Jaume Maristany

Use of Impella Recover LP 2.5 in elective high risk percutaneous coronary intervention

We describe a single-center experience in using the Impella Recover LP 2.5 in the setting of high-risk elective percutaneous coronary interventions. This device is placed percutaneously to support cardiac output and has a better profile than other left ventricular assist devices. Our study shows that the use of the Impella Recover LP 2.5 device is feasible, has an overall favorable safety profile, and may help prevent periprocedural and short-term complications derived from high-risk procedures.

Bioresorbable Scaffolds to Treat Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndromes (ACS), typically affecting female and younger individuals with no underlying atherosclerotic disease.1 Diagnosis of SCAD has traditionally relied on coronary angiography; however, new imaging modalities, and especially optical coherence tomography (OCT), improve diagnostic accuracy and help management.2 The optimal treatment strategy remains controversial and may vary from a completely conservative approach to percutaneous or even surgical revascularization, always guided by the clinical scenario and symptoms.1 When percutaneous coronary intervention is chosen, metal stents are usually implanted on vessels with no significant atherosclerotic lesions.3 Use of bioresorbable vascular scaffolds (BVS) may have an interesting therapeutic role for these patients because they disappear completely after 2 or 3 years and may allow for a complete functional recovery,4 which is particularly appealing in SCAD, where spontaneous healing is part of the natural history of this entity. In this sense, we describe 3 documented experiences corresponding to 3 different patients with ACS caused by SCAD from 3 different coronary arteries. Case 1: 58-year-old male, active smoker, with systemic hypertension and family history of coronary disease. He was admitted for presenting an inferior ST-segment–elevation myocardial …

Seguimiento a largo plazo tras el tratamiento percutáneo del tronco coronario izquierdo no protegido en pacientes de alto riesgo no aptos para cirugía de revascularización

INTRODUCTION AND OBJECTIVES Percutaneous coronary intervention is recommended in patients with unprotected left main stenosis non suitable for coronary artery bypass graft. Long-term follow-up of those patients remains uncertain. METHODS All patients with de novo unprotected left main stenosis treated with stent implantation were consecutively enrolled. Percutaneous coronary intervention was indicated according to the standards of care, taking into account clinical and anatomical conditions unfavorable for coronary artery bypass graft. The primary end point was the occurrence of major adverse cardiac events, a composite of death, nonfatal acute myocardial infarction, or target lesion revascularization. RESULTS Of 226 consecutive patients included, 202 (89.4%) were treated with drug-eluting stents. Mean age was 72.1 years, 41.1% had renal dysfunction, and mean Syntax score and EuroSCORE were 28.9 and 7.4, respectively. Angiographic and procedural success was achieved in 99.6% and 92.9% of patients. At 3 years, the rates of major adverse cardiac events, death, nonfatal acute myocardial infarction and target lesion revascularization were 36.2%, 25.2%, 8.4%, 8.0%, respectively. Target lesion revascularization was more frequently observed when ≥ 2 stents were implanted rather than a single stent (18.5% vs 5.8%, P=.03); and with bare metal stents rather than drug-eluting stents (13.0% vs 7.9%, P=.24). Definite stent thrombosis was observed in 2 patients (0.9%) and probable stent thrombosis in 7 (3.1%). Female sex, impaired left ventricular function, and use of bare metal stents were significantly related with all-cause mortality. CONCLUSIONS High-risk patients with unprotected left main stenosis treated with percutaneous coronary intervention presented with a high rate of major adverse cardiac events at long-term follow-up. Female sex, impaired left ventricular function, and use of bare metal stents were predictors of poor prognosis.

Minor Myocardial Damage During Percutaneous Coronary Intervention Does Not Affect Long-Term Prognosis

INTRODUCTION AND OBJECTIVES To determine whether long-term prognosis is affected by myocardial damage taking place during percutaneous coronary intervention (PCI). METHODS The study included consecutive patients undergoing PCI. Those with elevated baseline cardiac marker levels were excluded. Cardiac markers were evaluated and an ECG was recorded before and 12 and 24 hours after PCI. Patients were divided into three groups after PCI according to their cardiac marker levels: no myocardial damage (i.e. normal troponin and creatine kinase MB fraction [CK-MB]), minor damage (elevated troponin with normal CK-MB), and myonecrosis (elevated troponin and CK-MB). The occurrence of death, myocardial infarction or repeat revascularization during follow-up was recorded. RESULTS Minor myocardial damage associated with PCI was observed in 127 (16.8%) of the 757 patients included in the study and myonecrosis, in 46 (6.1%). During a follow-up of 45+/-14 months, cardiac events occurred in 151 (19.1%) patients. Mortality during follow-up was significantly higher in patients with myonecrosis (13%) than in the other two groups (4.8% and 3.9%; log rank, 6.83; P=.032). No difference was observed in the rate of myocardial infarction or repeat revascularization during follow-up. CONCLUSIONS Minor myocardial damage during PCI had no effect on long-term prognosis. In contrast, myonecrosis was associated with increased mortality. Consequently, the CK-MB level should be measured after all PCIs because of its prognostic implications, and strategies for reducing the risk of myonecrosis developing should be implemented.

Endothelial-Dependent Vasoconstriction in the Infarct-Related Artery Early After Myocardial Infarction Is Smaller Following Primary Angioplasty Than Thrombolytic Therapy

INTRODUCTION AND OBJECTIVES In patients with ST-elevation acute myocardial infarction treated by thrombolysis, both early endothelial dysfunction and long-term improvement in the infarct-related artery have been reported. Our aims were to assess the degree of endothelial dysfunction present after primary angioplasty and to compare it with that after thrombolysis. METHODS Endothelial function was assessed 9 days after infarction by infusing acetylcholine, at an increasing concentration, and subsequently nitroglycerine into the infarct-related artery in 16 patients who had undergone primary angioplasty and bare-metal stent implantation. In addition, endothelial function was compared with that in a group of 16 patients treated by thrombolysis in a different time period. The mean change in the diameters of segments distal to the culprit lesion or the treated lesion were evaluated by quantitative coronary angiography. RESULTS Baseline characteristics were similar in the two groups, except that patients in the primary angioplasty group were treated with clopidogrel and there were differences in residual stenosis in the infarct-related artery (3% in the primary angioplasty group compared with 62% in the thrombolysis group). At the maximum acetylcholine concentration, the degree of vasoconstriction was less in the primary angioplasty group than in the thrombolysis group (-4+/-5% vs. -20+/-21%; P=.018). CONCLUSIONS Early endothelium-dependent vasoconstriction in the infarct-related artery was lower in acute myocardial infarction patients treated by primary angioplasty and bare-metal stent implantation than in those treated by thrombolysis.

El daño miocárdico mínimo durante el intervencionismo coronario percutáneo no influye en el pronóstico a largo plazo

Introduccion y objetivos Evaluar el pronostico a largo plazo del dano miocardico producido durante el intervencionismo coronario percutaneo (ICP). Metodos Incluimos una serie de pacientes consecutivos a quienes se practico ICP, excluyendo a los que ya presentaban basalmente elevacion de marcadores cardiacos. El ECG y los marcadores de dano miocardico se evaluaron antes y a las 12 y 24 h tras el procedimiento. Segun el valor de dichos marcadores, se clasifico a los pacientes en tres grupos: ausencia de dano miocardico (troponina y CK-MB normal), dano miocardico minimo (elevacion del valor de troponina, con CK-MB normal) y mionecrosis (elevacion de troponina I y CK-MB). Muerte, infarto de miocardio y nueva revascularizacion fueron evaluados durante el seguimiento. Resultados De 757 pacientes incluidos, en 127 (16,8%) se detecto dano miocardico minimo asociado al procedimiento y en 46 (6,1%) mionecrosis. Durante un seguimiento de 45 ± 14 meses, 151 (19,1%) pacientes sufrieron eventos cardiacos. Los pacientes que presentaron mionecrosis tuvieron un significativo incremento de la mortalidad durante el seguimiento (13%) respecto a los otros dos grupos (el 4,8 y el 3,9%; log rank test, 6,83; p = 0,032). No se detectaron diferencias en la tasa de IAM o nueva revascularizacion en el seguimiento. Conclusiones El dano miocardico minimo durante el intervencionismo no influye en el pronostico a largo plazo. Por contra, la mionecrosis se asocia a un incremento de mortalidad. Este hecho implica la necesidad de determinar la CK-MB tras todo ICP debido a su implicacion pronostica y la aplicacion de estrategias que disminuyan la aparicion de mionecrosis.

Procedural, Functional and Prognostic Outcomes Following Recanalization of Coronary Chronic Total Occlusions. Results of the Iberian Registry

INTRODUCTION AND OBJECTIVES There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. METHODS Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. RESULTS A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 ± 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score ≤ 2 (80.5% vs 69.5%; P = .002), and in intravascular ultrasound-guided PCI (89.9% vs 76.2%, P = .001), which was an independent predictor of success. In contrast, severe calcification, length > 20mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. CONCLUSIONS Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality.