Guido Vittori

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.

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.

Percutaneous coronary implantation of sirolimus-eluting stents in unselected patients and lesions: clinical results and multiple outcome predictors.

BACKGROUND Sirolimus-eluting stents (SES) prevent restenosis and repeat percutaneous coronary intervention (PCI), but safety data in unselected patients are limited, especially for intermediate-term follow-up. METHODS All patients undergoing SES implantation at 4 Italian centers were enrolled into a dedicated database. Baseline, procedural, and outcome data at discharge and at follow-up were abstracted. Outcomes of interest were the occurrence of major adverse cerebrocardiovascular events (MACCE) at 6 months, as well as long-term event-free survival and multivariable event predictors. RESULTS One thousand four hundred twenty-four patients were enrolled (2,915 lesions, treated with 3,305 stents). Specifically, 1,074 (75.4%) subjects had multivessel disease, 399 (28.1%) had diabetes, 89 (6.3%) had ST-elevation myocardial infarction, and 44 (3.1%) underwent unprotected left main intervention. At 6 months, MACCE had occurred in 121 (9.0%) patients. After a median of 48.7 months (first-third quartile 41.8-55.3), MACCE-free survival was 69.2%+/-2.6%, with definite stent thrombosis occurring acutely in 6 (0.4%), subacutely in 11 (0.8%), after 30 days in 12 (0.8%), and cumulatively in 28 (2.0%). Major multivariable outcome predictors were diabetes (target lesion revascularization [TLR], MACCE), ejection fraction (TLR, MACCE), and maximal balloon length (TLR). CONCLUSIONS This large cohort of unselected patients supports the overall safety of unrestricted percutaneous SES implantation, as shown by the low rates of stent thrombosis. Event attrition remains, however, high at long-term follow-up, driven mainly by target vessel revascularization, with diabetes and ejection fraction as the most important prognostic factors.

Severe diffuse coronary artery spasm in the early phase of cardiogenic shock

Coronary artery vasospasm rarely appears as a diffuse phenomenon that involves all the coronary tree. We present a clinical case of acute myocardial infarction complicated by ventricular fibrillation and cardiogenic shock. Urgent coronary angiography showed occlusion of proximal Circumflex coronary artery and a TIMI I flow in the left anterior descending artery due to severe, diffuse coronary vasospasm. Patient was successfully treated with intra-aortic balloon pump and intracoronary bolus of nitroglycerin with restoration of flow in left coronary branches and complete resolution of shock.