL. A positive correlation was found between CD34+ concentration, age and infarct area. No correlation was detected between CD34+ concentration and occurrence of TVR, TLR and MACE. CONCLUSION: EPC capture stent implantation seems to be safe and effective in the clinical setting of AMI, representing a possible alternative to BMS and DES. CD34+ cells plasmatic concentration seems not to correlate to coronary restenosis and atheromasic disease progression.

Rationale and results of percutaneous coronary revascularization with endothelial progenitor cell capture stent in high-risk patients requiring undeferrable non-cardiac surgery.

AIM: Drug eluting stents (DES) are currently the gold standard for the treatment of significant coronary artery stenosis in high risk patients. In case of undeferrable non-cardiac surgery their use is still a challenge, due to the need of a prolonged dual antiplatelet therapy. We aimed to prospectively evaluate the efficacy and safety of the implantation of endothelial progenitor cells (EPC) capture stent followed by a short dual anti-platelet therapy (DAT) period in a high risk population of patients undergoing undeferrable non-cardiac surgery. METHODS: We examined all consecutive patients who received EPCs capture stents and underwent non-cardiac surgery within 60 days of percutaneous coronary intervention. Our primary outcome was the occurrences of cardiac death, myocardial infarction (MI), stent thrombosis (ST), target vessel revascularization (TVR) and major adverse cardiac events (MACE). RESULTS: Twenty-six patients underwent PCI and were enrolled, but only 20 underwent surgical intervention. Technical and procedural success rates were both 100%. No perioperative MACE was detected. After a mean long term follow-up of 15.4±10.3 months, 2 cases of cardiac death (10%), were recorded. No case of stent thrombosis was reported; no case of ischemia driven TLR was detected. The total MACE-free survival probability was 66.5%. CONCLUSION: EPC capture stent implantation in high-risk patients requiring undeferrable non-cardiac surgery seems to allow early cand safe discontinuation of DAT, and may be an attractive alternative to conventional stents.

[Prehospital management of acute myocardial infarct in an experimental metropolitan system of medical emergencies]. / Gestione preospedaliera dell'infarto miocardico acuto nell'ambito di un sistema di emergenza medica metropolitano sperimentale.

BACKGROUND: Feasibility, safety and efficacy of prehospital management of acute myocardial infarction (AMI) and prehospital thrombolysis have been widely demonstrated. On this background, in March 1992 we started up an Emergency Medical Service (EMS)--Servizio per le Emergenze Cardiologiche Territoriali, SECT--aimed to prehospital care of overall cardiac emergencies (CE), including AMI. The Service, operating in the metropolitan area of Turin (130 Km2, 964,000 inhabitants), is based on a properly equipped ambulance, manned with a physician and a nurse, skilled in treatment of CE. METHODS: From March 1992 to December 1994, 5000 missions were performed, 2586 (51.7%) for chest pain, 1383 (53.5%) of presumed cardiac origin. Within the latter group, 426 (30.8%) cases of AMI, 109 (7.9%) cases of suspected AMI and 848 (61.3%) cases of angina were identified and treated. Decision time in AMI patients (pts) was 189.4 +/- 289.5 min (median 73), longer in pts over 70 years and in women. By means of a direct phone line between Emergency Communication System and metropolitan Coronary Care Units (CCU), 303/423 (71.6%) AMI pts, were directly admitted to CCU. Prehospital thrombolysis (PT) was performed in 211/426 pts (49.5%), with delay from symptom onset of 126.8 +/- 106.1 min (median 93). A rtPA "front loaded" regimen was used, with a full heparin and ASA as adjunctive therapy. Exclusion criteria for PT in 215 pts were: age > 75 years in 109 pts (50.7%), delay from symptom onset > 6 hrs in 55 (25.6%), ST depression in 33 (15.3%), contraindications to thrombolysis in 18 (8.4%). Eligibility to PT was 8.1% in chest pain pts and 43.5% in pts with AMI diagnosis at discharge. Another group of 38 pts underwent thrombolysis in hospital, after a review of inclusion criteria, with a longer delay of 231 +/- 184 min (median 150). RESULTS: Out-of-hospital diagnosis was confirmed in 91% of both AMI pts and PT pts, and in 56.7% of suspected AMI pts. Overall complication rate was 32.1%, with similar rates in PT treated pts and not PT treated pts. Prehospital mortality rate was 0.7%. In-hospital mortality rate was 5.2% in PT pts with confirmed AMI, and 16.2% in not PT pts with confirmed AMI. CONCLUSIONS: Our experience confirm efficacy of out-of-hospital management of AMI within an EMS designed to treat overall CE, considering successful treatment of complications and early thrombolysis with reduction of time delay. Inclusion of SECT in the growing up "118" Emergency Medical System raises logistic questions. Process will be completed when the "medical final authority" will submit each intervention to a full evaluation in terms of efficiency and efficacy, and will not only prepare, as now happens, dispatch and intervention protocols.

[Out-of-hospital cardiac arrest in an experimental model of the management of cardiologic emergencies in a metropolitan area]. / L'arresto cardiaco extraospedaliero in un modello sperimentale di gestione delle emergenze cardiologiche in un'area metropolitana.

Since March 1992, an emergency medical system--EMS--(Servizio Emergenze Cardiologiche Territoriale, SECT) operates in the metropolitan area of Turin (130, 16 Km2), for a population of 964,000 inhabitants. SECT is based on a mobile intensive care unit, staffed with a physician and a nurse, trained in advanced cardiopulmonary resuscitation (CPR) and equipped to treat all cardiac emergencies. According to the "Utstein Style" we report the demographic and clinical features of the patients (pts) suffering Cardiac Arrest (CA) and the impact of SECT on out-of-hospital CA. During 26 months of activity, SECT performed 3,648 missions (most important among these: 457 acute myocardial infarction, 723 angina, 523 arrhythmias, 270 acute heart failure, 154 cardiac arrest), and managed 207 confirmed CA (154 calls for CA, 53 CA occurred after team arrival because of other symptoms). Resuscitation was attempted in 135 pts, in 72 pts medical personnel accerted an irreversible death state. 86% of CA occurred at home. In all cases a cardiac etiology was presumed. All CA were witnessed: 53 by EMS personnel, 82 by lay bystander. In 53 EMS witnessed CA, ventricular tachycardia (VT) or ventricular fibrillation (VF) was showed in 47.2%, asystole in 43.4%, other rhythms (Oth) in 9.4%. Return of spontaneous circulation (ROSC) was obtained in 52.8% pts, 76% in VT/VF Group. 43.4% were admitted alive to intensive care unit (ICU), 68% in VT/VF Group. 37.7% were discharged alive, 64% in VT/VF Group. In 82 lay witnessed CA initial rhythm was VT/VF in 31.7%, asystole in 59.7%, Oth. In 8.6%. CPR was attempted by lay bystander in 28% of cases. ROSC was obtained in 18.3%. CPR was attempted by lay bystander in 28% of cases. ROSC was obtained in 18.3% pts, 42.3% in VT/VF Group. 15.8% were admitted alive to ICU, 34.6% in VT/VF Group. 9.7% pts were discharged alive, 23% in VT/VF Group. Discharged alive rate in lay attempted CPR cases was 17.4%. The collapse-EMS CPR interval was 16 +/- 6.13 min (range 4-29), with a collapse-call receipt interval of 8.57 +/- 5.75 min (range 1-23) and a call receipt-EMS CPR interval of 8.06 +/- 3.56 min (range 2-19). The same intervals are significantly longer in not attempted CPR cases: respectively 26.53 +/- 10.73 min (range 10-65) -p < 0.001-, 19.29 +/- 11.3 min (range 5-60) -p < 0.001- and 8.26 +/- 3.96 (range 3-25) -p = NS-. Although far from the international effectiveness standards, SECT seemed to improve the out-of-hospital CA prognosis. High rate of CA occurred at home, time delay in early access link, better trend in survival in lay bystander attempted CPR cases and lack in early defibrillation lead to strategies for system improvement through targeted CPR training as well as semiautomatic external defibrillators introduction.