Jaime Elízaga

Drug-Eluting Stent Thrombosis Results From the Multicenter Spanish Registry ESTROFA (Estudio ESpañol sobre TROmbosis de stents FArmacoactivos)

OBJECTIVES This study sought to assess the incidence, predictors, and outcome of drug-eluting stent(DES) thrombosis in real-world clinical practice. BACKGROUND The DES thromboses in randomized trials could not be comparable to those observed in clinical practice, frequently including off-label indications. METHODS We designed a large-scale, nonindustry-linked multicentered registry, with 20 centers in Spain. The participant centers provided follow-up data for their patients treated with DES, reporting a detailed standardized form in the event of any angiography-documented DES-associated thrombosis occurring. RESULTS Of 23,500 patients treated with DES, definite stent thrombosis(ST) developed in 301: 24 acute, 125 subacute, and 152 late. Of the late, 62 occurred >1 year(very late ST). The cumulative incidence was 2% at 3 years. Antiplatelet treatment had been discontinued in 95 cases(31.6%). No differences in incidences were found among stent types. Independent predictors for subacute ST analyzed in a subgroup of 14,120 cases were diabetes, renal failure, acute coronary syndrome, ST-segment elevation myocardial infarction, stent length, and left anterior descending artery stenting, and for late ST were ST-segment elevation myocardial infarction, stenting in left anterior descending artery, and stent length. Mortality at 1-year follow-up was 16% and ST recurrence 4.6%. Older age, left ventricular ejection fraction <45%, nonrestoration of Thrombolysis In Myocardial Infarction flow grade 3, and additional stenting were independent predictors for mortality. CONCLUSIONS The cumulative incidence of ST after DES implantation was 2% at 3 years. No differences were found among stent types. Patient profiles differed between early and late ST. Short-term prognosis is poor, especially when restoration of normal flow fails.

Selective inhibition of the contractile apparatus. A new approach to modification of infarct size, infarct composition, and infarct geometry during coronary artery occlusion and reperfusion.

BackgroundMyocardial reperfusion is associated with calcium overload and cell contracture, mechanisms that may precipitate cell death. In this study, we tested the hypothesis that in vivo inhibition of this contracture could lead to cell preservation in an open-chest large animal model. Methods and ResultsRegional myocardium function was measured during a selective intracoronary infusion of 2,3-butanedione monoxime (BDM), a specific inhibitor of actin-myosin coupling, in the control state (10 pigs) and in a protocol of a 51-minute coronary occlusion followed by reperfusion (40 pigs). The effects on coronary artery blood flow in the basal state were also studied (seven pigs). Intramyocardial distribution of the infusate during coronary occlusion, myocardial water content after 30 minutes of reperfusion and area at risk, infarct size, type of histological necrosis, and infarct geometry after 24 hours of reperfusion were assessed. Methods used included electromagnetic flowmeter, radiolabeled microspheres, subendocardial sonomicrometers, fluorescein, triphenyl tetrazolium chloride and Massons trichrome staining, and computer quantification of infarct edges. In the absence of ischemia, BDM infusion inhibited regional shortening in a dose-dependent manner up to full systolic bulging while producing marked regional increase in coronary blood flow. During early reperfusion, BDM reduced end-diastolic length 76% more than the control infusion (p<0.05) and increased systolic bulging by 420% compared with no change in control animals. The ratio of infarct size/area at risk was reduced by 31% with BDM (p<0.05), with striking modifications of infarct histology and infarct geometry; specifically, the extent of contraction band necrosis was reduced by 63% from 105.5±18.2 to 39.2±13.6 mm2 (p<0.02), and more patches of necrosis (6.5±2.1 versus 1.600.4, p<0.05) and higher contour (7.7 ± 1.2 versus 5.03±0.2, p <0.05) and fractal (12.1±1.3 versus 7.8±0.2, p <0.05) indexes were found. ConclusionsSelective intracoronary infusion of BDM at doses inhibiting regional wall motion decreased infarct size after reperfusion. The effects of BDM on regional function, the reduction in contraction band necrosis at histology, and the peculiar configuration of these infarcts all suggest that inhibition of contracture can interfere with cell-to-cell progression of myocardial necrosis, supporting a role for contracture in reperfusion-induced cell death.

Primary angioplasty versus systemic thrombolysis in anterior myocardial infarction.

OBJECTIVES This study compares the efficacy of primary angioplasty and systemic thrombolysis with t-PA in reducing the in-hospital mortality of patients with anterior AMI. BACKGROUND Controversy still exists about the relative benefit of primary angioplasty over thrombolysis as treatment for AMI. METHODS Two-hundred and twenty patients with anterior AMI were randomly assigned in our institution to primary angioplasty (109 patients) or systemic thrombolysis with accelerated t-PA (111 patients) within the first five hours from the onset of symptoms. RESULTS Baseline characteristics were similar in both groups. Primary angioplasty was independently associated with a lower in-hospital mortality (2.8% vs. 10.8%, p = 0.02, adjusted odds ratio 0.23, 95% confidence interval 0.06 to 0.85). During hospitalization, patients treated by angioplasty had a lower frequency of postinfarction angina or positive stress test (11.9% vs. 25.2%, p = 0.01) and less frequently underwent percutaneous or surgical revascularization after the initial treatment (22.0% vs. 47.7%, p < 0.001) than did patients treated by t-PA. At six month follow-up, patients treated by angioplasty had a lower cumulative rate of death (4.6% vs. 11.7%, p = 0.05) and revascularization (31.2% vs. 55.9%, p < 0.001) than those treated by t-PA. CONCLUSIONS In centers with an experienced and readily available interventional team, primary angioplasty is superior to t-PA for the treatment of anterior AMI.

Endothelial dysfunction over the course of coronary artery disease

The vascular endothelium regulates blood flow in response to physiological needs. Endothelial dysfunction is closely related to atherosclerosis and its risk factors, and it constitutes an intermediate step on the progression to adverse events throughout the natural history of coronary artery disease (CAD), often affecting clinical outcomes. Understanding the relation of endothelial function with CAD provides an important pathophysiological insight, which can be useful both in clinical and research management. In this review, we summarize the current knowledge on endothelial dysfunction and its prognostic influence throughout the natural history of CAD, from early atherosclerosis to post-transplant management.

Mechanisms of Residual Lumen Stenosis After High-Pressure Stent Implantation A Quantitative Coronary Angiography and Intravascular Ultrasound Study

BACKGROUND Intravascular ultrasound (IVUS) studies have demonstrated that stents are frequently suboptimally expanded despite the use of high pressures for deployment. The purpose of this study was to identify the mechanisms responsible for such residual lumen stenosis. METHODS AND RESULTS Fifty-seven lesions from 50 patients treated with high-pressure (median+/-interquartile range, 14+/-2 atm) elective (44 de novo, 13 restenotic lesions) stenting were prospectively studied (29 Wiktor, Medtronic; 28 Palmaz-Schatz, Cordis Corp). Balloon subexpansion was calculated as the difference between maximal and minimal balloon cross-sectional areas at peak pressure measured by automatic edge detection; elastic recoil was calculated as the difference between minimal measured balloon size and IVUS-derived minimal lumen area within the stent. Angiographic residual diameter stenosis was 10+/-13% (reference diameter, 3.1+/-0.7 mm; balloon to artery ratio, 1.12+/-0.23) and IVUS-derived stent expansion was 80+/-28%. However, although balloon nominal size was 9.6+/-1.3 mm2 and maximal balloon size measured inside the coronary lumen was 12.5+/-3.2 mm2, final stent minimal lumen area was only 7.1+/-2.2 mm2. Balloon subexpansion of 4.0+/-1.8 mm2 (33%) and elastic recoil of 1.6+/-2.3 mm2 (20%) (both P<0.0001) were the two mechanisms responsible for residual luminal stenosis. Wiktor stent and peak inflation pressure correlated with balloon subexpansion, whereas Wiktor stent, de novo lesion, and minimal lumen area at baseline correlated with elastic recoil. CONCLUSIONS Despite high-pressure deployment, lumen dimensions after stenting are only 57% of maximal achievable. Inadequate balloon expansion and elastic recoil are responsible for residual lumen stenosis, suggesting that plaque characteristics and stent resistance deserve further investigation.

Influence of Collateral Circulation on In-Hospital Death From Anterior Acute Myocardial Infarction

OBJECTIVES Our purpose was to study whether the in-hospital prognosis of anterior acute myocardial infarction (AMI) is influenced by preexistent collateral circulation to the infarct-related artery. BACKGROUND Collateral circulation exerts beneficial influences on the clinical course after AMI, but demonstration of improved survival is lacking. METHODS We studied 238 consecutive patients with anterior AMI treated by primary angioplasty within the first 6 h of the onset of symptoms. Fifty-eight patients with basal Thrombolysis in Myocardial Infarction (TIMI) flow >1 in the infarct-related artery or with inadequate documentation of collateral circulation were excluded. Collateral channels to the infarct-related artery before angioplasty were angiographically assessed, establishing two groups: 115 patients (64%) without collateral vessels (group A) and 65 patients (36%) with collateral vessels (group B). RESULTS There were no differences in baseline characteristics between groups A and B, except for the greater prevalence of previous angina in group B (15% vs. 34%, p = 0.003). During the hospital stay, 26 patients (23%) in group A and 5 (8%) in group B died (p = 0.01). Cardiogenic shock accounted for 74% of deaths. Cardiogenic shock developed in 30 patients (26%) in group A and in 4 (6%) in group B (p = 0.001). The absence of collateral circulation appeared to be an independent predictor of in-hospital death (odds ratio 3.4, 95% confidence interval 1.2 to 9.6, p = 0.02) and cardiogenic shock (odds ratio 5.6, 95% confidence interval 1.9 to 17, p = 0.002). CONCLUSIONS Preexistent collateral circulation decreases in-hospital death from anterior AMI by reducing the incidence of cardiogenic shock.

Thrombosis of Second-Generation Drug-Eluting Stents in Real Practice: Results From the Multicenter Spanish Registry ESTROFA-2 (Estudio Español Sobre Trombosis de Stents Farmacoactivos de Segunda Generacion-2)

OBJECTIVES This study sought to evaluate second-generation drug-eluting stent (DES) thrombosis in clinical practice. BACKGROUND First-generation DES are associated with a significant incidence of late thrombosis. There is paucity of data regarding real practice late thrombosis incidence and predictors with second-generation DES, zotarolimus-eluting stent (ZES), and everolimus-eluting stents (EES). METHODS A prospective, large-scale, non-industry-linked multicenter registry was designed. Complete clinical-procedural data and systematic follow-up of all patients treated with these stents was reported in a dedicated registry supported by the Spanish Working Group on Interventional Cardiology. RESULTS From 2005 to 2008, 4,768 patients were included in 34 centers: 2,549 treated with ZES, and 2,219 with EES. The cumulative incidence of definite/probable thrombosis for ZES was 1.3% at 1 year and 1.7% at 2 years and for EES 1.4% at 1 year and 1.7% at 2 years (p = 0.8). The increment of definite thrombosis between the first and second year was 0.2% and 0.25%, respectively. In a propensity score analysis, the incidence remained very similar. Ejection fraction (adjusted hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.95 to -0.99; p = 0.008), stent diameter (adjusted HR: 0.37; 95% CI: 0.17to 0.81; p = 0.01) and bifurcations (adjusted HR: 2.1; 95% CI: 1.14 to 3.7; p = 0.02) emerged as independent predictors of thrombosis. In the subgroup of patients with bifurcations, the use of ZES was independently associated with a higher thrombosis rate (adjusted HR: 4; 95% CI: 1.1 to 13; p = 0.03). CONCLUSIONS In a real practice setting, the incidence of thrombosis at 2 years with ZES and EES was low and quite similar. The incidence of very late thrombosis resulted lower than was reported in registries of first-generation DES. In the subset of bifurcations, the use of ZES significantly increased the risk of thrombosis.

Registro de actividad de la Sección de Hemodinámica y Cardiología Intervencionista del año 1996

Se presentan los datos del Registro Espanol de Hemodinamica y Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia. El Registro recogela actividad realizada durante el ano 1996 en 81 centros que representan la totalidad de los laboratoriosde hemodinamica. En 73 centros se realizofundamentalmente hemodinamica en adultos y 8 llevaron a cabo exclusivamente actividad pediatrica. Los estudios diagnosticos se han incrementadoen un 10,7% (63.961) respecto al ano 1995, a expensas del aumento de las coronariografias. El volumen de intervenciones coronarias (15.009) ha sido un 21,4% superior al del ano 1995, aumentando a 375 el numero de angioplastias por millon de habitantes. Las cifras de exito (94%) y de complicaciones(2,9%) son similares a las registradas enanos anteriores. En lo que se refiere al empleo de dispositivos, cabe destacar el fuerte y sostenido aumento en la utilizacion de los stents intracoronarios: 7.104 procedimientos (el 47,3% de todas las intervenciones coronarias) y 8.873 protesis implantadas, lo que supone duplicar la actividad del ano 1995 en este campo. El implante del stent fue electivo en el 58% de los casos y la tasa de complicaciones resulto baja (el 1% de oclusion subaguda; el 1,8% de infartoagudo de miocardio y el 0,9% de mortalidad). La aterectomia direccional ha disminuido en un 47% mientras que la aterectomia rotacional ha au mentadoun 10% a pesar de disminuir el numero de centros que la practican. Al igual que en anos anteriores, se observa un ligero descenso en el numero de valvuloplastias en adultos, mientras que el intervencionismo en pediatria (607 procedimientos) ha aumentado un 30% con respecto al Registro anterior.

Comparison of Paclitaxel-Eluting Stents (Taxus) and Everolimus-Eluting Stents (Xience) in Left Main Coronary Artery Disease With 3 Years Follow-Up (from the ESTROFA-LM Registry)

Evidence regarding therapy with drug-eluting stents in the left main coronary artery (LM) is based mostly on trials performed with first-generation drug-eluting stents. The aim of this study was to evaluate long-term clinical outcomes after treatment for unprotected LM disease with paclitaxel-eluting stents (PES) and everolimus-eluting stents (EES). The ESTROFA-LM is a multicenter retrospective registry including consecutive patients with unprotected LM disease treated with PES or EES. A total of 770 patients have been included at 21 centers, 415 with treated PES and 355 with EES. Treatment with 2 stents was more frequent with PES (17% vs 10.4%, p = 0.007), whereas intravascular ultrasound was more frequently used with EES (35.2% vs 26%, p = 0.006). The 3-year death and infarction survival rates were 86.1% for PES and 87.3% for EES (p = 0.50) and for death, infarction, and target lesion revascularization were 83.6% versus 82% (p = 0.60), respectively. Definite or probable thrombosis was 1.6% for PES and 1.4% for EES (p = 0.80). The use of 2 stents, age, diabetes, and acute coronary syndromes were independent predictors of mortality. In the subgroup of distal lesions, the use of intravascular ultrasound was an independent predictor of better outcome. Comparison of propensity score-matched groups did not yield differences between the 2 stents. In conclusion, the results of this multicenter registry show comparable safety and efficacy at 3 years for PES and EES in the treatment of LM disease. The use of bifurcation stenting techniques in distal lesions was a relevant independent predictor for events. The use of intravascular ultrasound appears to have a positive impact on patients treated for LM distal disease.

Guías de práctica clínica de la Sociedad Española de Cardiología en cardiología intervencionista: angioplastia coronaria y otras técnicas

La cardiologia intervencionista ha experimentado en los ultimos anos un gran crecimiento. En esta guia de actuacion clinica se revisa la evidencia cientifica existente y su implicacion en la utilidad de las diferentes tecnicas en distintos contextos clinicos y anatomicos. La revision incluye los apartados: 1. Coronariografia. 2. Angioplastia con balon. 3. Stent coronario. 4. Otras tecnicas intervencionistas: aterectomia direccional, aterectomia rotacional, cateter de extraccion transluminal, balon de corte, laser intracoronario y transmiocardico e irradiacion intracoronaria. 5. Inhibidores de los receptores de la GP IIb/IIIa. 6. Nuevas tecnicas diagnosticas: ecografia intracoronaria, angioscopia, Doppler coronario y guia de presion. El grado de consenso de las fuentes consultadas y de los expertos son expresados utilizando la clasificacion en clases I, IIa, IIb y III, utilizada en las guias del American College of Cardiology/American Heart Association.