Ivan Chavez

A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Background— Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results— We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [≥80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. Conclusions— Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

ST-Elevation Myocardial Infarction Which Patients Do Quality Assurance Programs Include?

Background—In the United States, efforts are underway to improve timely access to percutaneous coronary intervention in ST-elevation myocardial infarction (STEMI). The Joint Commission (TJC) and the American College of Cardiology National Cardiovascular Data Registry (NCDR) have developed standardized definitions and clinical performance measures for STEMI. The purpose of this study was to determine differences in 3 quality-assurance registries for STEMI patients. Methods and Results—STEMI patients presenting to the Minneapolis Heart Institute at Abbott Northwestern Hospital (Minneapolis, Minn) are tracked by 3 distinct quality assurance programs: NCDR, TJC, and the level 1 MI registry (a regional system for percutaneous coronary intervention in STEMI which includes transfer patients). Over 1 year, we examined consecutive STEMI patients in level 1 and compared them with individuals meeting NCDR and TJC inclusion criteria. Of 501 STEMI patients treated using the level 1 MI protocol, 422 patients had a clear culprit (402 percutaneous coronary intervention, 13 coronary artery bypass grafting, 7 medical management). In the same period, 282 patients met inclusion criteria for NCDR (56% of the level 1 population), and 66 met inclusion criteria for TJC (13% of the level 1 population). Transfer patients (n=380) accounted for 87% of the discrepancy between level 1 and TJC. Pharmacoinvasive percutaneous coronary intervention (n=102) accounted for 47% of the discrepancy between level 1 and NCDR. Conclusions—Current inclusion criteria for enrollment in STEMI registries are not uniform. This may lead to variable quality assurance outcomes for the same patient cohort and has important implications for standardized quality measurement.

ST-Elevation Myocardial Infarction Diagnosed After Hospital Admission

Background— Treatment times for ST-elevation myocardial infarction (STEMI) patients presenting to percutaneous coronary intervention hospitals have improved dramatically over the past 10 years, particularly for patients using emergency medical services. Limited data exist regarding treatment times and outcomes for patients who develop STEMI after hospital admission. Methods and Results— With the use of a comprehensive prospective regional STEMI program database, we evaluated the characteristics and outcomes for patients who develop STEMI after hospital admission. Of the 3795 consecutive STEMI patients treated by the use of the Minneapolis Heart Institute regional STEMI program from March 2003 to January 2013, 990 (26.1%) presented initially to the percutaneous coronary intervention facility, including 640 arriving via emergency medical services, 267 self/family driven, and 83 already admitted to the hospital. Patients with in-hospital presentation were older with higher body mass indexes, were more likely to have hypertension, and to present with pre–percutaneous coronary intervention cardiac arrest and cardiogenic shock. Door-to-balloon times (diagnostic ECG-to-balloon for in-hospital patients) were longer than for patients using emergency medical services (76 versus 51 minutes; P<0.001), but similar to self/family–driven patients (76 versus 66 minutes; P=0.13). In-hospital patients had longer lengths of stay (5 versus 3 versus 3 days; P<0.001) and higher 1-year mortality (16.9% versus 10.3% versus 7.1%; P=0.032). These patients frequently had high-risk and complex reasons for admission, including 30.1% with acute coronary syndrome, 22.9% postsurgery, 13.3% respiratory failure, and 8.4% ventricular fibrillation. Conclusions— Patients who develop STEMI while in-hospital represent a unique, high-risk subset of patients. They have increased treatment time and lengths of stay and higher mortality rates than the patients presenting via emergency medical services or who are self/family driven.

Transseptal technique of percutaneous PFO closure results in persistent interatrial shunting

Our goal was to review the effectiveness of the transseptal and tunnel techniques of patent foramen ovale (PFO) closure. Percutaneous PFO closure is an increasingly common treatment for prevention of paradoxical embolism and is typically performed by passing the device through the defect tunnel itself. The transseptal technique, in which the septum primum is punctured to create a hole through which the device is passed, has been proposed for patients with long‐tunnel PFO. From May 2001 to December 2003, 120 patients underwent PFO closure at our institution and were included in this analysis. Defect closure was assessed by transesophageal echocardiography (TEE) with bubble study. Clinical follow‐up data were obtained by clinic visits or standardized telephone interviews. Device closure was successfully completed in all patients, with 12 (10%) undergoing transseptal closure and 108 (90%) undergoing tunnel closure. Immediately following the procedure, complete closure occurred in 6 of 12 (50%) of the transseptal group and 88 of 108 (81.5%) of the tunnel group (P = 0.0120). Of the 89 patients (74.2%) who returned for 6‐month TEE, complete closure was demonstrated in 4 out of 10 (40%) of the transseptal group and 58 out of 79 (73.4%) of the tunnel group (P = 0.0303). There have been four transient ischemic attacks during a mean follow‐up of 11 months. The transseptal technique of PFO closure results in a higher proportion of patients with persistent interatrial shunting when compared with the tunnel technique. Whether this is due to a difference in technique, device, or patient anatomy is unclear.

Real-Time Decision Support to Guide Percutaneous Coronary Intervention Bleeding Avoidance Strategies Effectively Changes Practice Patterns

Approximately 600 000 percutaneous coronary interventions (PCIs) are performed annually in the United States.1 Periprocedural bleeding is a common complication of PCI,2–6 occurring in 2% to 6% of cases.6–12 Bleeding is associated with major adverse events, including short- and long-term mortality,4,8–11,13 as well as prolonged hospital length of stay (LOS)7–10,14 and higher hospital costs.6,7,15,16 Periprocedural bleeding seems to be predictable and modifiable.4 A validated risk prediction algorithm may help clinicians estimate bleeding risk in patients undergoing PCI, and established bleeding avoidance strategies (BAS), such as bivalirudin, radial artery access, and vascular closure devices, have been demonstrated to reduce bleeding.2,16–24 However, recent studies have reported that patients at highest risk for bleeding are least likely to receive treatment with BAS.2,5 Accurate preprocedure bleeding risk assessment scoring may provide a significant opportunity for physicians to selectively use effective preventative tactics in patients most likely to benefit and improve PCI safety, care quality, and subsequently hospitalization costs. Bleeding events after cardiovascular procedures have been identified by the Centers for Medicare and Medicaid Services to be quality indicators among centers participating in its Acute Care Episode demonstration.2 However, data on the impact of pre-PCI bleeding risk assessment on physician practice patterns, BAS use, and quality outcomes are sparse. We developed a quality improvement program for PCI patients using a preprocedure bleeding risk score to stimulate the use of consensus BAS in high-risk, high-cost patients. The specific aims of the program were to improve patient safety and care quality and to decrease LOS and hospital costs by reducing bleeding events and associated complications in PCI patients. An interdisciplinary team …

Percutaneous Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock Is Associated with Improved Short- and Long-Term Survival.

Mortality due to refractory cardiogenic shock (RCS) exceeds 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has become an accepted therapy for RCS. The aim of our study was to evaluate outcomes of patients with RCS treated with percutaneous VA-ECMO (pVA-ECMO). Retrospective review of patients supported with VA-ECMO at our institution in 2012–2013. Clinical characteristics, bleeding, vascular complications, and outcomes including survival were assessed. A total of 37 patients were supported with VA-ECMO for RCS. The majority of VA-ECMO (76%) was placed in the catheterization laboratory. Nearly half (49%) of the patients presented with acute myocardial infarction. Seven patients (19%) underwent insertion of pVA-ECMO in the setting of cardiopulmonary resuscitation with mechanical chest compression device. Median duration of support was 5 days. Index hospitalization, 30-day, and 1-year survival were 65%, 65%, and 57%, respectively. Survival rate for discharged patients was 87.5% with a median follow-up of 450 days. Refractory cardiogenic shock supported with pVA-ECMO is associated with an improved survival in patients with a traditionally poor prognosis.

PROSPECTIVE DECISION SUPPORT TOOL GUIDES USAGE OF VASCULAR CLOSURE DEVICES THAT REDUCE BLEEDING COMPLICATIONS, LENGTH OF STAY, AND VARIABLE COSTS IN HIGH BLEED RISK PATIENTS

Bleeding is a common complication in percutaneous coronary intervention (PCI) and increases length of stay (LOS), costs, and mortality. Designed for rapid hemostasis, vascular closure devices (VCDs) are beneficial cases with a high bleeding risk but are utilized less often in these cases. A real-

Response to Letter Regarding Article, “ST-Elevation Myocardial Infarction Diagnosed After Hospital Admission”

We appreciate the kind words and support from Dr Dai et al regarding our Circulation study that described the characteristics and outcomes of patients who develop ST-segment–elevation myocardial infarction (STEMI) after hospital admission.1,2 We agree that this is a high-risk STEMI population that is currently underrecognized. These patients are less likely to receive reperfusion, and when they …

Ruptured Plaque Visualization by Noninvasive Coronary Computed Tomography Angiography

A 69-year-old man presented with 2 weeks of exertional chest pressure typical of angina pectoris. An exercise stress test reproduced his symptoms and caused 1.5 mm of ST depression. Because a relative had a fatal event associated with invasive coronary angiography, he wished to have only noninvasive testing. Coronary computed tomographic (CT) angiography using 16-slice technology (Siemens Sensation 16) …

Coronary Venous Bypass Lesions

Saphenous vein graft (SVG) percutaneous coronary interventions (PCIs) are common, currently representing approximately 6% of the overall PCI volume. SVG PCI is associated with higher risk of periprocedural complications and lower long-term patency compared with native coronary artery PCI; hence, the latter is preferred to SVG PCI whenever possible. Embolic protection devices and intragraft vasodilator administration can help to reduce the risk or consequences of distal embolization; however, they are currently underutilized. Drug-eluting stents can reduce the risk of in-stent restenosis and the need for repeat revascularization as compared with bare-metal stents in SVG lesions.