Chi-Ling Hang

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock

Objectives:This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention. Methods:Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2). Results:The incidence of profound shock (defined as systolic blood pressure remaining ≤75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups (21.7% vs. 21.0%, p > .5). Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room. The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups (p = .678). However, total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1 (all p < .04). Additionally, the hospital survival time was remarkably longer in patients in group 2 than in patients in group 1 (p = .0005). Furthermore, multivariate analysis demonstrated that unsuccessful reperfusion, presence of advanced congestive heart failure, profound shock, and age were independent predictors of 30-day mortality (all p < .02). Conclusion:Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.

Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting.

Although sporadic successful cases using the transradial approach (TRA) for carotid stenting have been reported, the safety and feasibility of carotid stenting using either TRA or a transbrachial approach (TBA) have not been fully investigated. Recently, we have developed a safe and feasible method of TRA for cerebrovascular angiographic studies. This study investigated whether a TBA approach using a 7‐French (F) Kimny guiding catheter for carotid stenting is safe and feasible for patients with severe carotid stenosis. Thirteen patients were enrolled into this study (age range, 63–78 years). Seven of these 13 patients had severe peripheral vascular disease. A retrograde‐engagement technique, involving looping 6‐F Kimny guiding catheter, was utilized for carotid angiographic study. For carotid stenting, the 6‐F Kimny guiding catheter was replaced with a 7‐F Kimny guiding catheter, and the procedure was performed as the follows. First, an extra‐support wire was inserted into the middle portion of external carotid artery (ECA). Second, a 0.035‐inch Teflon wire was advanced into the common carotid artery. Then, the 6‐F guiding catheter was exchanged for a 7‐F Kimny guiding catheter. Third, if the first and second steps did not provide adequate support for exchanging the guiding catheter, a PercuSurge GuardWire™ was inserted into the ECA, followed by distal balloon inflation for an anchoring support. FilterWire EX™ was used in 9 patients and PercuSurge GuardWire in 4 patients to protect from distal embolization during the procedure. The procedure was successful in all patients. No neurological or vascular bleeding complications were observed and all patients were discharged uneventfully. The TBA for carotid stenting was safe and effective, providing a last resort for patients unsuited to femoral arterial access and surgical intervention.

Clinical features and outcome of coronary artery aneurysm in patients with acute myocardial infarction undergoing a primary percutaneous coronary intervention.

Background: While coronary artery aneurysm is an uncommon anatomic disorder and has various forms, its clinical features and outcome and its impact on thrombus formation and the no-reflow phenomenon in the clinical setting of acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (p-PCI) have not been discussed. The purpose of this study was to evaluate whether this anatomic disorder predisposes to a high burden of thrombus formation, and subsequently leads to the no-reflow phenomenon and untoward clinical outcome in patients with AMI undergoing p-PCI. Methods and Results: In our hospital, emergency p-PCI was performed in 924 consecutive patients with AMI between May 1993 and July 2001. Of these 924 patients, 24 patients (2.6%) who had an infarct-related artery (IRA) with aneurysmal dilatation were retrospectively registered and constituted the patient population of this study. Angiographic findings demonstrated that the ectasia type (defined as diffuse dilatation of 50% or more of the length of the IRA) was found most frequently (70%), followed by the fusiform type (20%; defined as a spindle-shaped dilatation in the IRA) and the saccular type (10%; defined as a localized spherical-shaped dilatation in the IRA). The right coronary artery was the most frequently involved vessel (54.2%), followed by the left anterior descending (25.0%) and the left circumflex arteries (20.8%). Coronary angiography revealed that all of these aneurysmal IRA filled with heavy thrombus (indicated as high-burden thrombus formation). The no-reflow phenomenon (defined as ≤TIMI-2 flow) and distal embolization after p-PCI were found in 62.5 and 70.8% of the IRA, respectively. The incidence of cardiogenic shock and the 30-day mortality rate were 25 and 8.3%, respectively. The survival rate was 90.9% (20/22) during a mean follow-up of 19 ± 30 months. Conclusions: While aneurysmal dilatation of an IRA is an uncommon angiographic finding in the clinical setting of AMI, it is frequently associated with high-burden thrombus formation and has a significantly lower incidence of successful reperfusion. However, the long-term survival of these patients is excellent.

Level and value of circulating endothelial progenitor cells in patients with acute myocardial infarction undergoing primary coronary angioplasty: in vivo and in vitro studies

Levels of circulating endothelial progenitor cells (EPCs) in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary coronary intervention (PCI) were investigated in this study. Flow cytometric analysis of the circulating EPC level (CD31/CD34 [E(1)], CD62E/CD34 [E(2)], and KDR/CD34 [E(3)]) was determined from blood samples of 161 consecutive patients with STEMI undergoing primary PCI. Angiogenesis was evaluated using mononuclear cell-derived EPCs on Matrigel. The EPC number (E(1-3)) was lower in STEMI patients than in normal subjects (n = 25) (P < 0.005). Patients with high EPCs (E(1-3)) (≥1.2%) had a lower left ventricular ejection fraction, elevated white blood cell count and creatinine level, advanced Killip score (≥class 3), more advanced congestive heart failure (CHF) (≥class 3), and increased 30-day mortality than those with a low EPC (E(1-3)) level (<1.2%) (P < 0.0001). Angiogenesis was lower in patients with a high EPC level than those with a low EPC level and normal controls (P < 0.001). Both the advanced Killip score and the CHF were independent predictors of increased EPC levels (P < 0.05). Multivariate analysis identified a high EPC (E(3)) level to be the most important predictor of increased 30-day major adverse clinical outcome (MACO) (P < 0.0001). In conclusion, the circulating EPC level is a major independent predictor of 30-day MACO in patients with STEMI undergoing primary PCI.

Outcomes of patients with Killip class III acute myocardial infarction after primary percutaneous coronary intervention.

Objectives:Little is known about the outcomes of patients with Killip class III acute ST-segment elevation myocardial infarction in the reperfusion era. This study investigated the short- and long-term outcomes of these patients who underwent primary percutaneous coronary intervention. Methods:Between January 2002 and November 2009, a total of 1,278 consecutive patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 230 (17.0%) with Killip III, 216 (16.9%) with Killip II, and 832 (65.1%) with Killip I upon presentation were prospectively recruited. Results:Angiographic study showed significantly lower final thrombolysis in myocardial infarction 3 flow in patients with Killip III compared with those with Killip II and I (83.5% vs. 94.9% vs. 95.7%, p < .0001). The incidence of multiple vessel disease was also notably higher in Killip III than in Killip II and I (65.7% vs. 13.9% vs. 53.8%, p < .001). Besides, the incidence of advanced congestive heart failure (defined as greater than or equal to New York Heart Association functional class 3) during hospitalization was remarkably higher in Killip III compared to Killip II and I (71.3% vs. 13.9% vs. 6.6%, p < .001). Furthermore, the 30-day mortality and 1-yr cumulative mortality were notably higher in Killip III than in Killip II and I (20.0% vs. 4.2% vs. 1.7%, p < .001 and 31.7% vs. 7.9% vs. 4%, p < .001, respectively). Multivariate analysis showed that Killip III was independently predictive of 30-day and 1-yr mortality (all p < .04). Conclusion:Killip III remains strongly and independently predictive of 30-day and 1-yr mortality in ST-segment elevation myocardial infarction patients even undergoing primary percutaneous coronary intervention.

Predictors of contrast-induced nephropathy in chronic total occlusion percutaneous coronary intervention

AIMS Contrast-induced nephropathy (CIN) is a leading cause of morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI). Limited data, however, are available on predictors of CIN in PCI for chronic total occlusion (CTO) lesions. The aim of the study was to determine the risk of developing CIN in patients undergoing CTO PCI by studying the effects of clinical variables, interventional techniques, and CTO lesion characteristics on renal function. METHODS AND RESULTS This retrospective analysis included consecutive patients referred for CTO PCI between January 2002 and December 2009. CIN was defined as an elevated serum creatinine level ≥25% of baseline serum creatinine level at 48-72 hours after procedure. Patient characteristics, Mehran score, lesion characteristics, interventional procedure, and devices used were compared between CIN and non-CIN groups. For the 516 patients eligible for analysis, the incidence of CIN was 5.4% (28/516). Two patients needed transient haemodialysis (0.4%, 2/516). Analysis of risk using Mehran scoring found that the incidence of CIN was 0.5% (1/207) among low-risk patients, 3.4% (7/205) among moderate-risk patients, 15.9% (14/88) among high-risk patients and 37.5% (6/16) among very high-risk patients. The Mehran score high-risk group (11-15) and the very high-risk group (≥16) were definitely predictors of CIN after CTO PCI (OR: 27.022 [95% CI: 2.787-262.028, p=0.004]; OR: 32.512 [95% CI: 2.149-491.978, p=0.012]). Severe tortuosity was the only predictor of CIN after CTO PCI in angiographic and procedural findings (OR: 6.621 [95% CI: 1.090-40.227, p=0.040]). CONCLUSIONS Being in the Mehran score high-risk group (11-15) or the very high-risk group (≥16) and severe tortuosity were predictors of CIN after CTO PCI.

Short- and long-term outcomes after percutaneous transluminal coronary angioplasty in chronic hemodialysis patients

The aim of this study was to obtain data on the outcomes of chronic hemodialysis patients who underwent percutaneous transluminal coronary angioplasty (PTCA). A retrospective chart analysis identified 31 such patients between August 1992 and October 1996. The mean follow‐up period was 12.4 ± 11.7 months. Angiographic success was achieved in 39 of 41 (95.1%) stenoses attempted. There were three in‐hospital deaths. Clinical success was achieved in 28 of 31 patients (90%). Two of the 28 survivors were lost to follow‐up. Recurrent angina developed within 6 months in 14 of 26 patients (53.8%). Eleven and 17 of the 26 patients (42.3% and 65.4%) died within 6 and 14 months, respectively, after the PTCA procedure. Ten of the 17 deaths (58.8%) were due to cardiovascular events. Our study suggests that PTCA is technically feasible with high angiographic success rate in chronic hemodialysis patients. In‐hospital mortality rate and rate of recurrent angina are high. Long‐term prognosis is poor. Cathet. Cardiovasc. Intervent. 47:430–433, 1999.

Estimated Glomerular Filtration Rate as a Useful Predictor of Mortality in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background:This study evaluated the impact of estimated glomerular filtration rate (eGFR) on 30-day and 1-year mortalities in patients with an acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods:Between January 2002 and November 2009, 1432 consecutive patients who had experienced STEMI with an onset of chest pain <12 hours of undergoing primary PCI were prospectively enrolled. Patients were categorized into group 1 (eGFR <30 mL/min/1.73 m2), group 2 (eGFR = 30–60 mL/min/1.73 m2) and group 3 (eGFR >60 mL/min/1.73 m2). Results:The incidence of a high Killip class (defined as class ≥3) upon presentation, a requirement for mechanical ventilatory support for respiratory failure and intra-aortic balloon pump support for hemodynamic instability, and duration of hospitalization were substantially higher in group 1 than in groups 2 and 3, and notably higher in group 2 compared with group 3 (all P < 0.001). Conversely, the procedural success of primary PCI was remarkably lower in group 1 compared with groups 2 and 3, and it was also notably lower in group 2 than in group 3 (all P < 0.001). Additionally, both 30-day and 1-year mortalities were markedly increased in group 1 than in groups 2 and 3, and significantly higher in group 2 than in group 3 (all P < 0.001). Multivariate analysis showed that eGFR <30 mL/min/1.73 m2 was a significantly independent predictor of 30-day and 1-year mortalities (all P < 0.001). Conclusions:eGFR <30 mL/min/1.73 m2 was strongly and independently predictive of poor short-term and long-term prognostic outcomes in patients with STEMI undergoing primary PCI.

Comparison of Prognostic Outcome Between Left Circumflex Artery–Related and Right Coronary Artery–Related Acute Inferior Wall Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

This study evaluated the 30‐day clinical outcome of patients with acute inferior wall ST‐elevation myocardial infarction (AIW‐STEMI) from occlusion of the left circumflex artery (LCX) vs the right coronary artery (RCA) undergoing primary percutaneous coronary intervention (PCI).

Major Adverse Upper Gastrointestinal Events in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Coronary Intervention and Dual Antiplatelet Therapy

The aim of this study was to investigate the incidence of composite short-term and long-term major adverse upper gastrointestinal (UGI) events (MAUGIEs; defined as gastric ulcer, duodenal ulcer, gastroduodenal ulcer, or UGI bleeding) in patients with acute ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and routinely received dual-antiplatelet therapy. From May 2002 to September 2010, a total of 1,368 consecutive patients who experienced ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention were prospectively enrolled in the study. The incidence of in-hospital UGI bleeding complications and composite MAUGIEs was 8.9% and 9.9%, respectively. The in-hospital mortality rate was significantly higher in patients with in-hospital MAUGIEs than in those without (p <0.001). Multivariate analysis showed that age, advanced Killip score (≥3), and respiratory failure were the strongest independent predictors of in-hospital composite MAUGIEs (all p <0.003). The cumulative composite of MAUGIEs after uneventful discharge in patients without adverse UGI events who continuously received dual-antiplatelet therapy for 3 to 12 months, followed by aspirin therapy, was 10.4% during long-term (mean 4.0 years) follow-up. In conclusion, the results of this study show a remarkably high incidence of composite short-term and long-term MAUGIEs in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and received routine dual-antiplatelet therapy. Age, advanced Killip score, and respiratory failure were significantly and independently predictive of in-hospital composite MAUGIEs.