J. Murphy

Procedural and in-patient outcomes in patients aged 80 years or older undergoing contemporary primary percutaneous coronary intervention

AIMS Patients aged ≥80 years are often excluded or under-represented in trials assessing treatment modalities in STEMI. We assessed in-patient outcomes in elderly patients undergoing contemporary primary PCI (PPCI). METHODS AND RESULTS From Sept 2005 to July 2011 patients undergoing PPCI in our centre were identified. Demographic details, procedural data and in-patient outcomes were collated. Those aged ≥80 years were compared with those aged <80 years. In the study period 1,218 patients required PPCI, of which 224(18.4%) were ≥80 years. The elderly cohort were more likely to be female (44.3% vs. 20.3%; p<0.001), and have significant comorbidities. Times from first medical contact until TIMI 3 flow were similar between the two groups (medien 102 min vs. 109 min; p=0.19). There was no difference in rates of PCI success (97.3% vs. 98.3%; p=0.24), drug-eluting stent use (63.5% vs. 63.3%; p=1.00) and number of stents used. In-patient outcomes were worse in the elderly cohort with significantly higher rates of death (11.2% vs. 3.7%; p<0.001) and acute kidney injury (12.9% vs. 4.0%; p<0.001), with a trend towards more post-procedure cardiovascular accidents (CVA), access site complications and reinfarction. Length of stay was significantly longer in the elderly cohort (median days 5 vs. 3; p<0.001). CONCLUSIONS Important demographic differences exist in very elderly patients presenting with STEMI compared to younger patients though procedural data and PCI success rates are similar between the two groups. Those aged ≥80 years have significantly worse in-patient outcomes though death rates are not as high as historical data suggests.

Cost Benefit for Assessment of Intermediate Coronary Stenosis with Fractional Flow Reserve in Public and Private Sectors in Australia

BACKGROUND Fractional Flow Reserve (FFR) is a proven technology for guiding percutaneous coronary intervention (PCI), but is not reimbursed despite the fact that it is frequently used to defer PCI. METHODS Costs incurred with use of FFR were compared in both the public and private sectors with the costs that would have been incurred if the technology was not available using consecutive cases over a two year period in a public teaching hospital and its co-located private hospital. RESULTS FFR was performed on 143 lesions in 120 patients. FFR was < 0.80 in 37 lesions in 34 patients and 25 underwent PCI while 11 had CABG. It was estimated that without FFR 78 lesions in 70 patients would have had PCI with 17 patients having CABG with 35 additional functional tests. Despite a cost of

Optical coherence tomography (OCT) as an adjunct to percutaneous coronary intervention; a single centre experience.

A1200 per wire, FFR actually saved money. Mean savings in the public sector were

An unusual cause of myocardial ischaemia

1200 per patient while in the private sector the savings were

An unusual cause of embolic myocardial infarction

5000 per patient. CONCLUSIONS FFR use saves money for the Federal Government in the public sector and for the Private Health Funds in the private sector. These financial benefits are seen in addition to the improved outcomes seen with this technology.

Percutaneous coronary intervention via the radial artery: comparison of procedural success in emergency versus non-emergency cases

Intravascular imaging of coronary arteries has become increasingly common. Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are the two most recognized modalities utilized. Unlike IVUS which uses ultrasound waves, OCT creates an image by directing an optical beam of infrared light onto the tissue and measuring the reflected intensity of light [1]. Until recently OCT has predominantly been used in the research setting, though it has been shown to be safe and feasible to use in the clinical setting [2,3]. IVUS guided percutaneous coronary intervention has been shown to reduce target lesion revascularisation in certain patient cohorts [4,5] and although no similar outcome studies currently exist with OCT, it is arguable that the indications for its use would be similar to those established for IVUS. We sought to clarify the potentially under-appreciated clinical role that OCT may play in PCI. We report a single centre experience where OCT was used to help guide management in routine clinical practice. Between November 2010 and February 2012 all cases where OCT performed for clinical indications during PCI in our centre were retrospectively analysed. The OCT acquisition was performed using the C7 DragonflyTM intracoronary imaging catheter and the ILUMIENTM PCI Optimization System (St. Jude Medical). All images were acquired using a non-occlusive technique with injection of isosmolar iodixonoal (VisipaqueTM by GE healthcare) contrast to clear the vessel of blood [3].

Pop goes the balloon: a cautionary tale in transaortic intervention.

Insertion of an Implantable Cardiac Defibrillator (ICD) has been demonstrated to improve cardiac and overall survival in selected patients at risk of sudden cardiac death [1]. The wide range of patients that benefit from ICD insertion have resulted in implantation of such devices becoming commonplace. Peri-procedural complications are uncommon, with an overall incidence of approximately 3% and the most common complications comprise localised haematoma over the site of the generator, lead displacement and haemothorax [2]. We describe a rare but potentially fatal complication related to ICD insertion in a patient who had previously undergone coronary artery bypass grafting (CABG). A 52 year old man with a history of myocardial infarction and previous CABG presented with ventricular tachycardia and haemodynamic embarrassment requiring emergent electrical cardioversion. Subsequent cardiac biomarkers and electrolytes were within normal limits. Transthoracic echocardiography (TTE) demonstrated inferobasal hypokinesis with mild-moderately impaired left ventricular systolic function. Coronary angiography was performed and demonstrated patent grafts (left internal mammary artery (LIMA) graft to the left anterior descending (LAD) with a saphenous veins graft to the posterior descending branch of the right coronary artery and obtuse marginal). The patient underwent insertion of an implantable cardiac defibrillator (ICD) with standard atrial and ventricular leads inserted via the left subclavian vein. One hour following the end of the procedure the patient complained of retrosternal chest pain. Electrocardiograph (ECG) demonstrated

Spontaneous Intrastent Dissection Late Neointimal Separation Within a Bare Metal Stent Causing Acute Coronary Syndrome

A 35-year-old female presented with acute inferior ST-elevation myocardial infarction and underwent emergency cardiac catheterization. Diagnostic images revealed an occlusive filling defect at the first bifurcation of a large dominant circumflex artery ( Panel A ). The other epicardial coronary arteries were normal. Aspiration thrombectomy removed a significant volume of thrombus and angiography then demonstrated the circumflex …

Absence of a ‘smoker's paradox’ in field triaged ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention

BACKGROUND STEMI and unstable acute coronary syndromes are associated with widespread adrenergic activation which may increase radial artery (RA) spasm, requiring cross-over to the femoral artery (FA) during percutaneous coronary intervention (PCI). We assessed the incidence of failed trans-radial artery PCI in emergency cases compared with non-emergency cases. METHODS PCI procedures performed by default radial artery operators were assessed in our centre over a 25 month period. Those who had both RA and FA access were identified to assess if the double punctures were elective or due to failure of the RA approach. Cross-over rates were compared between emergency and non-emergency cases. RESULTS 680 cases of PCI were performed, 153 in an emergency setting. In non-emergency cases 403/527 (76.5%) were performed via the RA. In the emergency setting 139/153 (90.8%) were completed by the RA. Previous CABG with multiple arterial conduits was the most common reason for elective FA PCI in both groups. The RA to FA cross-over rate was low with no significant difference between the emergency and non-emergency groups (emergency 1.4%, non-emergency 1.2%, p=1.0). In both groups there was no significant difference between RA and FA procedures in terms of fluoroscopy times (emergency: mean 13.1 ± 7.9 min vs 16.1 ± 16.1 min, p=.25, non-emergency: 16.6 ± 10.3 min vs 18.7 ± 13.6 min, p=.07) or contrast volumes (emergency: mean 231 ± 126 ml vs 229 ± 102 ml, p=.77, non-emergency: 223 ± 85 ml vs 237 ± 91 ml, p=.15). CONCLUSIONS The vast majority of PCI can be successfully performed via the RA. Cross-over rates to the FA are low and are not more common in emergency patients.

Thrombolysis in myocardial infarction (TIMI) risk score and gender in the era of primary PCI—Is there a difference?

Abstract This case report and images describe the rare complication of percutaneous aortic valvuloplasty balloon rupture with subsequent mass micro-bubble embolism and haemodynamic collapse. It serves as a cautionary reminder that despite routine standard preparation and technique this adverse event can still occur.