J. Baan

Primary percutaneous coronary intervention for ST elevation myocardial infarction in octogenarians: trends and outcomes

Objective The general population is gradually ageing in the western world. Therefore, the number of octogenarians undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is increasing. We aim to provide insight into temporal trends in the annual proportions of octogenarians among STEMI patients undergoing primary PCI and their clinical characteristics and outcomes over an 11-year observational period. Design Single-centre observational study. Patients Between 1997 and 2007, 4506 STEMI patients were treated with primary PCI at the authors institution. Patients aged over 80u2005years were identified. Main outcome measures Temporal trends in the annual proportion of octogenarian STEMI patients and their baseline characteristics, 30-day and 1-year mortality were analysed. Results A total of 379 octogenarians (8.4% of the total population) was treated with primary PCI between 1997 and 2007. Over time, the annual proportion of octogenarians gradually increased from four of 113 (3.5%) in 1997 to 51 of 579 (8.8%) in 2007 (p for trend <0.01). In the total cohort of 379 patients, 30-day mortality was 21% (81 patients) and 1-year mortality was 28% (107 patients). There was no improvement in survival among octogenarian STEMI patients over the 11-year study period. Conclusion The annual proportion of octogenarian STEMI patients increased significantly over the 11-year study period. Mortality among these high-risk patients was high and did not improve during the study period. Unfortunately, little is known about the optimal treatment of the elderly as they are underrepresented in many randomised clinical trials. Further studies into the optimal STEMI management strategy for the elderly are warranted.

Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion

Objective: To describe patients with a distinct electrocardiogram (ECG) pattern without ST-segment elevation in the presence of an acute occlusion of the proximal left anterior descending (LAD) artery. Design: Single-centre observational study. Patients: Patients with acute anterior wall myocardial infarction who were referred for primary percutaneous coronary intervention (PCI) between 1998 and 2008. Results: We identified patients with a static, distinct ECG pattern without ST-segment elevation and an occlusion of the proximal LAD artery during urgent coronary angiography before PCI. Of 1890 patients who underwent primary PCI of the LAD artery, we could identify 35 patients (2%) with this distinct ECG pattern. The ECG showed ST-segment depression at the J-point of at least 1 mm in precordial leads with upsloping ST-segments continuing into tall, symmetrical T-waves. Patients with this distinct ECG pattern were younger, more often male and more often had hypercholesterolaemia compared to patients with anterior myocardial infarction and ST-segment elevation. Conclusions: In patients presenting with chest pain, ST-segment depression at the J-point with upsloping ST-segments and tall, symmetrical T-waves in the precordial leads of the 12-lead ECG signifies proximal LAD artery occlusion. It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.

Six-month clinical outcomes of the Tryton Side Branch Stent for the treatment of bifurcation lesions

AimsPercutaneous coronary intervention (PCI) of a bifurcation lesion (BL) is still associated with poorer clinical outcomes when compared with PCI of a non-BL. Therefore, several dedicated coronary bifurcation stents, such as the Tryton Side Branch Stent™ (Tryton Medical, Durham, NC, USA), were developed to improve clinical outcomes. We investigated 6-month clinical outcomes after placement of a Tryton stent in 91 patients treated for 93 BLs in our centre.Methods and resultsAll consecutive patients who have undergone PCI of a BL treated with the Tryton stent in our centre were included. Outcomes were defined as any death, cardiac death, myocardial infarction (MI), any revascularisation, ischaemia-driven target vessel revascularisation (TVR), ischaemia-driven target lesion revascularisation (TLR), stent thrombosis, and target vessel failure (TVF; composite of cardiac death, MI, and ischaemia-driven TVR). Event rates were estimated using the Kaplan-Meier method. Thirty-eight (42xa0%) patients with acute coronary syndrome (ACS) were included (16xa0% ST-segment elevation MI (STEMI)). The 6-month event rates were 5.4xa0% (death), 4.3xa0% (cardiac death), 2.2xa0% (MI), 4.5xa0% (any revascularisation), 4.5xa0% (TVR), 4.5xa0% (TLR) and 9.7xa0% (TVF).ConclusionIn a real-world all-comers single-centre registry, the use of the Tryton Side Branch Stent was associated with acceptable procedural and promising clinical outcomes at 6xa0months, including ACS and STEMI patients.

Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock

BackgroundGuidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality.MethodsFrom a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. ‘IABP pre PCI’ (nu2009=u200959) and ‘IABP post PCI’ (nu2009=u2009140). Outcomes were assessed by propensity stratification and multivariate logistic regression.ResultsAll-cause 30-day mortality for the IABP versus the no IABP group was 47xa0% vs. 28xa0%, respectively, in univariate analysis resulting in an odds ratio (OR) of 1.67 (95%CI, 1.16 to 2.39). However, analyses adjusting outcomes by propensity stratification and logistic regression, respectively, neutralised this OR. In the IABP pre-PCI group vs. the post-PCI group 30-day mortality was 64xa0% vs. 40xa0%, resulting in an OR of 1.56 (95xa0% CI, 1.18 to 2.08). However, after propensity stratification analysis and multivariate logistic regression analysis, there were no significant differences in odds of 30-day mortality.ConclusionIn our cohort of patients with STEMI complicated by CS treated with primary PCI we observed a difference in mortality between those treated with IABP and those treated without IABP in favour of the ‘no IABP’ group. The mortality difference was eliminated after adjustment for differences in case mix by propensity stratification or by logistic regression analysis. Neither did we observe any difference in mortality between patients whose IABP treatment was initiated before or immediately after PCI.

Prognostic value of post-procedural aPTT in patients with ST-elevation myocardial infarction treated with primary PCI

Unfractionated heparin is the most commonly used anticoagulant in ST-elevation myocardial infarction (STEMI) and its effect can be monitored with activated partial thromboplastin time (aPTT). However, the optimal aPTT range during heparin therapy after primary percutaneous coronary intervention (PCI) is yet to be defined. A mean aPTT was calculated of all aPTT measurements in the first 24 hours after pPCI in a total of 1,876 STEMI patients. Mean aPTT measurements were stratified into four categories; < 1.5 times the upper limit of normal (ULN), 1.5 - 2.0 times ULN (the therapeutic group), 2.01 - 3.99 times ULN, and ≥ 4 times ULN. Compared to patients with a therapeutic aPTT, patients with aPTTs < 1.5 times ULN had no increase in recurrent ischaemic events and had similar rates of bleeding complications. Patients with a mean aPTT ≥ 4 times ULN had higher rates recurrent ischaemic and haemorrhagic complications. After multivariable analyses, aPTT ratios ≥ 4 times ULN were no longer associated with recurrent ischaemic events, but remained a strong predictor of severe and moderate bleeding (hazard ratio [HR] 4.64, p = 0.016 and HR 2.27, p = 0.052). In conclusion, in 1,876 STEMI patients treated with pPCI, low aPTTs in the first 24 hours after PCI were not associated with an increase in ischaemic events, whereas high aPTT values were associated with more frequent bleeding complications. These results indicate no clear benefit as well as a safety concern with heparin treatment after primary PCI.

Coronary microcirculatory dysfunction is associated with left ventricular dysfunction during follow-up after STEMI

BackgroundCoronary microvascular resistance is increased after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), which may be related in part to changed left ventricular (LV) dynamics. Therefore we studied the coronary microcirculation in relation to systolic and diastolic LV function after STEMI.MethodsThe study cohort consisted of 12 consecutive patients, all treated with primary PCI for a first anterior wall STEMI. At 4xa0months, we assessed pressure-volume loops. Subsequently, we measured intracoronary pressure and flow velocity and calculated coronary microvascular resistance. Infarct size and LV mass were assessed using magnetic resonance imaging.ResultsPatients with an impaired systolic LV function due to a larger myocardial infarction showed a higher baseline average peak flow velocity (APV) than the other patients (26u2009±u20097 versus 17u2009±u20095xa0cm/s, pu2009=u20090.003, respectively), and showed an impaired variable microvascular resistance index (2.1u2009±u20091.0 versus 4.1u2009±u20091.3xa0mmHgu2009cm−1∙s−1, pu2009=u20090.003, respectively). Impaired diastolic relaxation time was inversely correlated with hyperaemic APV (ru2009=u2009−0.56, pu2009=u20090.003) and positively correlated with hyperaemic microvascular resistance (ru2009=u20090.48, pu2009=u20090.01). LV dilatation was associated with a reduced variable microvascular resistance index (ru2009=u20090.78, pu2009=u20090.006).ConclusionA larger anterior myocardial infarction results in impaired LV performance associated with reduced coronary microvascular resistance variability, in particular due to higher coronary blood flow at baseline in these compromised left ventricles.

Percutaneous left ventricular partitioning device for chronic heart failure

We report the first implantation of a percutaneous left ventricular partitioning device in the Netherlands. This device is developed for patients with chronic heart failure due to a left ventricular apical aneurysm caused by an anterior myocardial infarction.

Effects of left ventricular unloading on reperfusion-related AIVR in acute myocardial infarction.

Accelerated idioventricular rhythm (AIVR) often occurs in the setting of acute myocardial infarction, specifically after reperfusion. We studied the direct left ventricular (LV) dynamic effects of AIVR compared with sinus rhythm. Furthermore, we observed an interesting finding of LV unloading on the occurrence of AIVR.

Autopsy after transcatheter aortic valve implantation.

Autopsy after transcatheter aortic valve implantation (TAVI) is a new field of interest in cardiovascular pathology. To identify the cause of death, it is important to be familiar with specific findings related to the time interval between the procedure and death. We aimed to provide an overview of the autopsy findings in patients with TAVI in their medical history divided by the timing of death with specific interest in the added value of autopsy over a solely clinically determined cause of death. In 8 European centres, 72 cases with autopsy reports were available. Autopsies were divided according to the time interval of death and reports were analysed. In 32 patients who died ≤72xa0h postprocedure, mortality resulted from cardiogenic or haemorrhagic shock in 62.5 and 34.4%, respectively. In 31 patients with mortality >72xa0h to ≤30xa0days, cardiogenic shock was the cause of death in 51.6% followed by sepsis (22.6%) and respiratory failure (9.7%). Of the nine patients with death >30xa0days, 88.9% died of sepsis, caused by infective endocarditis in half of them. At total of 12 patients revealed cerebrovascular complications. Autopsy revealed unexpected findings in 61.1% and resulted in a partly or completely different cause of death as was clinically determined. Autopsy on patients who underwent TAVI reveals specific patterns of cardiovascular pathology that clearly relate to the time interval between TAVI and death and significantly adds to the clinical diagnosis. Our data support the role of autopsy including investigation of the cerebrum in the quickly evolving era of cardiac device technology.

Trends in patient characteristics and clinical outcome over 8 years of transcatheter aortic valve implantation

AimIn the evolving field of transcatheter aortic valve implantations (TAVI) we aimed to gain insight into trends in patient and procedural characteristics as well as clinical outcome over an 8‑year period in axa0real-world TAVI population.MethodsWe performed axa0single-centre retrospective analysis of 1,011 consecutive patients in axa0prospectively acquired database. We divided the cohort into tertiles of 337 patients; first interval: January 2009–March 2013, second interval: March 2013–March 2015, third interval: March 2015–October 2016.ResultsOver time, axa0clear shift in patient selection was noticeable towards lower surgical risks including Society of Thoracic Surgeons predicted risk of mortality score and comorbidity. The frequency of transfemoral TAVI increased (from 66.5 to 77.4%, pu202f=u20090.0015). Device success improved (from 62.0 to 91.5%, pu202f<u20090.0001) as did the frequency of symptomatic relief (≥1xa0New York Heart Association class difference) (from 73.8 to 87.1%, pu202f=u20090.00025). Complication rates decreased, including in-hospital stroke (from 5.0 to 2.1%, pu202f=u20090.033) and pacemaker implantations (from 10.1 to 5.9%, pu202f=u20090.033). Thirty-day mortality decreased (from 11.0 to 2.4%, pu202f<u20090.0001); after adjustment for patient characteristics, axa0mortality-risk reduction of 72% was observed (adjusted hazard ratio [HR]: 0.28, 95% confidence interval [CI]: 0.13–0.62). One-year mortality rates decreased (from 23.4 to 11.4%), but this was no longer significant after axa0landmark point was set at 30xa0days (mortality from 31xa0days until 1xa0year) (adjusted HR: 0.69, 95% CI: 0.41–1.16, pu202f=u20090.16).ConclusionAxa0clear shift towards axa0lower-risk TAVI population and improved clinical outcome was observed over an 8‑year period. Survival after TAVI improved impressively, mainly as axa0consequence of decreased 30-day mortality.