Brunon Tomasiewicz

Patients with acute myocardial infarction and severe target lesion calcifications undergoing percutaneous coronary intervention have poor long-term prognosis

BACKGROUND To assess the influence of severe target lesion calcification (TLC) on the outcomes of patients undergoing percutaneous coronary interventions (PCI) due to acute myocardial infarction (AMI). AIM Contemporary data concerning coronary artery calcifications (CAC) are based on pooled analyses from randomised trials with short follow-up. We still lack the knowledge on how CAC in target lesions affect long-term prognosis of patients with AMI in everyday practice. METHODS We evaluated clinical and laboratory data of 206 consecutive patients who underwent coronary angiography and PCI due to AMI. Primary endpoints were all-cause death and recurrent hospitalisations due to acute coronary syndrome (ACS). RESULTS Severe TLC lesions were present in 17% of patients. These patients were older (71 vs. 65 years, p = 0.02) and more often diagnosed with non-ST segment elevation myocardial infarction (77% vs. 58%, p = 0.03). Patients with severe TLC had lower rates of PCI success (80% vs. 97%, p < 0.0001) and less often achieved full revascularisation during index procedure (14% vs. 41%, p = 0.003). During 30 months follow-up patients with severe TLC more often suffered from another ACS (37% vs. 13%, p = 0.0005) and had higher all-cause mortality (31% vs. 16%, p = 0.04). Multivariate Cox regression model showed severe TLC to be an independent predictor of another ACS (HR 2.8; 95% CI 1.4-5.6; p = 0.004). CONCLUSIONS Severe TLC are not uncommon in patients with ACS. The presence of severe TLC is a prognostic factor of another ACS in AMI patients undergoing PCI.

Novel predictors of outcome after coronary angioplasty with rotational atherectomy. Not only low ejection fraction and clinical parameters matter

Introduction Most established risk factors after rotational atherectomy (RA) of heavily fibro-calcified lesions are associated with patients’ general risk and clinical related factors and are not specific for either coronary and culprit lesion anatomy or the RA procedure. Aim To assess novel predictors of poor outcome after percutaneous coronary intervention using RA in an all-comers population. Material and methods A total of 207 consecutive patients after RA were included in a single-center observational study. Primary endpoints were 1-year mortality and 1-year major adverse cardiac events (MACE). Secondary endpoints were angiographic and procedural success and in-hospital complications. Results Procedural complications occurred in 19 (8%) patients. In-hospital mortality was 1%, peri-procedural myocardial infarction (MI) was 9%, and acute stroke occurred in one patient. The 1-year MACE rate was 20% with all-cause mortality 10%, MI 10% and stroke 1%. Multivariable analysis revealed heart failure with left ventricle ejection fraction (LVEF) ≤ 35% (p = 0.02) and uncrossable lesion, as compared to undilatable lesion (p = 0.01), as independent predictors of 1-year mortality and residual SYNTAX score ≤ 8 as an independent predictor of favorable outcome (p = 0.04). Heart failure with LVEF ≤ 35% (p < 0.01) and uncrossable lesion (p = 0.04) were independent predictors of 1-year MACE. Conclusions The presence of a novel factor, uncrossable lesion, as compared to undilatable lesion, is associated with poor outcome, and low residual SYNTAX score ≤ 8 is associated with favorable outcome in 1-year follow-up after the RA procedure and can help in risk stratification of patients undergoing complex coronary intervention with RA.

Left ventricle assist device supported rotational atherectomy of the highly calcified last remaining vessel in a patient with acute myocardial infarction and reduced left ventricular function

An 84-year-old man with history of myocardial infarction (MI) and poorly controlled hypertension was admitted to the orthopaedics department due to femoral neck fracture. Just after right hip hemiarthroplasty the patient reported acute chest pain. Electrocardiogram showed ST segment depression in leads I, II, V4–V6. Highly sensitive troponin I was raised to 3.489 (N < 0.059) ng/mL. Echocardiography revealed decreased left ventricular ejection fraction (LVEF) 40% and diffused wall motion abnormalities. The patient was diagnosed with non-ST segment elevation MI and referred to urgent coronary angiography, which showed severe calcifications in all coronary arteries and proximal occlusion in both the circumflex and right coronary artery (RCA). Left anterior descending artery (LAD), the last remaining vessel giving collaterals to RCA, revealed highly calcified 80% stenosis in the proximal segment (Fig. 1). The heart team decided that high-risk percutaneous coronary intervention (PCI) with rotational atherectomy optimally with left ventricle assist device (LVAD) is the best therapeutic option. The procedure began by placing an Impella CP (Abiomed, USA) into the left ventricle via the left femoral artery. The left coronary artery was intubated with an EBU 3.75/7 F guiding catheter via right femoral access. Due to ectasia in LAD wiring was extremely difficult, time consuming, and possible only after use of a microcatheter. The highly calcified lesion in the proximal part of the vessel was resistant to rotational atherectomy and subsided only after 18 runs with 1.5 mm burr at 145,000 rpm (Fig. 2). Just after the last burr passage, slow flow in the LAD occurred. The patient became bradycardic and his blood pressure dropped to 50/20 mm Hg. Simultaneously maximal Impella flow (4 L/min) was established. External cardiac massage was about to be started but finally was not induced because the patient improved quickly after increasing Impella flow. Within minutes his blood pressure gradually increased to a stable level. No catecholamines were required. The procedure was continued with 1.75 mm burr for following seven runs with no other complications. After successful predilatation two Synergy (Boston Scientific, USA) stents 3.5/38 mm and 4.0/24 mm were implanted. Postdilatation with noncompliant balloons provided an optimal final result (Fig. 3). After the procedure the patient was completely angina free. Standard pharmacotherapy was recommended. Rotational atherectomy of the last remaining vessel in patients with decreased LVEF and with MI is considered contraindicated due to increased risk of slow/no-flow phenomenon, which could easily lead to rapid deterioration of the patient’s haemodynamics. However, in this patient no other therapeutic option was possible. This case shows that careful planning and appropriate preparation with LVAD implantation prior to the procedure allows the prevention of potentially fatal complications of high-risk PCI. Continuous haemodynamic support ensured by LVAD allows elaborated and often lifesaving procedures to be performed in very high-risk patients. To our knowledge this is the first such case published in Polish literature.

TCT-238 Outcomes and clinical predictors of mortality of patients treated with rotational atherectomy: a single center registry

100, 34, and 1476 of these patients, respectively. TVF at 2 years occurred in 22.1% of the patients treated with RA, 25.0% treated with cutting balloon, and 17.1% treated with balloon angioplasty only; these rates were predominantly driven by target vessel revascularization (15.2%, 14.4%, and 9.5%, respectively). The propensity score-adjusted hazard ratio for TVF associated with RA vs angioplasty alone or cutting balloon was 1.08 (95% CI 0.69-1.68, p1⁄40.73).

Mechanical stent failure as a cause of life-threatening left main restenosis

A 67-year-old woman with a history of diabetes, hypertension, severe obesity and hypercholesterolemia was admitted to our center with the diagnosis of non ST-segment elevation myocardial infarction. Electrocardiography showed 3 mm ST-segment depressions in leads I, aVF, and V3–V6 and elevation in lead aVR. Troponins were positive and ejection fraction assessed in echocardiography was 50%, without valve abnormalities. Five months earlier, the patient underwent elective percutaneous coronary intervention (PCI) of the left main coronary artery (LMCA) and left anterior descending artery (LAD) using 2 overlapping everolimus-eluting stents (Promus-Premier, Boston Scientific): 3.5/32 mm to the LMCA/LAD and 2.5/32 mm to the LAD with non-compliant 4.0 mm balloon high pressure postdilatation in the LMCA and with full expansion, an optimal angiographic result, unfortunately without intravascular ultrasound (IVUS) assistance. Qualification for PCI at that time followed the Heart Team meeting and discussion with the patient (low values of both Syntax-Score (21) and EuroSCORE II (0.9%)) – she preferred the option of PCI more than coronary artery bypass grafting (CABG).

Multilevel embolic protection in a patient with acute myocardial infarction and a huge thrombus in the right coronary artery

A 51-year-old man, a smoker with poorly controlled hypertension and obesity, was admitted to our centre with recurrent resting chest pain for the preceding 24 h. Electrocardiography showed sinus rhythm 80/min with 1-mm ST-segment elevation with negative T waves in V1, II, III, and aVF, and troponin level was positive. After administration of unfractioned heparin, clopidogrel, acetylsalicylic acid, nitroglycerin, and morphine the patient was transported to a catheterisation laboratory for urgent coronary angiography. The procedure was performed via right radial artery and revealed 80% stenosis of medial left anterior descending artery and proximal occlusion of dominant right coronary artery with massive thrombus (Fig. 1). After right coronary artery intubation with a 6 F guiding catheter a Fielder wire (Asahi) was placed distally in the artery. Abciximab was administered intravenously and several aspirations of Eliminate thrombectomy catheter (Terumo, 6 F compatible) were performed, but with little success. Taking into consideration the persistent huge thrombus and the risk of “no-flow” phenomenon we decided to insert a Filter-Wire (Boston Scientific) for distal protection and to use a self-expanding stent Stentys-DES (Stentys) 3.5–4.5/27 mm (Fig. 2), which was successfully placed and postdilated by a 4.5/15 mm balloon to 15 atm. The result was TIMI-3 flow with clinical stabilisation (Fig. 3). Thrombus debris was evacuated from the thrombectomy catheter and from the filter (Fig. 4). Echocardiography performed 2 days later revealed akinesis of the basal segment of the inferior wall with preserved ejection fraction. The patient was discharged home 4 days after the procedure; dual antiplatelet therapy (for 12 months) and remaining standard therapy was recommended. Treatment should always be individualised according to the patient’s conditions. We decided to open the artery and prevent “no-flow” phenomenon in quite an aggressive manner. Abciximab was used routinely in patients with acute myocardial infarction and huge thrombus burden. In our opinion manual thrombectomy, in spite of currently only IIb class recommendation, is very helpful in such cases as well. We also used a self-expandable stent instead of a balloon-expandable stent. These kinds of stent proved their efficacy in APPOSITION trials. They adhere closely to the vessel wall in patients with acute myocardial infarction and prevent distal embolisation of thrombi. We inserted additionally a Filter-Wire as distal protection. Although distal filters are recommended only for interventions in venous grafts, we decided to use it in this particular case, with optimal final result. We conclude that for more complex procedures heterogeneous devices should be available in high-volume catheterisation laboratories.

Impact of pre-hospital electrocardiogram teletransmission on time delays in ST segment elevation myocardial infarction patients: a single-centre experience

Introduction Delay in diagnosis and treatment has a great influence on morbidity and mortality of ST-segment elevation myocardial infarction (STEMI) patients. Every 30 min of delay in reperfusion is associated with an 8% increase in mortality. ECG teletransmission was proved to effectively shorten time delays in STEMI treatment. In 2012 an ECG teletransmission program was introduced in the Lower Silesia region. Aim To assess the frequency of ECG teletransmission in STEMI patients and its influence on time delays. Material and methods We conducted a retrospective analysis of all patients admitted to our hospital with STEMI in 2013. Time delays, treatment and clinical characteristics of patients with and without teletransmission performed were compared. Results The study included 137 patients, of whom 49 (36%) had teletransmission performed. Direct transport to a percutaneous coronary intervention (PCI)-capable hospital was more frequent in patients with ECG teletransmission performed (88% vs. 63%, p = 0.002). In patients with teletransmission pain-emergency room time and total ischemic time were shorter (respectively 125 (91–184) min vs. 201 (113–339) min, p = 0.001 and 159 (136–244) min vs. 259 (170–389) min, p < 0.001). There were no differences in in-hospital delay, patients’ characteristics, or applied therapy. Conclusions The percentage of STEMI patients who had ECG teletransmission performed was low. Patients with ECG teletransmission had a shorter total ischemic time and lower percentage of indirect transport to a PCI-capable hospital.