Gabriele Giuliani

ST-Segment Elevation Myocardial Infarction Due to Early and Late Stent Thrombosis. A New Group of High-Risk Patients

OBJECTIVES The aim of this retrospective study was to compare clinical and angiographic outcomes between patients presenting with ST-segment elevation myocardial infarction (STEMI) due to stent thrombosis (ST) and de novo coronary thrombosis. BACKGROUND There are limited data for procedural and mid-term outcomes of patients with ST presenting with STEMI. METHODS From January 2004 to March 2007, 115 definite ST patients were observed: 92 (80%) of them presented as STEMI and were compared with a consecutive group of 98 patients with de novo STEMI. All patients underwent primary percutaneous coronary intervention. Primary end points were successful angiographic reperfusion and distal embolization. Major adverse cardiovascular and cerebrovascular events (MACCE), evaluated at 6-month follow-up, were defined as death, nonfatal myocardial reinfarction, target vessel revascularization, and cerebrovascular accident. RESULTS Successful reperfusion rate was lower in patients with ST (p < 0.0001), whereas distal embolization rate was higher (p = 0.01) in comparison with patients with de novo STEMI. Stent thrombosis proved to be an independent predictor of unsuccessful reperfusion at propensity-adjusted binary logistic regression (odds ratio 6.8, p = 0.004). In-hospital MACCE rate was higher in patients with ST (p = 0.003), whereas no differences were observed at 6-month follow-up among hospital survivors between the 2 groups (p = 0.7). CONCLUSIONS Stent thrombosis identifies a subgroup of patients with STEMI with poor angiographic and early clinical outcomes, suggesting that the management of these patients should be improved.

Early and Long-Term Clinical Results of AngioJet Rheolytic Thrombectomy in Patients With Acute Pulmonary Embolism

Anticoagulant and thrombolytic therapies are a mainstay in the management of acute pulmonary embolism (PE), especially when hemodynamic compromise is present. However, systemic drugs cannot achieve timely and effective treatment of acute PE in all patients. In such a setting, mechanical removal of thrombus from the pulmonary circulation holds the promise of significant clinical benefits, although it remains untested. We report early and long-term outcome of patients with massive or submassive acute PE treated with rheolytic thrombectomy by means of the 6Fr Xpeedior AngioJet device at our institution. Three main groups were defined pre hoc: subjects with severe (i.e., shock), moderate, or mild hemodynamic compromise. Technical and procedural successes, obstruction, perfusion and Miller indexes, and clinical events were appraised. In total 25 patients were treated with thrombectomy (8 in severe, 12 in moderate, and 5 in mild hemodynamic compromise). Technical and procedural successes were obtained in all patients, as confirmed by the significant improvement in obstruction, perfusion and Miller indexes overall, and in each subgroup (all p values <0.001). Improvement in obstruction, perfusion, and Miller indexes at the end of the procedure could also be confirmed in patients (n = 8) treated with local fibrinolysis and in the absence of concomitant thrombolysis (n = 17, p <0.05). Four patients died in hospital, all other patients but 1 were safely discharged after an appropriate hospital stay, and all were alive at long-term follow-up (median 61 months). In conclusion, this study supports at early and long-term follow-up the effectiveness and safety of rheolytic thrombectomy for PE.

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism

Objectives: To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE). Background: The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate. Methods: We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index ≥ 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all‐cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT. Results: Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in‐hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long‐term follow‐up (35.5 ± 21.7 months) except three who expired due to cancer and acute myocardial infarction. Conclusions: In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed.

Heart rate as an independent prognostic risk factor in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND It has been shown that elevated heart rate identified patients with coronary artery disease and left ventricular dysfunction at increased risk of cardiovascular outcomes. OBJECTIVE We sought to assess the prognostic impact of heart rate at presentation in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS We collected 6-month follow-up data in 2477 consecutive patients with STEMI treated by primary PCI. Patients with atrio-ventricular block (n=64) and atrial fibrillation (n=34) were excluded from the analysis. The association of baseline heart rate with cardiovascular outcomes was analysed using Cox proportional hazard models for groups with a heart rate of 80 beats per min (bpm) or greater (n=799) versus those with a heart rate between 60 and 79 bpm (n=1192) and those with a heart rate less than 60 bpm (n=388). The variables related to mortality were: age (hazard ratio (HR) 1.072, 95% confidence interval (CI) 1.052-1.092, p<0.0001), cardiogenic shock (HR 4.622, 95% CI 2.892-7.387, p<0.0001), previous myocardial infarction (HR 1.724, 95% CI 1.036-2.869, p=0.036), peak creatine-kinase value (HR 1.227, 95% CI 1.142-1.318, p<0.0001), heart rate 80 bpm or greater (HR 2.170, 95% CI 1.414-3.332, p=0.0001), and optimal PCI result (HR 0.126, 95% CI 0.065-0.244, p=0.0001). For every increase of 5 bpm, there were increases in mortality (HR 1.321, 95% CI 1.232-1.415, p=0.0001), but not in reinfarction or in coronary revascularization rates. CONCLUSION In patients with acute myocardial infarction undergoing primary PCI, elevated heart rate (80 bpm or greater) identifies those at increased risk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients.

Optical coherence tomography in unprotected left main coronary artery stenting.

AIMS: Delayed or incomplete stent endothelisation and stent malapposition may predispose to DES thrombosis that can be a catastrophic event in the left main coronary artery (LMCA). OCT can accurately identify stent struts and arterial tissue, but is limited by the need of vessel blood clearance and penetration; also no data exist on its use in LMCA. We sought to verify whether optical coherence tomography (OCT) can accurately assess arterial wall response after drug eluting stent (DES) implantation in the LMCA. METHODS AND RESULTS: OCT images were obtained in 15 patients (mean age 70.7 + or - 8.0 years) six months after LMCA DES implantation. Acquisitions were performed without proximal balloon occlusion during isoosmolar contrast injection through a 6 Fr guiding catheter without side holes at a speed of 2-3 mL/sec. Offline image analyses were performed to evaluate assessable stent area (all slices), strut coverage, apposition, and abnormal tissue responses for every three slices (= every 0.45 mm). All OCT images were obtained without periprocedural complications. Overall, 69 + or - 20% of the stent inner area was analysable; this corresponded to 2.7 + or - 0.8 analysable quadrants per slice. Out of 1,281 struts, 1,136 (88.7%) were well apposed and fully covered, 101 (7.8%) were uncovered; and 45 (3.5%) were malapposed although nine of the malapposed struts (20%) were covered by some tissue. In five patients OCT detected abnormal intraluminal tissue, and in two cases this finding was related to uncovered struts. CONCLUSIONS: OCT assessment of vascular response after LMCA DES implantation is safe and feasible. Further development of OCT imaging technology will be necessary for complete evaluation of LMCA stents.

Left ventricular support device for cardiogenic shock during myocardial infarction due to stent thrombosis: A single centre experience

BACKGROUND Stent thrombosis (ST) is a new, rare, cause of STEMI. Few data are available about incidence and clinical impact of shock complicating acute myocardial infarction due to ST (st-STEMI). METHODS From January 2004 to March 2007, 92 st-STEMI patients were observed: 14 (15.2%) of them presented with cardiogenic shock and were evaluated in the present analysis. In particular, clinical and angiographic characteristics of survivors and non-survivors to PCI were compared. RESULTS St-STEMI was related to left main or multivessels stent thrombosis in 35.7% of cases; whereas in 93% of cases st-STEMI occurred in a territory with previous myocardial infarction. All patients underwent IABP implantation immediately before coronary angiography, whereas Impella LP 2.5 pump was used in 21% of cases when persistent cardiac low-output signs were recorded. PCI was successful in 80% of cases. In-hospital survival was 28.6%. Death occurred within the first 48 h in the majority of patients. At six-months all patients survived to the acute phase were alive. Survivors had significantly lower thrombus grade after wire passage (p=0.03) and, albeit not significant, they showed a higher rate of very late ST, longer times from symptoms onset to revascularization, and higher TIMI flow grade either before and after PCI. CONCLUSION The incidence of cardiogenic shock in st-STEMI is high, particulary it seems to be two times higher than the rate reported during myocardial infarction. One third of cases is related to left main or multiple vessels ST. Shock in st-STEMI represents a dramatic event with very low in-hospital and early survival.

Comparison of primary angioplasty in rural and metropolitan areas within an integrated network.

AIMS To compare reperfusion times and in-hospital outcome of patients with STEMI treated with primary percutaneous coronary intervention (PCI) in a teaching hospital (TH) with or without inter-hospital transfer and in community hospitals. METHODS AND RESULTS We performed a retrospective analysis of 536 patients with STEMI treated between January 2005 and December 2006 with primary PCI. Three groups were identified. A: 207 patients presented to the TH. B: 121 patients transferred to TH from metropolitan area hospitals (MAH). C: 208 patients presented in two rural area hospitals (RAH) with primary PCI capability. Baseline characteristics were similar. Door-to-balloon (DtB) times were significantly (p<0.001) higher in group B (median 120, range 90-180 min) both compared to group A (median 60, range 45-90 min) and C (median 73, range 55-99 min). In group B 79,5% of patients present a DtB > 90 min. In-hospital mortality was 4.9%, 3.3% and 4.3% respectively in group A, B and C without significant differences. CONCLUSIONS The expansion of primary PCI to RAH achieves reperfusion delays similar to that of patients admitted to TH. Transferred patients present very higher DtB when compared to patients treated on-site. In-hospital outcome are similar but further studies are warranted.