Emmanuel Berman

Primary percutaneous coronary intervention for ST elevation myocardial infarction in nonagenarians

Objective To assess outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients. Methods We conducted a multicentre retrospective study between 2006 and 2013 in five international high-volume centres and included consecutive all-comer nonagenarians treated with primary PCI for STEMI. There were no exclusion criteria. We enrolled 145 patients and collected demographic, clinical and procedural data. Severe clinical events and mortality at 6 months and 1 year were assessed. Results Cardiogenic shock was present at admission in 21%. Median (IQR) delay between symptom onset and balloon was 3.7 (2.4–5.6) hours and 60% of procedures were performed through the transradial approach. Successful revascularisation of the culprit vessel was obtained in 86% of the cases (thrombolysis in myocardial infarction flow of 2 or 3). Major or clinically relevant bleeding was observed in 4% of patients. Median left ventricular ejection fraction post PCI was 41.5% (32.0–50.0). The in-hospital mortality was 24%, with 6 months and 1-year survival rates of 61% and 53%, respectively. Conclusions In our study, primary PCI in nonagenarians with STEMI was achieved and feasible through a transradial approach. It is associated with a high rate of reperfusion of the infarct-related artery and 53% survival at 1 year. These results suggest that primary PCI may be offered in selected nonagenarians with acute myocardial infarction.

Impact of renal failure on all-cause mortality and other outcomes in patients treated by percutaneous coronary intervention

BACKGROUND Patients with renal failure (RF) have been systematically excluded from clinical trials; consequently their outcomes have not been well studied in the setting of percutaneous coronary intervention (PCI). AIMS To compare cardiovascular outcomes after contemporary PCI in patients with versus without RF, according to clinical presentation (ST-segment elevation myocardial infarction [STEMI], acute coronary syndrome [ACS] or stable coronary artery disease [sCAD]). METHODS Consecutive patients undergoing PCI with stent were prospectively included from 2007 to 2012. RF was defined as creatinine clearance<60mL/min. The primary endpoint was all-cause mortality; secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE: composite of cardiovascular death, myocardial infarction, stroke and target lesion revascularization [TLR]), TLR and Academic Research Consortium definite/probable stent thrombosis (ST) at 1 year. RESULTS Among 5337 patients, 23% had PCI for STEMI, 34% for ACS and 43% for sCAD, while 27% had RF. RF patients had a higher unadjusted death rate than those with preserved renal function (nRF) in all PCI indication groups (STEMI, 41% vs. 7.5%; ACS, 19% vs. 6%; sCAD, 10% vs. 3%; P<0.0001 for all). The rate of MACCE was also higher in RF patients whatever the PCI indication (STEMI, 45% vs. 15%; ACS, 23% vs. 14%; sCAD, 14% vs. 9%; P<0.05 for all). Rates of TLR (5.5-7.4%) and ST (<2.5%) were similar (P>0.05 for both). sCAD-RF and STEMI-nRF patients had similar rates of mortality (P=0.209) and MACCE (P=0.658). RF was independently associated with mortality, with a doubled relative risk in STEMI versus ACS and sCAD groups (odds ratio 5.3, 95% confidence interval 3.627-7.821 vs. 2.1, 1.465-3.140 and 2.3, 1.507-3.469, respectively; P<0.0001). CONCLUSION RF is a stronger independent predictor of death after PCI in STEMI than in ACS or sCAD patients. sCAD-RF and STEMI-nRF patients had similar prognoses.

Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients scheduled for heart valve surgery

BACKGROUND Coronary angiography (CA), an invasive and expensive procedure, is still recommended in most patients referred for elective valve surgery. Multislice computed tomography (MSCT) is a promising alternative technique to rule out significant coronary artery lesions. AIM To evaluate MSCT in detecting significant coronary artery lesions in patients referred for elective valve surgery. METHODS Between August 2007 and December 2010, patients referred for elective valve surgery were identified prospectively and underwent 64-slice MSCT and CA. We compared significant coronary stenoses, defined as a reduction of luminal diameter ≥ 50%, to establish the diagnostic accuracy of MSCT. All coronary segments were analysed and uninterpretable lesions were scored positive. RESULTS Forty-eight patients were included (62.5% male; mean age 65 ± 12 years), the majority had aortic insufficiency (37.7%) or aortic stenosis (32.0%). The prevalence of significant coronary artery stenoses was 27.1%. The sensitivity, specificity, positive and negative predictive values of MSCT were 77%, 89%, 71% and 91%, respectively, in a patient-based analysis; 82%, 86%, 64% and 94% in a revascularization-based analysis; 67%, 94%, 52% and 97% in a vessel-based analysis; and 65%, 98%, 52% and 99% in a segment-based analysis. Overall, CA could have been avoided in 65% of patients. CONCLUSION In patients referred for elective valve surgery, MSCT had a high diagnostic accuracy to rule out significant coronary stenoses. However, larger multicenter studies in an unselected population of patients are needed to determine its place within the range of diagnostic tool in the preoperative assessment of valvular heart disease.

0165: Outcome after drug-eluting stents for cardiac allograft vasculopathy

Purpose Cardiac allograft vasculopathy (CAV) constitues a primary cause of death after heart transplantation. Bare metal stents (BMS) have been used for revascularization, but they are associated with a high-risk of restenosis. Abstract 0474 – Figure: Kaplan-Meier estimates of one-year mortality Figure options Download full-size image Download as PowerPoint slide Limited data have shown favourable results with percutaneous coronary interventions (PCI) using drug-eluting stents (DES) in this specific population. Our study focuses on intra-stent restenosis (ISR) for DES in CAV, on new revascularisation and mortality. Methods 97 consecutive heart transplant recipients with successful PCI were treated with DES (n=106) and BMS (n=25). They were prospectively followed-up at one year after PCI. An angiographic lesion-based analysis at 12-month follow-up and a patient-based survival analysis were performed. Results The lesion-based analysis within 12 months after PCI showed an ISR rate with BMS of 12% and an ISR rate with DES of 3.8%. The target lesion revascularization (TLR) was 8% for BMS and 2.8% for DES. However, the target vessel revascularization was higher (16.5%) and the remote lesion revascularization was 8.7%, indicating the rapid occurrence of new significant lesions. Cardiac mortality at one year was 9.7% and extra- cardiac mortality was 2.9%. Conclusions DES are associated with a low rate of TLR and can safely be used in heart transplant recipients with coronary artery disease. However, new significant lesions occurred at one year indicating a progression of CAV.

0443: Primary percutaneous coronary intervention for ST elevation myocardial infarction in nonagenarians: a multicentre study

Background There are limited data on outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients. Methods and Results We conducted a multicentre retrospective study between 2006 and 2013 in 5 international high-volume centers and included 145 nonagenarians treated with primary PCI for STEMI. Cardiogenic shock was present at admission in 21%. Mean delay between symptom onset and balloon was 5,8±7,6 hours and 60% of procedures were performed through the transradial approach. Successful revascularization of the culprit vessel was obtained in 86% of the cases (TIMI flow of 2 or 3). Major or clinically-relevant bleeding was observed in 4% of patients. Mean cardiac troponin Ic was 65±79 ng/ml and mean LVEF post-PCI was 42±13%. The in-hospital mortality was 24% with 6 months and 1 year survival of 58% and 49% respectively. Conclusions In our study, primary PCI in nonagenarians with STEMI was successful and feasible through a transradial approach. It is associated with a high rate of successful reperfusion of the infarct-related artery and nearly 50% survival at one year. These results suggest that primary PCI should be offered in selected nonagenarians with acute myocardial infarction (table next page). Abstract 0443 – Table Procedural Findings Time from symtoms to PCI (h) 5.8±7.6 Catheterizzation access (%) Radial 60 Single Vessel Coronary Disease (%) 53 Single Vessel Coronary PCI (%) 74 Infarct-related coronary artery (%) Left main 4 Left anterior descending 41 Circumflex 14 Right 45 CABG 3 Thrombus aspiration (%) 14 TMI flow grade after procedure (%) 0 12 1 1 2 6 3 81 Coronary stenting (%) BMS 75 DES 9 POBA 10 Procedure success (%) Successful PCI 86 Failed PCI 11 Complicated PCI 3 Use of protection device (%) 2 IABP (%) 0 Use of inotropes during procedure (%) 26

032: Thirty months outcomes after PCI of unprotected left main coronary artery according to the SYNTAX score

Aims To assess middle term outcomes according to SYNTAX score and rates of delayed surgical/bleeding events after unprotected left main (LM) coronary artery (ULMCA) PCI in an unselected patients population. Methods Consecutive patients treated by PCI for ULMCA were included among a single center 3508 PCI database within 36 months. Syntax scores were calculated, post discharge extracardiac surgery or hemorrhage were recorded during follow-up as clinical outcomes (Death, TVR, MACCE=cardiovascular death+MI+stroke+TLR). Results 102 (3.6%) patients underwent PCI of the LM, including 21 protected LM. Among the 81 patients with PCI of ULMCA, mean age was 65±13, 27% had urgent PCI for AMI or cardiogenic shock, 61% had DES. SYNTAX score was 28±14 in mean and ≤22 in 30 (37%), 23 to 32 in 22 (27%) and ≥33 in 29 (36%) patients. At 30±11 months follow up (98% of the patients), death occurred in 24 patients (30%), TVR in 16 (20%) and MACCE in 35 (43%). Clinical events according to the SYNTAX score are shown in figure. No cardiovascular death occurred in patients with syntax ≤22. MACCE rates were significantly lower when DES were used (24% vs. 64%, p During follow-up, 20 (25%) and 12 (15%) patients underwent unplanned extracardiac surgery and/or hemorrhage, leading to antiplatelet withdrawal in 31% of the cases. Conclusions In unselected patients treated by PCI of ULMCA with Syntax score ≤22, outcomes were found to be excellent with no cardiovascular death observed at 30 months. DES and non-urgent PCI were associated with a better prognosis. One patient out of three underwent unplanned extracardiac surgery or hemorrhage during follow up. Download full-size image Figure: 30-months outcomes according to SYNTAX score