Jan Vojáček

ST-Segment Elevation Myocardial Infarction Treated by Radial or Femoral Approach in a Multicenter Randomized Clinical Trial The STEMI-RADIAL Trial

OBJECTIVES This study sought to compare radial and femoral approaches in patients presenting with ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI) by high-volume operators experienced in both access sites. BACKGROUND The exact clinical benefit of the radial compared to the femoral approach remains controversial. METHODS STEMI-RADIAL (ST Elevation Myocardial Infarction treated by RADIAL or femoral approach) was a randomized, multicenter trial. A total of 707 patients referred for STEMI <12 h of symptom onset were randomized in 4 high-volume radial centers. The primary endpoint was the cumulative incidence of major bleeding and vascular access site complications at 30 days. The rate of net adverse clinical events (NACE) was defined as a composite of death, myocardial infarction, stroke, and major bleeding/vascular complications. Access site crossover, contrast volume, duration of intensive care stay, and death at 6 months were secondary endpoints. RESULTS The primary endpoint occurred in 1.4% of the radial group (n = 348) and 7.2% of the femoral group (n = 359; p = 0.0001). The NACE rate was 4.6% versus 11.0% (p = 0.0028), respectively. Crossover from radial to femoral approach was 3.7%. Intensive care stay (2.5 ± 1.7 days vs. 3.0 ± 2.9 days, p = 0.0038) as well as contrast utilization (170 ± 71 ml vs. 182 ± 60 ml, p = 0.01) were significantly reduced in the radial group. Mortality in the radial and femoral groups was 2.3% versus 3.1% (p = 0.64) at 30 days and 2.3% versus 3.6% (p = 0.31) at 6 months, respectively. CONCLUSIONS In patients with STEMI undergoing primary PCI by operators experienced in both access sites, the radial approach was associated with significantly lower incidence of major bleeding and access site complications and superior net clinical benefit. These findings support the use of the radial approach in primary PCI as first choice after proper training. (Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention [PCI] [STEMI-RADIAL]; NCT01136187).

The effect of early treatment by cerivastatin on the serum level of C-reactive protein, interleukin-6, and interleukin-8 in the patients with unstable angina and non-Q-wave myocardial infarction

The aim of our study was to evaluate whether a single dose of cerivastatin at the time of admission of patients with unstable angina pectoris (UAP) or non-Q-wave myocardial infarction (NQMI) can influence the serum level of C-reactive protein (CRP), interleukin-6 (IL-6) and interleukin-8 (IL-8) 24 h later. Forty-four patients with rest chest pain and subendocardial ischemia on ECG were randomized to receive cerivastatin 0.3 mg at the time of admission (group C+) to standard therapy or to remain just on standard therapy (group C−). Blood samples for determination of troponin I (TI), CRP, IL-6 and IL-8 were collected at admission (entry level) and 24 h later (final level). Patients with non-physiological baseline levels of TI, as well as patients with progression to Q wave MI were excluded. All baseline, clinical and demographic data and final values of TI were comparable in the two groups. In patients treated with cerivastatin (group C+, n = 13) we observed decrease in the CRP level (−6.73 ± 3.93 mg/L); on the other hand, in group C− (n = 17) the CRP level increased (+7.92 ± 2.77 mg/L, p = 0.004). Similar differences were observed also in IL-6: in group C+ the level was significantly reduced as compared with the increase in group C− (−0.76 ± 0.52 vs. 4.58 ± 1.49 ng/L, p = 0.005). The level of IL-8 was not affected. Our results suggest that early treatment with cerivastatin can decrease the serum level of CRP and IL-6 in patients with UAP/NQMI; this might positively influence their prognosis. Nevertheless, further studies are needed to support this hypothesis.

Precordial thump efficacy in termination of induced ventricular arrhythmias.

INTRODUCTION Reports about the efficacy of precordial thump (PT) in the termination of ventricular arrhythmias (VA) vary widely. Very little recent data about the mechanical termination of VA induced during programmed ventricular stimulation are available. METHODS We prospectively studied 485 consecutive patients (May 2001 to December 2007) who underwent electrophysiology study with programmed ventricular stimulation as part of their assessment for primary or secondary prevention of sudden cardiac death. In cases of induction of sustained non-tolerated VA, one of two experienced cardiologists applied a precordial thump for termination of these arrhythmias immediately after the onset of unconsciousness. When PT was ineffective, the arrhythmia was terminated by electrical cardioversion. Tolerated VA was terminated by antitachycardic pacing. RESULTS Sustained VA was induced in 237 patients. In 82 patients with tolerated VA, overdriving was used successfully. Sustained induced VA was not tolerated in 155 patients (mean age 64 years (32-82), 133 males and 22 females, 126 patients with coronary artery disease, left ventricular ejection fraction 30+/-11%). Mean RR interval of induced VA was 226+/-47ms. Mean time to termination of arrhythmia (by PT or DC shock) was 26s (12-280s). PT terminated VA (polymorphic ventricular tachycardia) in only two patients; in 153 patients (98.7%), PT was ineffective. We did not observe any complication of PT application. CONCLUSION Efficacy of PT in termination of induced non-tolerated VA is very low even with early application after VA onset.

Isolated thoracic aortitis: clinicopathological and immunohistochemical study of 11 cases.

Isolated thoracic aortitis (ITA) is diagnosed in a variable proportion of patients operated on for dilation/aneurysm of ascending aorta. The etiopathogenesis of ITA remains unclear. We studied 11 cases of ITA in order to determine the role of IgG4-mediated immune responses in its pathogenesis. The series included nine women and two men aged 52-79 years. All patients developed aortic incompetence due to dilation/aneurysm of ascending aorta. None of the patients had a history of IgG4-related disease neither did they develop features of such disease during the follow-up period. The microscopic findings included the presence of lymphoplasmacellular fibrosing infiltrate of varied intensity involving the adventitia and media of aorta. This inflammation was associated with severe medial elastic fiber defects. Obliterative phlebitis of the vasa vasorum was absent. Immunohistochemically, the inflammatory infiltrate comprised T- and B-lymphocytes as well as plasma cells. The plasma cell population was polyclonal with a predominance of IgG-producing cells. In all the cases, IgG4-producing plasma cells were detected. In five cases, the count exceeded 20 cells per high-power field. The IgG4/IgG ratio ranged from 0.07 to 0.98 (median 0.55). In six cases with the ratio >0.50, severe adventitial fibrosis was present. To the best of our knowledge, ours is the first study focused on investigating the role of IgG4-positive plasma cells in the development of ITA. Our results suggest that a subset of ITA may represent aortic manifestation of IgG4-related disease. Further research is necessary in order to clarify this issue.

Time course of endothelin-1 plasma level in patients with acute coronary syndromes.

An elevated plasma level of endothelin-1 was reported in several cardiovascular conditions including unstable angina pectoris and myocardial infarction. The present study was designed to evaluate the time course of the endothelin-1 release in unstable angina pectoris and to assess its relationship to the development of myocardial infarction and coronary vessel occlusion. The cohort studied included 32 patients with the clinical diagnosis of unstable angina pectoris who had been admitted to the coronary care unit and subsequently underwent coronary angiography (group A). Fourteen patients with chronic stable angina pectoris referred to routine diagnostic coronary angiography served as the control group (group B). A significant difference in the endothelin-1 plasma level was found between both groups, the values being 10.2 ± 5.3 and 6.0 ± 3.1 pg/ml (p < 0.01), respectively. There were, however, no significant differences between the following subdivisions of group A: patients with and without subsequent myocardial infarction; those with angiographically documented occlusion of at least one major branch of the coronary artery and no occlusion; and finally, those with persisting symptoms of angina pectoris and with favorable response to treatment. Neither was there any difference found among the subgroups differing in the time interval between the onset of chest pain and blood sampling. The time course of endothelin plasma concentrations showed elevated values lasting for more than 96 h after the index episode of prolonged chest pain. No correlation with the subsequent clinical course could be inferred. Thus, plasma endothelin level was elevated in patients with unstable angina pectoris and myocardial infarction and the increase persisted for several days after the onset of symptoms.

Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium.

Whats known on the subject? and What does the study add?

Improved Patency of the Aortocoronary Bypass by Antithrombotic Drugs

A total of 1,017 bypasses were performed in 442 patients operated on in our department between January 1, 1981, and May 30, 1984. The overall early postoperative graft patency rate in our hospital was 91.5%. About 10% of the grafts had a flow rate of 40 ml/min or less, measured intraoperatively, and most occluded grafts were in this group. This article presents our experience with low-flow bypasses whose patency rates we attempted to improve. Patients with aortocoronary bypasses (ACBs) and with intraoperative blood flow rates of 40 ml/min or less were divided into two groups. The treated group was given, from day 0 onward, a 500-mg dose of acetylsalicylic acid twice a day and a 75-mg dose of dipyridamole three times a day. The control group was given no medication. Control coronary arteriography was performed at one month and then at one year after the operation. One month postoperatively, 34 out of 41 ACBs in the treated group were patent; in the control group, only 17 out of 37 were patent (p less than .001). One year after the operation, 24 out of 37 ACBs in the treated group were patent, whereas in the control group only 8 out of 38 ACBs were patent (p less than .001). We conclude that antiplatelet drugs have a beneficial effect on the short-term and long-term patency of ACBs.

The percutaneous closure of a large pseudoaneurysm of the ascending aorta with an atrial septal defect Amplatzer occluder: Two-year follow-up

Pseudoaneurysm of the ascending aorta is a high-risk complication following cardiac surgery. The present report describes excellent two-year follow-up results after the percutaneous closure of a very large pseudoaneurysm with an Amplatzer atrial septal defect occluder. The original cavity in the anterior mediastinum with maximal diameter 15 cm remained as only a small scar. The patient was without serious health problems both early and after two years.

Long-term follow-up after deferral of coronary intervention based on myocardial fractional flow reserve measurement.

ObjectiveTo assess long-term results after deferring coronary intervention (percutaneous coronary intervention (PCI)) of an intermediate lesion with a value of myocardial fractional flow reserve (FFR) ≥0.75 in a ‘real life’ patient population with no respect to results of stress tests (if performed) or coronary disease extent. MethodsPCI of an intermediate lesion was deferred in a group of 85 consecutive patients (54 men, 61±10 years) on the basis of the result of FFR ≥0.75 (mean FFR, 0.89±0.06%). FFR was measured in 111 stenoses (mean diameter stenosis, 54±8%, left anterior descending coronary artery, 65 (58%), left circumflex coronary artery, 24 (22%), right coronary artery, 22 (20%). Multi-vessel disease (defined as visually assessed diameter reduction of more than 50% in at least two arteries of more than 1.5 mm diameter, supplying at least two of the three major coronary artery perfusion territories) was present in 67% of patients (one-vessel disease, 28 patients (33%), two-vessel disease, 39 patients (46%), three-vessel disease, 18 patients (21%). Recorded events during follow-up were as follows: all-cause death, cardiac death, non-fatal myocardial infarction, ischemia-driven target lesion transcatheter revascularization (TLR) and coronary artery bypass graft (CABG). Angina class (Canadian Cardiovascular Society (CCS) classification) and the need for anti-anginal drugs were recorded. ResultsFollow-up was completed in 85 patients (100%). Mean duration of follow-up was 22.6±6.6 months (range 4–33 months). Events occurred in 11 patients (13%). Seven patients died; this included two cardiac deaths. A non-fatal myocardial infarction occurred in one patient, one patient needed TLR and three patients underwent CABG. Estimated 33 month cardiac-event-free survival (Kaplan–Meier) was 91±4%. Angina class decreased [1.6±1.2 compared with 0.8±0.8 (P<0.0001)] without difference with respect to the use of anti-anginal drugs (1.7±0.8 compared with 1.7±0.9, P=NS). ConclusionsDeferring coronary interventions of intermediate stenosis based on FFR measurement is safe with respect to long-term follow-up, irrespective of the extent of coronary artery disease.

Use of the biochip microarray system in detection of myocardial injury caused by radiofrequency catheter ablation.

Abstract Background: In a prospective study, we measured plasma markers of myocardial damage induced by radiofrequency catheter ablation (RFA) with the protein biochip microarray system. Methods: A total of 32 consecutive patients undergoing RFA for atrioventricular nodal re-entry tachycardia (AVNRT), right atrial flutter (AFL) and atrial fibrillation (AF) were included in the study. Cardiac troponin I (cTnI), creatine kinase isoenzyme MB (CK-MB), heart-type fatty acid binding protein (hFABP) and glycogen phosphorylase BB (GPBB) were measured using biochip array technology at baseline and 24 h after the procedure. Results: Values for all markers increased 24 h after RFA (cTnI: 0.92±0.49 μg/L vs. 0.33±0.06 μg/L, p<0.001; CK-MB: 3.79±2.04 μg/L vs. 1.85±0.55 μg/L, p<0.001; hFABP: 2.82±0.95 μg/L vs. 2.00±0.95 μg/L, p<0.001; GPBB: 9.07±5.83 μg/L vs. 4.70±2.50 μg/L, p<0.001). The correlations between plasma marker levels and RFA time were cTnI: r=0.63, p<0.01; CK-MB: r=0.75, p<0.01; hFABP: r=0.55, p<0.05, GPBB: r=0.51, p<0.05; the correlation between RFA time and number of RF applications was significant (r=0.81, p<0.001). Patients with RFA due to AF or flutter had elevated cTnI, CK-MB and hFABP levels compared to patients with AVNRT (cTnI: 1.14± 0.49 μg/L vs. 0.59±0.25 μg/L, p<0.05; CK-MB: 4.46± 2.07 μg/L vs. 2.81±1.54 μg/L, p<0.05; hFABP: 3.21± 0.98 μg/L vs. 2.25±0.54 μg/L, p<0.01). Conclusions: Myocardial injury induced by RFA can be detected by cTnI, CK-MB, hFABP and GPBB. Plasma cTnI, CK-MB and hFABP levels significantly increased in patients with AFL and AF compared to patients with AVNRT. The increase of cTnI, CK-MB and GPBB levels correlates with the total duration of RFA. Clin Chem Lab Med 2008;46:1726–8.