Alexandre Berger

Comparison of in-hospital mortality for acute myocardial infarction in Switzerland with admission during routine duty hours versus admission during out of hours (insight into the AMIS plus registry)

To improve long-term survival, prompt revascularization of the infarct-related artery should be done in patients with acute myocardial infarction (AMI); therefore, a large proportion of these patients would be hospitalized during out of hours. The clinical effects of out-of-hours AMI management were already questioned, with conflicting results. The purpose of this investigation was to compare the in-hospital outcome of patients admitted for AMI during out of hours and working hours. All patients with AMI included in the AMIS Plus Registry from January 1, 1997, to March 30, 2006, were analyzed. The working-hours group included patients admitted from 7 a.m. to 7 p.m. on weekdays, and the out-of-hours group included patients admitted from 7 p.m. to 7 a.m. on weekdays or weekends. Major cardiac events were defined as cardiovascular death, reinfarction, and stroke. The study primary end points were in-hospital death and major adverse cardiac event (MACE) rates. A total of 12,480 patients met the inclusion criteria, with 52% admitted during normal working hours, and 48%, during out of hours. Patients admitted during weekdays included more women (28.1% vs 26%; p = 0.009), older patients (65.5 +/- 13 vs 64.1 +/- 13 years; p = 0.0011), less current smokers (40.1% vs 43.5%; p <0.001), and less patients with a history of ischemic heart disease (31.5% vs 34.5%; p = 0.001). A significantly higher proportion of patients admitted during out of hours had Killips class III and IV. No differences in terms of in-hospital survival rates between the 2 groups (91.5% vs 91.2%; p = 0.633) or MACE-free survival rates (both 88.5%; p = 1.000) were noted. In conclusion, the outcome of patients with AMI admitted out of hours was the same compared with those with a weekday admission. Of predictors for in-hospital outcome, timing of admission had no significant influence on mortality and/or MACE incidence.

Three-year follow-up of the first prospective randomized comparison between paclitaxel and sirolimus stents: the TAXi-LATE trial.

Analysis of the 3‐year outcome of the original population of the TAXi trial which compared the efficacy of the paclitaxel (PES) and the sirolimus (SES) stents in a randomized “real world” investigation.

Closure of ostium secundum atrial septum defect with the atriasept occluder: Early European experience

Objectives: This multicentre study sought to report the safety and efficacy of the ATRIASEPT septal occluder to repair atrial septal defect (ASD). Background: The ATRIASEPT is a low profile, flexible, double disk occluder with centering system specifically designed for closure of ostium secundum ASD. Method: Patients were enrolled from four participating European sites and followed up for 12 months post procedure. Outcomes were evaluated, including closure success and incidence of adverse events. Results: Seventy‐six patients received the ATRIASEPT device. Mean size of the defect was 15 ± 4 mm. Closure success was observed in 69 patients (89%) at the end of the procedure. Sixty‐four patients had a six‐month follow up with a complete closure by 58 patients (90%). Minor adverse events occurred in two patients. Significant functional improvement was reported by all symptomatic patients. Conclusion: Percutaneous closure of ASD ostium secundum type defects with the ATRIASEPT is safe and effective with high success rate and excellent mid‐term outcome.

Occlusion of internal mammary grafts: a review of the potential causative factors.

Abstract The outcome of patient undergoing CABG is largely dependant on the long-term patency of the conduit used. Internal mammary artery (IMA) is considered whenever possible due to its improved long-term functionality over saphenous vein graft. However, a 10% rate of late arterial closure is described without well-known predictors. Chronic competition induced by a moderate coronary lesion on the bypassed native vessel is thought to be a major factor of arterial graft shrinkage even if conflicting data are reported in the available literature. Therefore, the decision to use an IMA to bypass a moderate native coronary lesion should be carefully weighted. When angiography is doubtful, more accurate functional investigations should be considered. Among them, pressure-derived fractional flow reserve could give an immediate answer of whether an intermediate lesion should be bypassed.

Out of hours percutaneous coronary interventions in acute coronary syndromes: long‐term outcome

The management of acute coronary syndromes, comprising ST segment elevation myocardial infarction (STEMI) and non-STEMI, is based on prompt restoration of coronary blood flow. Numerous randomised trials have confirmed that mechanical modalities of revascularisation are superior to pharmacological approaches even when transfer to hospital with catheterisation facilities is considered. A similar success rate of percutaneous coronary intervention (PCI) is difficult to achieve during the night and on weekends, however, due to the specific related settings. Experienced interventional team and a well-established hospital logistics are needed 24 h a day to give adequate treatment within a short time. So far, results have been conflicting in the studies on emergency PCI performed during the normal working day compared with out of hours. We therefore carried out a prospective study to specifically investigate this comparison. All consecutive patients with acute coronary syndromes treated by PCI between 1 August 2001 and 31 August 2003 were prospectively allocated to two groups according to the time of the invasive procedure. Patients with STEMI were enrolled if acute chest pain concomitant to ST segment elevation by more than 1 mm in two contiguous leads was confirmed. Patients with non-STEMI were enrolled if they had acute chest pain with ST segment depression by more than 0.5 mm or negative T waves in at least two contiguous leads or a positive cardiac biomarker (troponin I). Patients were then allocated to the out of hours group if they were treated during …

Aneurysm of the renal artery in a patient with the Marfan syndrome, treated by stenting and coils implantation.

Renal artery aneurysm is rare but is being increasingly encountered due to the wider use of CT scan. The aneurysms are usually discovered incidentally. The etiology included atherosclerosis, fibromuscular disease, and Ehlers–Danlos syndrome [1]. Although the natural history of renal artery aneurysms is not known with certainty, potential complications including embolization and rupture have been reported especially in pregnant women [2]. Indications for treatment remains unclear but current indications include symptomatic or enlarging aneurysms, renal embolization, aneurysms in pregnant females or those considering pregnancy, renovascular hypertension, and aneurysms > 2.5 cm. Surgery, and even autotransplantation have been described and used in most of the cases [3]. More recently percutaneous approaches using covered stents have been reported [4]. Although elegant, the use of covered stents may be associated with a risk of late thrombosis and in some cases are not adapted for anatomical reasons. We report the case of a 38-year-old woman with the Marfan syndrome. Her father had aortic dissection and she had mild hypertension treated with b-blockers. She came to the hospital because of severe and sudden back pain. Clinical examination was unremarkable (BP 130/80; pulse 76). Cardiac and pulmonary auscultation was normal. ECG and blood tests were also normal. Because of the Marfan syndrome, CT scan was performed and showed aneurysm of the primary branch of the left renal artery (Fig. 1A and B). Back pain was considered to be due to the aneurysm, and cure with percutaneous intervention was decided. Implantation of a covered stent was not chosen for the reasons mentioned before. We, thus, decided to implant a conventional stent in the primary branch (Fig. 2) and release coils within the aneuvrysm to close the cavity. The stent is scaffolding that protect the vessel wall from the intrusion of coils. The intervention was performed in local anesthesia. Through a 7 Fr guiding catheter, a 0.014-in. wire (Persuador, Medtronic, Minneapolis, MN, USA) was inserted in the primary branch of the renal artery. A 3.5/16 mm Coroflex (Braun, Tüttlingen, Germany) stent was implanted at a pressure of 12 atm. Then, the stent struts were crossed with a 0.014 wire and a Transit catheter (Cordis, Miami Lakes, FL, USA) was used to deliver the coils. Several different coils (Boston Scientific, Minneapolis, MN, USA) in length and diameter were implanted up to a final length of 90 cm (Figs. 3 and 4). At the end of the procedure the aneurysm was completely closed. A control CT scan the day after the procedure confirmed the patency of the renal artery and of the stented branch as well as the complete occlusion of the aneurysm (Fig. 5A and B). Two months after the intervention the patient was in a good shape and had no complications. She reported a complete cessation of the pain and tension of the back. CT scan or angiography was not performed because of the irradiation induced by these procedures in a young women and the absence of clinical indication. Abdominal ultrasound showed a normal flow in the renal artery and a kidney with a

A propensity score-matched comparison between Cardia and Amplatzer PFO closure devices - insights from the SOLUTION registry (Swiss percutaneOus patent foramen ovale cLosUre in recurrent clinical events prevenTION).

AIMS To compare clinical outcome of Amplatzer PFO (APFO) to Cardia PFO (CPFO) occluder. Percutaneous patent foramen ovale (PFO) closure prevents stroke recurrence in stroke due to paradoxical embolism. METHODS AND RESULTS The primary endpoint was a composite of stroke, TIA, or peripheral embolism at follow-up. The secondary endpoint was residual shunt. Outcome was compared among 934 (APFO: 712; CPFO: 222) patients, and in 297 propensity score-matched patients. The primary endpoint occurred in 29 patients (0.71/100 patient-years): four (2%) with the CPFO (0.31/100 patient-years), and 25 (4%) with the APFO (0.89/100 patient-years) (p=0.20). Residual shunt at six months was more frequent with the CPFO (31% versus 9%, p<0.001). No differences in residual shunts were seen at the last available echocardiographic follow-up (9±18 months): APFO 11%, CPFO 14%, p=0.22. CONCLUSIONS This study suggests that PFO closure with APFO or CPFO is equally effective for the prevention of recurrent events. Residual shunt was more frequent at six months with CPFO, but was similar to APFO at later follow-up.

Direct stenting with a combined intravascular ultrasound-coronary stent delivery platform: a feasibility trial.

IVUS is considered as the most accurate tool for the assessment of optimal stent deployment. Direct stenting has shown to be a safe, efficient, and resource‐saving procedure in selected patients. In a prospective 1‐month feasibility trial, a new combined IVUS‐coronary stent delivery platform (Josonics Flex, Jomed, Helsingborn, Sweden) was evaluated during direct stenting in consecutive patients considered eligible for direct stenting. The feasibility endpoint was successful stent deployment without any clinical adverse event, while the efficacy endpoint was strategic adaptation according to standard IVUS criteria for optimal stent deployment at the intermediate phase (after a result considered angiographically optimal) and at the end of the intervention (after optimization according to IVUS standards). A total of 16 patients were successfully treated with this device without any major clinical complication. At the intermediate phase, optimal stent deployment was achieved in four patients only, while at the end only one patient had nonoptimal IVUS stent deployment. In particular, the minimal in‐stent cross‐section area increased from 6.3 ± 1.2 to 8.3 ± 2.5 mm2. These preliminary data demonstrate the feasibility of direct stenting with a combined IVUS‐stent catheter in selected patients and confirm the results from larger randomized trials on the impact of IVUS on strategic adaptations during coronary stent placement. Cathet Cardiovasc Intervent 2003;59:451–454.

Transcutaneous aortic valve implantation using the carotid artery access: Feasibility and clinical outcomes

BACKGROUND Transcarotid access is an alternative route for transcutaneous aortic valve implantation (TAVI) in patients with impossible transfemoral access. AIMS We evaluated the safety, effectiveness and early and late clinical outcomes of CoreValve® implantation via the common carotid artery. METHODS Eighteen patients (10 men, 8 women; mean age 84±5 years) at high surgical risk (mean EuroSCORE II 16±13%) with significant peripheral artery disease underwent TAVI via common carotid artery access under general anaesthesia. Mean aortic valve area was 0.64±0.13cm2 (0.36±0.07cm2/m2). RESULTS At a mean follow-up of 605±352 days, two patients (11%) had died in hospital, on days 6 and 20, as a result of sepsis with multiorgan failure (n=1) or pneumonia (n=1). There were no perioperative deaths, myocardial infarctions or strokes. Perioperative prosthesis embolization occurred in one patient (6%), requiring implantation of a second valve. In-hospital complications occurred in four patients (23%): blood transfusion for transient significant bleeding at the access site in one patient (6%); permanent pacemaker implantation in two patients (11%); and pericardial drainage in one patient (6%). The rate of event-free in-hospital stay was 66%. Post-procedural echocardiography showed very good haemodynamic performance, with a mean gradient of 8±3mmHg. Moderate paravalvular leak was present in one patient (6%). Mean intensive care unit stay was 48±31h; mean in-hospital stay was 7±3 days. CONCLUSION TAVI performed by transcarotid access in this small series of severely ill patients was associated with a low incidence of complications, which were associated with the procedure itself rather than the access route.

Long-Term Clinical Outcome after Sirolimus-Stent Implantation for in Sirolimus-Eluting Stent Restenosis

Restenosis after sirolimus-eluting stents (SES) remains a clinical problem. We report our experience with the use a second SES in the first SES to treat in-SES restenosis. Twenty-seven patients with in-SES restenosis were included in the registry. In-SES restenosis was focal in 34%, diffuse in 59% and proliferative in 7%. The procedure was successful in all patients without any acute in-hospital complications. During a mean follow-up of 14 ± 7 months MACE occurred in 8 patients (30%), (1 death, 1 myocardial infarction, 4 target lesion revascularisation, 1 target vessel revascularisation and 1 patient underwent CABG). Nineteen patients (70%) had an event-free outcome. In conclusion SES placement to treat in-SES is safe and feasible and could be considered as a therapeutic option. However the incidence of MACE remains high on a long-term period. The use of stents has significantly improved the outcome of percutaneous coronary interventions (PCI) (1,2). However, despite major advances in angioplasty and stenting, in-stent restenosis remains a major limitation. Recently, drug-eluting stents and especially sirolimus-eluting stents (SES) have emerged as a very promising approach in preventing restenosis, and several different compounds have been shown to have a major impact on both the angiographic and the clinical outcome (6-9). However, even after drug eluting stents implantation in-stent restenosis (ISR) remains and represents a clinical challenge. Several approaches have been proposed to deal with ISR like plain old balloon angioplasty (POBA), rotational atherectomy, brachytherapy (1-3). Few reports are actually available about the use of SES in SES for ISR treatment. We report our experience about the use SES for treating an ISR after SES implantation.