Javier Soriano

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.

Primary Angioplasty Reduces the Risk of Left Ventricular Free Wall Rupture Compared With Thrombolysis in Patients With Acute Myocardial Infarction

OBJECTIVES This study aimed to evaluate the effect of primary angioplasty (PA) over the risk of free wall rupture (FWR) in reperfused acute myocardial infarction (AMI). BACKGROUND It has been suggested that PA reduces the risk of FWR compared with thrombolysis. However, few studies have evaluated this issue, and there are no data demonstrating this hypothesis. METHODS A total of 1,375 patients with AMI treated with PA (n = 762, 55.4%) or thrombolysis (n = 613, 44.6%) within 12 h after symptoms onset were included. The diagnosis of FWR was made either in the presence of sudden death due to electromechanical dissociation with large pericardial effusion on an echocardiogram or when demonstrated post mortem or at surgery. A multivariable analysis was performed including type of reperfusion strategy. RESULTS The overall incidence of FWR was 2.5% (n = 34): 1.8% and 3.3% in patients treated with PA and with thrombolysis, respectively (p = 0.686). The following characteristics were associated with a higher rate of FWR in the univariable analysis: age >70 (5.2% vs. 1.2%, p < 0.001), female gender (5.1% vs. 1.8%, p = 0.006), anterior location (3.3% vs. 1.4%, p = 0.020) and treatment >2 h after symptoms onset (3.6% vs. 1.7%, p = 0.043). In the multivariable analysis, age >70 (odds ratio [OR]: 4.12, 95% confidence interval [CI]: 2.04 to 8.62, p < 0.001) and anterior location (OR: 2.91, 95% CI: 1.36 to 6.63, p = 0.008) were independent risk factors of FWR, whereas treatment with PA was an independent protective factor (OR: 0.46, 95% CI: 0.22 to 0.96, p = 0.0371). CONCLUSIONS In patients with AMI, PA reduces the risk of FWR in comparison with thrombolysis.

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.

Frequency of left ventricular free-wall rupture in patients with acute myocardial infarction treated with primary angioplasty.

A total of 590 patients with myocardial infarction treated with primary angioplasty were studied, to assess the incidence and related factors of free-wall rupture in patients with acute myocardial infarction when treated with primary angioplasty. The incidence of free-wall rupture was 2.2% (13 patients); this incidence was higher in patients >65 years old, women, nonsmokers, as well as in those with anterior location and an initial TIMI grade 0 flow, but it was similar in patients with a successful or unsuccessful angiographic result.

Efficacy of invasive strategy for the management of acute myocardial infarction complicated by cardiogenic shock

This retrospective study evaluates the influence of an invasive strategy of urgent coronary revascularization on the in-hospital mortality of patients with acute myocardial infarction (AMI) complicated early by cardiogenic shock. Among 1,981 patients with AMI admitted to our institution from 1994 to 1997, 162 patients (8.2%) developed cardiogenic shock unrelated to mechanical complications. The strategy of management was considered invasive if an urgent coronary angiography was indicated within 24 hours of symptom onset. Every other strategy was considered conservative. Fifty-seven patients who developed the shock late or after a revascularization procedure, or who died on admission, were excluded. The strategy was invasive in 73 patients (70%). Five of them died before angiography could be performed and 65 underwent angioplasty (success rate 72%). By univariate analysis the invasive strategy was associated with a lower mortality than conservative strategy (71% vs 91%, p = 0.03), but this association disappeared after adjustment for baseline characteristics. Older age, nonsmoking, and previous ischemic heart disease were independent predictors of mortality. In conclusion, we have failed to demonstrate that a strategy of urgent coronary revascularization within 24 hours of symptom onset for patients with AMI complicated by cardiogenic shock is independently associated with a lower in-hospital mortality. This strategy was limited by the high mortality within 1 hour of admission in patients with cardiogenic shock, the modest success rate of angioplasty in this setting, and the powerful influence of some adverse baseline characteristics on prognosis.

Coronary stenting during rescue angioplasty after failed thrombolysis.

Compared with primary angioplasty [percutaneous transluminal coronary angioplasty (PTCA)], rescue PTCA is associated with lower angiographic success and higher reocclusion rates, especially after thrombolysis with tissue‐type plasminogen activator (tPA). Although stent placement during primary PTCA has been demonstrated to be safe and even to improve the angiographic results achieved by balloon‐alone PTCA, there are few data on stent placement during rescue PTCA after failed thrombolysis. This study sought to assess the feasibility and safety of stent implantation during rescue angioplasty in myocardial infarction after failed thrombolysis. The study population consisted of 20 patients with acute myocardial infarction referred for rescue PTCA after failed thrombolysis consecutively treated with coronary stenting. The thrombolytic agent was tPA in 15 patients (75%), streptokinase in 1 (5%), and anisoylated streptokinase plasminogen activator complex (APSAC) in 1 (5%); 3 patients (15%) were included in the INTIME II study (tPA vs. lanoteplase). After stenting, aspirin 200 mg daily plus ticlopidine 250 mg b.i.d. were administered. Thirty stents (1.5 ± 1.0 per patient) were implanted. Angiographic success was achieved in 19 patients (95%). Two patients (10%) died, both because of severe bleeding complications. One patient (5%) suffered a reinfarction, but no patients suffered postinfarction angina or needed new target vessel revascularization. Eighteen patients (90%) were discharged alive and free of events. All these patients remained asymptomatic and free of target vessel revascularization at 6‐month follow‐up. Stent placement during rescue PTCA after failed thrombolysis is feasible and safe and is associated with a good angiographic result and clinical outcome. Bleeding complications seem to be, however, the main limitation of this reperfusion strategy. Cathet. Cardiovasc. Intervent. 47:1–5, 1999.

Resultados de la angioplastia primaria en pacientes con enfermedad multivaso

Introduccion Entre los pacientes con infartoagudo de miocardio que son tratados mediante angioplastiaprimaria, aquellos con enfermedad multivasopresentan un peor pronostico. No obstante, noesta claro si este efecto se debe solo a una mayorprevalencia de shock cardiogenico o si la enfermedadmultivaso constituye un factor pronostico independiente. Objetivos Estudiar si la enfermedad multivasoconstituye o no un factor pronostico independienteen los pacientes con infarto agudo de miocardiotratados mediante angioplastia primaria, y en sucaso aclarar los mecanismos por los que la enfermedadmultivaso contribuye a una mayor mortalidaden estos pacientes. Pacientes y metodos Entre agosto de 1991 y octubrede 1996, 312 pacientes con infarto agudo demiocardio fueron tratados mediante angioplastiaprimaria en nuestro centro. La evolucion intrahospitalariade los pacientes con enfermedad multivasose comparo con la de los pacientes con enfermedadde un vaso. Resultados Los pacientes con enfermedad multivaso(n = 158; 51%) tenian mayor edad (64 ± 11frente a 61 ± 13 anos; p = 0,017) y mas frecuenciade diabetes (el 35 frente al 20%; p = 0,007), hipertension(el 54 frente al 39%; p = 0,012), infartoagudo de miocardio previo (el 29 frente al 5%; p Conclusiones En la poblacion de pacientes coninfarto agudo de miocardio tratados con angioplastiaprimaria, la enfermedad multivaso se asocia auna mayor mortalidad intrahospitalaria. Ello sedebe no solo a una mayor frecuencia de insuficienciacardiaca grave, sino que unas caracteristicas basalesde peor pronostico, una mayor incidencia dealgunas complicaciones y una mas frecuente necesidadde nueva revascularizacion pueden contribuir ala mayor mortalidad de estos pacientes.

Direct injury to right coronary artery in patients undergoing tricuspid annuloplasty.

BACKGROUND Direct injury to the right coronary artery as a result of reparative operation on the tricuspid valve is a rare, probably underdiagnosed, but serious complication, which often involves dramatic clinical consequences. So far, only five cases have been described in the literature. METHODS We describe our single-center experience of this complication, and review and analyze relevant clinical and anatomic considerations related to this entity. Cases previously reported in the literature were also reviewed. RESULTS We describe four cases of direct injury to the right coronary artery in patients undergoing tricuspid annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had right ventricular dilatation and severely dilated tricuspid annulus. Right coronary artery occlusion always occurred between the right marginal artery and the crux of the heart. Patients presented with hemodynamic or electrical instability. Coronary flow could be restored in 2 patients (percutaneously 1; surgically 1), both of whom finally survived, while it was not technically possible in the other 2 (1 died). CONCLUSIONS Occlusion of the right coronary artery in patients undergoing tricuspid annuloplasty is a rare complication that may occur if great annulus dilatation is present, thus altering both normal annular geometry and the relationship between the right coronary artery and the tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered in the immediate postoperative period in an unstable patient, especially when complementary tests support this diagnosis. Prompt recognition and treatment can positively affect the patients outcome, most often by means of an emergency revascularization strategy.

Angioplastia coronaria en el infarto agudo de miocardio: ¿en qué pacientes es menos probable obtener una reperfusión coronaria adecuada?

Introduction. In patients with acute myocardial infarction treated with primary angioplasty, the inability to achieve successful coronary reperfusion is associated with higher mortality. The objective of the study was to identify which characteristics may predict a lower angiographic success rate in patients with acute myocardial infarction treated with coronary angioplasty. Patients and methods. The study population is constituted by the 790 patients with acute myocardial infarction that were treated with angioplasty within the 12 hours after the onset of symptoms from 1991 to 1999 at our institution. A successful angiographic result was considered in presence of a residual stenosis < 50% and a TIMI flow 2 or 3 after the procedure. Results. A successful angiographic result and a final TIMI 3 flow were achieved in 736 (93.2%) and 652 (82.5%) patients, respectively. In-hospital mortality was higher in patients with angiographic failure than in those with angiographic successful result (48 vs. 10%; p < 0.01). Age under 65 (91 vs. 95%; p = 0.02), non smoking (90 vs. 96%; p < 0,01), previous infarction (87 vs. 94%; p < 0.01), angioplasty after failed thrombolysis (83 vs. 94%; p = 0.02), cardiogenic shock (80 vs. 95%; p < 0.01), undetermined location (67 vs. 93%; p < 0.01), non-inferior location (92 vs. 96%; p = 0.04), left bundle branch block (64 vs. 94%; p < 0.01), multivessel disease (91 vs. 95%; p = 0.02), left ventricular ejection fraction < 0.40 (89 vs. 97%; p < 0.01), no utilization of coronary stenting (90 vs. 96%; p < 0.01), and use of intraaortic balloon counterpulsation pump (82 vs. 95%; p < 0.01) were associated with a lower angiographic success rate. In the multivariable analysis, the following were independent predictors for angiographic failure: left bundle branch block (odds ratio [OR], 12.95; CI 95%, 3.00-53.90), cardiogenic shock (OR, 4.20; CI 95%, 1.95-8.75), no utilization of coronary stent (OR, 3.44; CI 95%, 1.71-7.37), and previous infarction (OR, 2.82; CI 95%, 1.29-5.90). Conclusion. Coronary angioplasty allows a successful coronary recanalization in most patients with acute myocardial infarction. Some basic characteristics, however, may identify some subsets in which a successful angiographic result may be more difficult to obtain.