Jerzy Pręgowski

Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial).

BACKGROUND Previous studies with thrombectomy showed different results, mainly due to use of thrombectomy as an additional device not instead of balloon predilatation. The aim of the present study was to assess impact of aspiration thrombectomy followed by direct stenting. METHODS Patients with ST elevation myocardial infarction (STEMI) <6 hours from pain onset and occluded infarct-related artery in baseline angiography were randomized into aspiration thrombectomy followed by direct stenting (TS, n = 100) or standard balloon predilatation followed by stent implantation (n = 96). The primary end point of the study was the electrocardiographic ST-segment elevation resolution >70% (STR > 70%) 60 minutes after primary angioplasty (percutaneous coronary intervention [PCI]). Secondary end points included angiographic myocardial blush grade (MBG) after PCI, combination of STR > 70% immediately after PCI and MBG grade 3 (optimal myocardial reperfusion), Thrombolysis In Myocardial Infarction flow after PCI, angiographic complications, and in-hospital major adverse cardiac events. RESULTS Aspiration thrombectomy success rate was 91% (crossing of the lesion with thrombus reduction and flow restoration). There was no significant difference in STR ≥ 70% after 60 minutes (53.7% vs 35.1%, P = .29). STR > 70% immediately after PCI (41% vs 26%, P < .05), MBG grade 3 (76% vs 58%, P < .03), and optimal myocardial reperfusion (35.1% vs 11.8%, P < .001) were more frequent in TS. There was no difference in between the groups in 6-month mortality (4% vs 3.1%, P = .74) and reinfarction rate (1% vs 3.1%, P = .29). CONCLUSIONS Aspiration thrombectomy and direct stenting is safe and effective in STEMI patients with early presentation (<6 hours). The angiographic parameters of microcirculation reperfusion and ECG ST-segment resolution directly after PCI were significantly better in thrombectomy group despite the lack of the difference in ST-segment resolution 60 minutes after PCI.

Volumetric intravascular ultrasound evidence that distal embolization during acute infarct intervention contributes to inadequate myocardial perfusion grade.

We studied 35 consecutive patients with myocardial infarction (MI) who were treated with direct infarct percutaneous coronary intervention (PCI) using standard angiographic (complete assessment of flow grade and blush grade) and pre- and post-PCI volumetric intravascular ultrasound analysis. Plaque reduction, which is evidence of distal embolization, contributes to inadequate tissue reperfusion in this lesion setting and supports the use of distal protection in the setting of an acute MI.

Altered Plasma Fibrin Clot Properties Are Associated With In-Stent Thrombosis

Objectives—We sought to investigate whether patients with in-stent thrombosis (IST) display altered plasma fibrin clot properties. Methods and Results—We studied 47 definite IST patients, including 15 with acute, 26 subacute and 6 late IST, and 48 controls matched for demographics, cardiovascular risk factors, concomitant treatment and angiographic/stent parameters. Plasma clot permeability (Ks), which indicates a pore size, turbidity (lag phase, indicating the rate of fibrin clot formation, &Dgr;Absmax, maximum absorbance of a fibrin gel, reflecting the fiber thickness), lysis time (t50%) and maximum rate of d-dimer release from clots (D-Drate) were determined 2 to 73 (median 14.7) months after IST. Patients with IST had 21% lower Ks, 14% higher &Dgr;Absmax, 11% lower D-Drate, 30% longer t50% (all P<0.0001) and 5% shorter lag phase compared to controls (P=0.042). There were no correlations between clot variables and the time of IST or that from IST to blood sampling. Multiple regression analysis showed that Ks (odds ratio=0.36 per 0.1 &mgr;m2, P<0.001), D-Drate (odds ratio=0.16 per 0.01 mg/L/min, P<0.001) and stent length (odds ratio=1.1 per 1 mm, P=0.043) were independent predictors of IST (R2=0.58, P<0.001). Conclusions—IST patients tend to form dense fibrin clots resistant to lysis, and altered plasma fibrin clot features might contribute to the occurrence of IST.

Aspiration coronary thrombectomy for acute myocardial infarction increases myocardial salvage: single center randomized study.

Objectives: The aim of the study was to assess if aspiration thrombectomy in high risk patients with STEMI and angiographic evidence of thrombus may improve myocardial salvage. Background: It is unclear if thrombus aspiration before percutaneous intervention (PCI) improves myocardial salvage. Methods: The trial was a prospective randomized study. The inclusion criteria were: first STEMI within 12 hr from symptoms onset, culprit lesion in left anterior descending or right coronary artery, culprit artery TIMI flow ≤ 2 and angiographic evidence of thrombus. The primary endpoint was myocardial salvage index (MSI) as assessed by 99mTc‐sestamibi SPECT imaging. Results: We randomized 137 patients (98 male, mean age 64.1 ± 12.5 years) either to aspiration thrombectomy followed by standard PCI with stent implantation (n = 67) or to standard primary PCI (n = 70). Index perfusion defect was similar in both study groups: 34.2% ± 13.1% in thrombectomy group versus 37.1% ± 12.0% in primary PCI group (P = 0.2). MSI was larger in aspiration thrombectomy group than in control patients [25.4% (IQR 13.5–44) vs. 18.5% (IQR 7.7–30.3) respectively, P = 0.02]. The final infarct size was smaller in patients treated with aspiration thrombectomy (23.1% ± 13.3% vs. 28.9% ± 10.2% in the control group, P = 0.002). Conclusions: Aspiration thrombectomy improves myocardial salvage in high risk STEMI patients with angiographic evidence of thrombus.

Comparison of Usefulness of Percutaneous Coronary Intervention Guided by Angiography plus Computed Tomography Versus Angiography Alone Using Intravascular Ultrasound End Points

The aim of our study was to assess the impact of coronary computed tomographic angiographic (CTCA) guidance on outcomes of percutaneous coronary intervention (PCI). The study was a randomized single-center trial. Consecutive eligible patients with CTCA-detected significant coronary lesions who were scheduled for PCI were randomized to an angiographically guided versus an angiographically plus computed tomographically guided (ACTG) group. In the ACTG group the operator preliminarily planned PCI based on computed tomographic angiogram. The coprimary end points were minimal stent area and minimal reference lumen area assessed in all patients with intravascular ultrasound performed after achieving optimal angiographic results. Seventy-one patients (50 men, mean age 65 ± 8 years) were randomized. After invasive angiography, PCI of 32 lesions (30 patients) in the ACTG and in 32 lesions (30 patients) in the angiographically guided group was performed. A stented segment length was longer and nominal stent diameter tended to be larger in the ACTG group (23.8 ± 6.7 vs 19.5 ± 6.5 mm, p = 0.01; 3.27 ± 0.44 vs 3.09 ± 0.41 mm(2), p = 0.110). Minimal stent area tended to be larger (6.62 ± 2.01 vs 5.80 ± 2.02 mm(2), p = 0.100) and the smallest peri-stent reference lumen area was significantly larger in the ACTG group (6.76 ± 3.01 vs 5.0 ± 1.62 mm(2), p = 0.006) with a smaller plaque burden (50 ± 16% vs 58 ± 13%, p = 0.025). In conclusion, CTCA analysis before PCI significantly influences treatment strategy and results in better lesion coverage as defined by intravascular criteria.

Coronary Computed Tomographic Angiography for Prediction of Procedural and Intermediate Outcome of Bypass Grafting to Left Anterior Descending Artery Occlusion With Failed Visualization on Conventional Angiography

Conventional coronary angiography (CCA) has considerable limitations regarding visualization of distal vessel segments in chronic total occlusion. We assessed the ability of coronary computed tomographic angiography (CCTA) to predict the success of coronary artery bypass grafting (CABG) to the chronically occluded left anterior descending coronary artery (LAD) incompletely visualized on CCA. Thirty symptomatic patients rejected for CABG on the basis of the CCA findings underwent preoperative CCTA before intended transmyocardial laser revascularization. The LAD was explored operatively in all patients, and CABG to the LAD was attempted if the distal vessel was suitable for anastomosis. The procedural outcome of CABG and the 6-month patency of the left internal mammary artery graft at follow-up CCTA were defined as the primary and secondary end point, respectively. The primary and secondary end points were achieved in 80% and 77% of patients, respectively. We found a significant correlation between the intraoperative and computed tomographic measurement of distal LAD diameter (R = 0.428, p = 0.037). On multivariate analysis, the maximum diameter of the distal LAD by CCTA (odds ratio 8.16, p = 0.043) was the only independent correlate of procedural success of CABG. A cutoff value of 1.5 mm for the mean distal LAD diameter predicted left internal mammary artery graft patency with 100% specificity and 83% sensitivity. Successful CABG resulted in significant improvements in angina class and left ventricular function in LAD segments at 6 months of follow-up. In conclusion, CCTA predicted both the procedural and the intermediate outcome of CABG to chronic LAD occlusion with failed visualization on CCA.

Clustering of admission hyperglycemia, impaired renal function and anemia and its impact on in-hospital outcomes in patients with ST-elevation myocardial infarction.

OBJECTIVE To examine the incidence and inter-relationships between admission hyperglycemia, anemia and impaired renal function and its impact on clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated with primary PCI. METHODS The study group comprised 1880 patients with STEMI treated with primary PCI, enrolled in a prospective registry. RESULTS The primary endpoint of in-hospital death occurred in 88 (4.7%) patients. Hyperglycemia (glucose >11.1mmol/L) was present in 352(18.7%), anemia (hematocrit <36% women, <39% men) in 396(21.1%), and increased serum creatinine (> or =1.2mg/dL women, > or =1.3mg/dL men) in 423(22.5%) patients. 1026(54.6%) subjects had none of the triad risk factors. Two overlapping conditions were observed in 207(11%) and 3 in 40(2.1%) patients. Compared to the expected distribution, an increased prevalence was observed in patients with zero, two or three risk factors, and decreased prevalence was present in patients with one risk factor (p<0.001). In multivariable model including important baseline risk factors and the whole triad risk factors, hyperglycemia, anemia, and increased serum creatinine were independently associated with the primary outcome (hazard ratio (HR); 95% confidence interval (CI): 2.67; 1.56-4.55, and 2.03; 1.19-3.46, and 1.72;1.01-2.93, respectively). Adjusted HR (95% CI) for the incidence of the primary outcome associated with 1, 2 and 3 examined risk factors as compared to 0 of the risk factors was 2.7(1.4-5.4), 5.4(2.6-8.3) and 8.3(3.0-23.2), respectively. CONCLUSIONS Hyperglycemia, anemia, and impaired renal function are independently of each other related to in-hospital death in patients with STEMI treated with primary PCI. The triad risk factors cluster and accumulation of these risk factors is related to stepwise, additive increase of risk of in-hospital mortality.

Dose volume histogram assessment of late stent malapposition after intravascular brachytherapy.

PURPOSE Positive remodeling and decreased neointima proliferation are among the causes for Late Stent Malapposition (LSM). It was our interest to investigate a possible relationship between dose and incidence of LSM. METHODS Index and follow up IVUS examinations of 238 patients (152 treated with Intravascular Brachytherapy (IVBT), 86 control) enrolled in IVBT trials were reviewed to identify patients with LSM. 7.2% of patients treated with IVBT and 2.3% of patients in the control group were found to have LSM on their 6-month follow-up IVUS. Using the index IVUS study. Dose Volume Histograms (DVH) were constructed for a segment of the adventitia comprising an arc deep to the area where LSM is present at follow up. For control, two areas: an arc deep to complete apposition (Control 1) and a segment within the stent but 5 mm apart from the LSM (Control 2). Volumes were defined by IVUS images that were 1 mm apart and the media-adventitial contour was taken to be 0.5 mm thick from the border. RESULTS DVH of 90% and 50% adventitial volume of LSM area received a significantly (p < .05) higher dose compared to both controls. Calculated are 12 LSM sites in 9 patients and 9 control sites. At all 12 sites Mean Cross Sectional Area of External Elastic Membrane (EEM CSA) was significantly larger in the LSM group at follow up compared to index (p-.001). CONCLUSIONS DVH analysis showed a positive correlation between radiation dose to the adventitia and incidence of LSM. The myofibroblasts in the adventitia are known to be the target for irradiation. Proliferation of myofibroblasts leads to neointima formation. LSM may be due to the higher dosages delivered to 50% and 90% of the adventitia volume (LSM area) which may have led to profound neointima suppression. In turn the neointima could not compensate positive remodeling reflected by an increase in EEM CSA.

Computed tomography angiography for prediction of atrial fibrillation after coronary artery bypass grafting: Proof of concept

BACKGROUND Postoperative atrial fibrillation (AF) is a serious complication of coronary artery bypass grafting (CABG). There are scant data on the application of coronary computed tomography angiography (CCTA) for prediction of postoperative AF. METHODS A total of 102 patients (77 male, mean age: 64±10 years) with pre-procedural CCTA undergoing isolated CABG were enrolled. Clinical risk factors were collected. Qualitative and quantitative CCTA analysis of the atria, pulmonary veins (PV), and epicardial adipose tissue (EAT) along the left atrium (LA) was performed to determine the predictors for postoperative AF. The primary endpoint was defined as any in-hospital AF requiring treatment. RESULTS Postoperative AF occurred in 24% of patients. Patients with AF had higher body mass index (29.7±4.8kg/m(2) vs 27.3±3.9kg/m(2), p=0.013), larger right atrial area (25.4±5.3cm(2) vs 22.3±6.4cm(2), p=0.035), LA systolic volume (114.7±32.8ml vs 96.8±30.4ml, p=0.015), LA EAT volume (5.6±3ml vs 4±2.5ml, p=0.009), and right superior PV ostium area (3.8±1.3cm(2) vs 3±1cm(2), p=0.021) compared to non-AF patients. By multivariable analysis, only LA EAT volume [odds ratio (OR): 1.21, 95% confidence interval (CI): 1.01-1.44, p=0.036] and right superior PV ostium area (OR: 1.63, 95% CI: 1.06-2.50, p=0.026) were independent predictors of AF. The optimal cut-offs for LA EAT volume and right superior PV ostium were >3.4ml and >4.1cm(2), respectively (max. sensitivity: 83%, max. specificity: 86%). CONCLUSIONS Increased LA EAT and right superior PV ostial size are independently associated with AF after CABG. CCTA might be used as a noninvasive prediction tool for AF in patients undergoing CABG.

Advanced computed tomographic anatomical and morphometric plaque analysis for prediction of fractional flow reserve in intermediate coronary lesions

OBJECTIVE To determine the application of advanced coronary computed tomography angiography (CCTA) plaque analysis for predicting invasive fractional flow reserve (FFR) in intermediate coronary lesions. METHODS Sixty-one patients with 71 single intermediate coronary lesions (≥ 50-80% stenosis) on CCTA prospectively underwent coronary angiography and FFR. Advanced anatomical and morphometric plaque analysis was performed based on CCTA data set to determine optimal criteria for significant flow impairment. A significant stenosis was defined as FFR ≤ 0.80. RESULTS FFR averaged 0.85 ± 0.09, and 19 lesions (27%) were functionally significant. FFR correlated with minimum lumen area (MLA) (r=0.456, p<0.001), minimum lumen diameter (MLD) (r=0.326, p=0.006), reference lumen diameter (RLD) (r=0.245, p=0.039), plaque burden (r=-0.313, p=0.008), lumen area stenosis (r=-0.305, p=0.01), lesion length (r=-0.692, p<0.001), and plaque volume (r=-0.668, p<0.001). There was no relationship between FFR and CCTA morphometric plaque parameters. By multivariate analysis the independent predictors of FFR were lesion length (beta=-0.581, p<0.001), MLA (beta=0.360, p=0.041), and RLD (beta=-0.255, p=0.036). The optimal cutoffs for lesion length, MLA, MLD, RLD, and lumen area stenosis were >18.5mm, ≤ 3.0mm(2), ≤ 2.1mm, ≤ 3.2mm, and >69%, respectively (max. sensitivity: 100% for MLA, max. specificity: 79% for lumen area stenosis). CONCLUSIONS CCTA predictors for FFR support the mathematical relationship between stenosis pressure drop and coronary flow. CCTA could prove to be a useful rule-out test for significant hemodynamic effects of intermediate coronary stenoses.