Guido Kassner

Multi-vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction. A single-center experience.

BackgroundRecanalization of the culprit lesion is the main goal of primary angioplasty for acute ST-segment elevation myocardial infarction (STEMI). Patients presenting with acute myocardial infarction and multivessel disease are, therefore, usually subjected to staged procedures, with the primary percutaneous coronary intervention (PCI) confined to recanalization of the infarct-related artery (IRA). Theoretically at least, early relief of stenoses of non-infarctrelated arteries could promote collateral circulation, which could help to limit the infarct size. However, the safety and feasibility of such an approach has not been adequately established.MethodsIn this single-center prospective study we examined 73 consecutive patients who had an acute STEMI and at least one or more lesions ≥ 70% in a major epicardial vessel other than the infarctrelated artery. In the first 28 patients, forming the multi-vessel (MV) PCI group, all lesions were treated during the primary procedure. In the following 45 patients, forming the culprit-only (CO) PCI group, only the culprit lesion was treated during the initial procedure, followed by either planned-staged or ischemiadriven revascularization of the non-culprit lesions. Fluoroscopy time and contrast dye amount were compared between both groups, and patients were followed up for one year for major adverse cardiac events (MACE) and other significant clinical events.ResultsThe two groups were well balanced in terms of clinical characteristics, number of diseased vessels and angiographic characteristics of the culprit lesion. In the MV-PCI group, 2.51 lesions per patient were treated using 2.96 ± 1.34 stents (1.00 lesions and 1.76 ± 1.17 stents in the CO-PCI group, both p < 0.001). The fluoroscopy time increased from 10.3 (7.2–16.9) min in the CO-PCI group to 12.5 (8.5–19.3) min in the MV-PCI group (p = 0.22), and the amount of contrast used from 200 (180–250) ml to 250 (200–300) ml, respectively (p = 0.16). Peak CK and CK-MB were significantly lower in patients of the MV-PCI group (843 ± 845 and 135 ± 125 vs 1652 ± 1550 and 207 ± 155 U/l, p < 0.001 and 0.01, respectively). Similar rates of major adverse cardiac events at one year were observed in the two groups (24% and 28% in multi-vessel and culprit treatment groups, p = 0.73). The incidence of new revascularization in both infarct- and noninfarct-related arteries was also similar (24% and 28%, respectively, p = 0.73).ConclusionWe may state from this limited experience that a multi-vessel stenting approach for patients with acute STEMI and multi-vessel disease is feasible and probably safe during routine clinical practice. Our data suggest that this approach may help to limit the infarct size. However, larger studies, perhaps using drug-eluting stents, are still needed to further evaluate the safety and efficiency of this procedure, and whether it is associated with a lower need of subsequent revascularization and lower costs.

Long-term clinical outcome of rotational atherectomy followed by drug-eluting stent implantation in complex calcified coronary lesions

To assess long‐term outcome after rotational atherectomy (RA) is followed by drug‐eluting stent (DES) implantation in complex calcified coronary lesions.

Stuck rotablator: the nightmare of rotational atherectomy.

AIMS Rotational atherectomy (RA) is frequently performed to modify complex fibrocalcific coronary lesions with high procedural success. A stuck rotablator is a rare but life-threatening complication. However, its description remains sporadic and it has never been systematically analysed. The aim of this analysis is to present our experience and summarise the available literature about stuck rotablator, and to identify risk factors and possible management strategies for this complication. METHODS AND RESULTS We analysed our experience of 442 RA procedures and identified four cases of stuck rotablator. Two of these cases were rotablations in freshly implanted stents. All cases were managed percutaneously. We further analysed the available literature and identified a total of 11 reports with 14 cases of a stuck rotablator burr; seven were managed surgically and seven with endovascular approaches. Based on our experience and the literature review we developed an algorithm to guide operators while managing this complication. CONCLUSIONS Entrapment of a rotablation burr is a rare but very serious complication of RA. Operators performing RA should be aware of this risk and be prepared to manage it adequately. In our experience, the risk seems to be higher when rotablating freshly implanted underexpanded stents.

Longitudinal Deformation of Contemporary Coronary Stents: An Integrated Analysis of Clinical Experience and Observations from the Bench

OBJECTIVE  To report clinical experience with longitudinal stent deformation (LSD) and observations from the bench. BACKGROUND  LSD was recently reported with thin-strut coronary stents. Whether it is related to a particular stent or constitutes a class-effect remains debatable. METHODS After 2 cases of LSD were reported, information was sent to operators to warn of this event and identify possible cases. All cases were reviewed to ensure LSD had occurred. Simultaneously, bench testing was conducted to identify the susceptibility of stents to longitudinal compression and whether LSD detection is influenced by fluoroscopic stent visibility. RESULTS  Between July 2010 and November 2011, 2,705 coronary interventions were performed with 4,588 stents (Promus Element = 41.6%, Xience Prime = 24.4%). Six patients with LSD were identified, all with Promus Element (0.31%). Wire bias was a predisposing factor in 4 cases. All patients were treated with postdilatation and/or additional stenting. No adverse events occurred (mean 5.8 months). In bench testing, LSD occured in all examined stents, but at different levels of applied force (weight). Most shortening at 50 g was observed with Promus Element (38.9%), as was the best visibility of LSD on x-ray images. With postdilatation all stents showed some re-elongation. CONCLUSION In our practice LSD was a rare observation only seen with the Promus Element stent. When subjected to longitudinal compression in a bench test all contemporary stents can be compressed. Compression of Promus Element occurs at a lower force, but it is the only stent where deformations are detected with x ray. Postdilatation can partially improve LSD.

Determination of haemodynamic significance of intermediate coronary lesions using three-dimensional coronary reconstruction

AIMS This study evaluates three-dimensional (3-D) reconstruction of the coronary arteries in assessment of angiographically borderline lesions. METHODS AND RESULTS Three-dimensional (3-D) quantitative coronary angiography (QCA) was performed for 41 intermediate coronary stenotic lesions (IL) in 31 patients. Measurements of cross-sectional stenosis (CSS), diameter stenosis (DS) and plaque volume (PV) were correlated with the fractional flow reserve (FFR) values measured with a commercially-available pressure guide-wire. FFR <0.75 was considered significant. Using FFR, only 9/41 lesions appeared haemodynamically significant (FFR <0.75). When compared to lesions with an FFR >0.75, these lesions had higher CSS (65.3+/-9.4% vs. 44.7+/-10.6%, p=0.0001), higher DS (48+/-5.7% vs. 32.5+/-9.9%, p=0.0001), and higher PV (41.6+/-7.6% vs. 29.4+/-6.7%, p=0.0005), as measured by 3-D QCA. Regression analysis showed significant correlations between FFR and CSS (r=-0.481, p=0.001) and PV (r=-0.443, p=0.004), and a modest correlation between FFR and DS (r=-0,320, p=0.041). Compared with FFR, a CSS of 57% had the highest sensitivity and specificity (88.9% and 87.5%, respectively) for determining significant IL. Multivariate analysis showed 3-D-determined CSS to better predict FFR compared to the other measured variables (p=0.012). CONCLUSIONS Parameters obtained by 3-D QCA showed a significant correlation with FFR values. A cross-sectional stenosis >57% obtained by 3-D QCA has a high degree of sensitivity and specificity to detect a haemodynamically significant intermediate coronary stenosis.

Long-Term Clinical Outcome of Thin-Strut Cobalt-Chromium Stents in the Drug-Eluting Stent Era: Results of the COBALT (Comparison of Bare-Metal Stents in All-Comers’ Lesion Treatment) Registry

BACKGROUND Despite widespread penetration of drug-eluting stents (DES) in clinical practice, a relevant percentage of patients with coronary artery disease are still treated with bare-metal stents (BMS). Contemporary BMS, however, are less well investigated and comparative data on clinical outcome are lacking. METHODS AND RESULTS This single-center registry aimed to assess characteristics and outcome of patients treated with 2 different new-generation cobalt-chromium BMS, the MULTI-LINK VISION and PRO-Kinetic stents. During the study, adopted criteria for BMS selection were: (1) limited compliance to dual antiplatelet therapy, (2) ST-elevation myocardial infarction (MI) or saphenous vein graft (SVG) interventions, and (3) noncomplex lesions located either in the right coronary artery or in the nonproximal segments of the left coronary artery. During a 24-month period 1,176 patients were treated with the VISION (n = 438) or PRO-Kinetic stent (n = 738). Median duration of follow-up was 549.5 and 528.5 days, respectively. Target lesion revascularization (TLR) and target vessel revascularization were numerically lower in the VISION group (10.4 vs. 12.3% and 11.9 vs. 15.2%, P = 0.24 and 0.11). Death (4.1 vs. 4.3%, P = 0.85), MI (2 vs. 2.3%, P = 0.78), and ARC definite stent thrombosis (0.5 vs. 0.5%, P = 0.84) were similar. By multivariate analysis, variables associated with TLR were SVG interventions (HR 2.21, 95% CI 1.26-3.86), total stent length (HR 1.01, 95% CI 1.00-1.02), and smoking (HR 1.51, 95% CI 1.05-2.16). CONCLUSION In the DES era, the use of last-generation thin-strut BMS in selected patients is associated with acceptable clinical outcome, with similar clinical results for both the MULTI-LINK VISION and PRO-Kinetic stents.

Diazepam versus fentanyl for premedication during percutaneous coronary intervention: results from the Myocardial Protection by Fentanyl during Coronary Intervention (PROFIT) Trial.

BACKGROUND Sedation is a cornerstone in the premedication for percutaneous coronary intervention (PCI). Benzodiazepines and opioids are frequently used. Previous results suggest that opioids mimic the adaptation to ischemia during repeated balloon inflations and may provide direct myocardial protection in addition to their sedative effect. However, no comparative data exist. METHODS We conducted a prospective, randomized, controlled, single-blind trial comparing diazepam and fentanyl in 276 patients undergoing elective PCI. Patients were randomized to either diazepam 5 mg sublingually or fentanyl 0.05 mg or 0.1 mg intravenously at least 5 minutes prior to the first balloon inflation. The primary end-point was the postprocedural elevation of myocardial markers of necrosis defined as an elevation of cardiac troponin T > or = 0.01 ng/ml. RESULTS The three groups had similar baseline clinical, angiographic, and procedural characteristics, with no significant differences in lesion morphology, procedural complexity, or adjunctive medical treatment. No significant variation in the hemodynamic response to the study drugs was observed in the three groups. The rate of postprocedural troponin T elevation was 28% in the diazepam group, 20% in the fentanyl 0.05 mg group, and 30% in the fentanyl 0.1 mg group (P = 0.26). Rates of postprocedural myocardial infarction were 3%, 2%, and 2%, respectively (P = 0.84), with one case of in-hospital death in the diazepam group and no urgent TVR in the whole study population. CONCLUSION Although providing a well-tolerated alternative to diazepam for sedation during PCI, fentanyl did not provide additional cardioprotection assessed through the postinterventional elevation of cardiac troponin T during elective coronary intervention.

Comparison of Bailout and Planned Rotational Atherectomy for Heavily Calcified Coronary Lesions: A Single-Center Experience

OBJECTIVES The aim of this study was to compare outcomes of bailout and planned rotational atherectomy (RA) in the treatment of calcified coronary lesions. BACKGROUND Current guidelines recommend RA as a bailout procedure for calcified or fibrotic lesions that cannot be adequately dilated before stenting. Nonetheless, planned RA is sometimes performed in certain challenging anatomies. METHODS Data of patients treated with RA between 2002 and 2014 at a single-center registry were retrospectively analyzed. The bailout RA group included patients where RA was employed after failure of balloon dilatation or stent delivery. Planned RA included patients where RA was employed electively without previous device failure. RESULTS The study comprised 204 patients (221 lesions) and 308 patients (338 lesions) treated with bailout or planned RA, respectively. Angiographic success was achieved in the majority of cases, but was lower in the bailout RA group (93.7% vs. 97.6%, P = 0.02). Coronary dissections occurred more frequently in the bailout RA group (8.6% vs. 4.4%, P = 0.04), mean contrast amount was higher (279 ± 135 mL vs. 202 ± 92 mL, P < 0.001), and fluoroscopy time and procedural duration were longer in that group (32 min [IQR 21-51] vs. 18 min [IQR 14-28], P < 0.001 and 111 ± 50 min vs. 76 ± 35 min, P < 0.001, respectively). In-hospital death and myocardial infarction were not significantly different between the groups (2.9% vs. 1.3%, P = 0.21 and 6.9% vs. 4.2%, P = 0.19). In-hospital major adverse cardiac events (MACE) were higher in the bailout RA group (10.3% vs. 5.5%, P = 0.04). The 2-year estimated rates of MACE (25.2% vs. 28.7%, log rank P = 0.52) and its components death, myocardial infarction, and target vessel revascularization were not significantly different between the groups. Equivalence of 2-year MACE rates was also seen in all examined subgroups. CONCLUSION Shortened procedural duration and reduction of coronary dissections were observed with planned RA for selected lesions. However, this strategy does not affect long-term clinical outcomes.

High-speed rotational atherectomy of the left main coronary artery: a single-center experience in 50 high-risk patients

BACKGROUND Certain patients with complex calcified left main (LM) disease have a prohibitive risk for bypass surgery. Rotational atherectomy (RA) prior to stent implantation is an option for this subset of patients. OBJECTIVE To analyze acute and long-term results of RA in the LM location. METHODS We present a single-center analysis of RA in severe LM disease applied in patients with high surgical risk. RESULTS RA was performed in the LM location in 50 consecutive patients with a mean age of 73years. In 30% of the patients clinical presentation was an acute coronary syndrome, and 42% had diabetes. LM bifurcation was involved in 80% of the cases, 36% had a Medina class 1.1.1 lesion, and 38% of RA procedures were performed as bailout. In 38% of patients the left main was protected. Median logistic EuroSCORE was 12.4% (interquartile range, IQR, 5.24-36.11%) and mean SYNTAX Score was 28.6±8.2. The median burr size was 1.5mm and a two-stent strategy was required in 58% of interventions. Drug-eluting stents were implanted in 86% of procedures. Angiographic success rate was 96%, and in-hospital major adverse cardiac event rate was 10%. Survival free of cardiac death at 12 and 24months was 87.6% and 78.4%. Target lesion revascularization rates (TLR) were 13.3% and 18.8%, respectively. Cardiac deaths were significantly higher in patients with acute coronary syndromes compared with patients with stable angina (cardiac death free survival was 72.7% and 94% at 12months, p=0.01). The TLR rate was numerically higher in diabetic patients (21.1% vs. 7.7% at one year, p=0.18). CONCLUSION Acute and long-term outcomes after LM rotational atherectomy are satisfactory, considering the high procedure- and patient-related risks.

Clinical and hemodynamic predictors of natriuretic peptide elevation among aortic valve disease patients

We investigated the relative contribution of hemodynamic and clinical factors to serum natriuretic peptide elevation in seventy-one patients with either aortic stenosis or aortic regurgitation. We found that pulmonary hypertension, heart failure and renal failure are the most powerful independent predictors of natriuretic peptide elevation in patients with aortic valve disease, irrespective of the type or severity of valvular lesion itself.