Balaji Pakshirajan

Coronary intervention in anomalous origin of the right coronary artery (ARCA) from the left sinus of valsalva (LSOV): A single center experience

OBJECTIVE To assess the technical challenges in percutaneous coronary intervention of Anomalous right coronary artery arising from the left sinus of valsalva. METHODS Between year 2008 and 2012, a total of 17 patients underwent PCI for an angiographically significant lesion in the right coronary artery of an anomalous origin in the LSOV. Their procedure details such as usage of catheters, radiation time, amount of contrast used were assessed. RESULTS A total of 17 patients with anomalous right coronary artery underwent PCI during the above mentioned period. 8 patients had type A origin, 3 had type B origin and the remaining 6 had type C origin. Type A origin RCA were successfully cannulated in 6 patients with Judkins left 5.0 and in 2 patients using Judkins left 4.0. Extra back up (EBU) 3.5 were doing well in 2 patients of Type B origin and the remaining one patient was successfully cannulated using Judkins left 4.0. In type C origin 4 patients had successful cannulation with Amplatz Left 1.0, 1 patient with Amplatz Left 2.0 and 1 patient with Judkins left 4.0. The mean fluoroscopic time was 20.7 min and amount of contrast used was 210 ml. CONCLUSION PCI of anomalous RCA origin from LSOV requires appropriate guide catheter selection according to the anatomy of origin for successful cannulation and to reduce the contrast usage and radiation exposure.

Outcome of primary PCI – An Indian tertiary care center experience

Objective To assess the feasibility and outcomes of primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) in Indian Scenario. Methods Between January 2005 and December 2012, consecutive STEMI patients who underwent PPCI within 12 h of onset of chest pain were prospectively enrolled in a PPCI registry. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital and 30 day major adverse cardiovascular events (MACE) [death, reinfarction, bleeding, urgent coronary artery bypass surgery (CABG) and stroke] were assessed. Results A total of 672 patients underwent PPCI during this period. The mean age was 52 ± 13.4 years and 583 (86.7%) were males, 275 (40.9%) were hypertensives and 336 (50%) were diabetics. Thirty one (4.6%) patients had cardiogenic shock (CS). Anterior myocardial infarction was diagnosed in 398 (59.2%) patients. The median chest pain onset to hospital arrival time, door-to-balloon time and total ischemic times were 200 (10–720), 65 (20–300), and 275 (55–785) minutes respectively. In-hospital adverse events occurred in 54 (8.0%) patients [death 28 (4.2%), reinfarction 8 (1.2%), major bleeding 9 (1.3%), urgent CABG 4 (0.6%) and stroke 1 (0.14%)]. Nineteen patients with CS died (mortality rate – (61.3%)). At the end of 30 days, 64 (9.5%) patients had MACE [death 35 (5.2%), reinfarction 10 (2.1%), major bleeding 10 (1.5%), urgent CABG 4 (0.6%) and stroke 1 (0.1%)]. Conclusion Our study has shown that PPCI is feasible with good outcomes in Indian scenario. Even though the recommended door-to-balloon time can be achieved, the total ischemic time remained long. CS in the setting of STEMI was associated with poor outcomes.

Primary Percutaneous Thrombus Aspiration Alone as Definitive Intervention for Left Main Coronary Artery Occlusion Presenting as Acute Anterior Wall ST Elevation Myocardial Infarction

Primary angioplasty and stenting remains the standard of care for patients presenting with acute ST-segment elevation myocardial infarction. Recently, thrombus aspiration has been shown to improve the myocardial perfusion and outcomes in STEMI. In a subset of patients thrombus aspiration may result in optimal perfusion and minimal residual stenosis. These patients may be managed without additional stenting. Three patients with anterior wall STEMI were successfully managed with thrombus aspiration alone without additional stenting. All three are doing well at 30 day follow up with significant improvement in left ventricular ejection fraction.

☆Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI—A tertiary care center experience

Background Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival. Materials and methodolgy During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017). Results Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR = 0.99, 0.99–1; p = 0.02), left ventricular ejection fraction (LVEF) (OR = 0.90, 0.82–0.98; p = 0.02), need for cardio-pulmonary resuscitation (OR = 0.12, 0.24–0.66; p = 0.01), and post PCI TIMI flows (OR = 0.08, 0.02–0.29; p < 0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2. Conclusion Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset.

Registry to evaluate early and long-term disease management in PAH (REVEAL)

Pulmonary artery hypertension (PAH) is a condition with significant clinical symptoms, poor quality of life and early mortality. Heath-Edwards classification which was based primarily on pulmonary vascular histology changes include a spectrum of lesions like vasoconstriction, intimal hyperplasia, medial hypertrophy, plexiform arteriopathy, perivascular inflammation, and thrombotic lesions within the pulmonary vasculature (1-3).

Prevalence of parameters of suboptimal scaffold deployment following angiographic guided bioresorbable vascular scaffold implantation in real world practice - an optical coherence tomography analysis

AIM To assess the prevalence of suboptimal bioresorbable vascular scaffold (BVS, Abbott Vascular, Santa Clara, California) deployment in real world practice with intracoronary optical coherence tomography (OCT) imaging. METHODS Consecutive patients who underwent percutaneous coronary intervention using BVS and the final optimization assessed with OCT imaging in two tertiary care centers between December 2012 and February 2015 were evaluated for parameters of suboptimal scaffold deployment by OCT. RESULTS Overall, 36 scaffolds were implanted in 27 patients during this period. Mean age of the population was 54.7±8.2years and 19 (70.4%) were type B2/C lesions. The prevalence of parameters of suboptimal scaffold deployment were: underexpansion-22(61.1%), geographic miss-3(8.3%), tissue prolapse-7(25.9%), scaffold pattern irregularity-1(2.8%), longitudinal elongation-7(38.8%). Of the 7 overlaps imaged: excessive overlap was observed in 3 and scaffold gap in one. The median duration of follow up was 679days (range 193-963days). There were four events during this period. None were associated with suboptimal scaffold deployment. CONCLUSION OCT based parameters of suboptimal scaffold deployment are common in real world scenario and were not associated with adverse outcomes on long term follow up. These findings need to be confirmed in larger studies.