Josef Bis

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).

Out-of-hospital cardiac arrests in patients with acute ST elevation myocardial infarctions in the East Bohemian region over the period 2002-2004.

Background: Early reperfusion by direct percutaneous coronary intervention (PCI) in patients with ST segment elevation acute myocardial infarctions (STEMI) with an out-of-hospital cardiac arrest (OHCA) reduces hospital and longterm mortality. Aims: Evaluating the significance of direct PCI for the short-term (discharge from acute hospitalization) and 1-year survival in patients with acute STEMI after OHCA. Methods: In this prospective study, from April 1, 2002 up to August 31, 2004, a total of 26 hospitalized individuals (22 men, 4 women, aged 35–79 years, median 58.5) from the East Bohemian region with OHCA (primary group of 718 individuals) with acute STEMI were included. Urgent coronary angiography was performed in 20 individuals, and direct PCI was done in 19 of them. The remaining 6 patients did not undergo angiography. Results: Fifteen patients (57.7%) survived acute hospitalization, of whom 11 were without neurological deficits. In the subgroup with urgent coronary angiography 14 patients (70%) survived hospitalization, and in the subgroup without coronarography only 1 patient survived hospitalization (16.7%). In the subgroup with PCIs, 13 out of the 19 patients survived (68.4%). None of the patients died during the 1-year follow-up after being discharged from acute hospitalization. According to the urgent coronarography the artery most commonly responsible for the infarction was the left anterior descending artery (50%). Initial TIMI flow grade 0–I was found in 17 patients and grade II–III in 3 individuals. After PCI, irrespective of stent implantation, an optimal angiographic success (TIMI flow grade II–III) was obtained in 17 cases. Conclusion: Short-term survival of patients after OHCA with STEMI treated with direct PCI was found to be 68.4%. Out of 6 patients not receiving reperfusion therapy 1 survived (16.7%). Over the course of the 1-year follow-up none of the patients died.

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.

Histopathology of aspirated thrombi during primary percutaneous coronary intervention in patients with acute myocardial infarction.

Thrombus aspiration in the setting of primary percutaneous coronary intervention is a recently recommended technique that facilitates thrombus removal from the culprit lesions in acute myocardial infarction (AMI) patients. Thrombectomy specimens from 50 patients with symptoms of AMI lasting usually not more than 12 h were examined by methods of routine histology, immunohistochemistry (IHC), and electron microscopy (ELMI). In 36 patients, there were fresh thrombi, in 10 older thrombi (8 of them with simultaneous presence of a fresh thrombi) and in 3 atheroma material only (in additional 7 patients atheroma material was admixed to the thrombi), and in one patient, there was carcinoma embolus. To help to distinguish between fresh and older thrombi, we recommend IHC (presence of macrophages and endothelia) and ELMI (loss of density of the erythrocyte matrix and presence of macrophages). On the other hand, changes of neutrophils (IHC degranulation/lysis) and of platelets (ELMI degranulation) appear early and thus contribute little to distinguishing between fresh and older thrombi. It could be concluded that, in a substantial proportion of patients with AMI, there is a discrepancy between duration of the symptoms and microscopic picture of the coronary thrombus. The thrombus may apparently be symptomless for a period of days or even weeks.

Good Short-Term but not Long-Term Reproducibility of the Antiplatelet Efficacy Laboratory Assessment

Background: The antiplatelet effect of acetylsalicylic acid (ASA) varies among individual patients. We assessed the short-term reproducibility (STR) and long-term reproducibility (LTR) of light transmission aggregometry (LTA). Methods: Residual platelet reactivity was measured twice using LTA in a group of 207 consecutive patients (56 females, mean age 67 ± 9 years) on ASA therapy in 10 ± 6 months interval. The STR was assessed in 15 patients (6 females, mean age 61 ± 7 years) with 10 measurements on 2 consecutive days. Results: There was no correlation between both measurements in the long-term part of the study, and also Bland-Altman plot showed a diverging pattern. However, LTA STR was good with a correlation coefficient of .800 (P < .05) confirmed by Bland-Altman plot. Conclusions: Although short-term intraindividual reproducibility of LTA assessment of platelet reactivity is very good, in the long-term perspective the antiplatelet ASA effectivity may be influenced by additional variables and repeated measurements are warranted.

A pilot data analysis of a metabolomic HPLC-MS/MS study of patients with COPD

BACKGROUND Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition with multiple clinical faces. Metabolomic profiling studies small molecules present in biological samples by combined use of chromatography with mass spectrometry. OBJECTIVES The goal of our work was to perform a high performance liquid chromatography combined with tandem mass spectrometry (HPLC-MS/MS) metabolomic study to compare the concentrations of metabolites in COPD patients and in controls. MATERIAL AND METHODS Participants were recruited at the University Hospital, Hradec Králové, Czech Republic, with the approval of the ethics committee. The analysis of blood samples was performed at Health Sciences Center (HSC) in Kuwait. The blood samples were analyzed for concentrations of acylcarnitines and amino acids by high performance liquid chromatography (Waters 2690 HPLC; Waters, Milford, USA) and a triple-quadruple tandem mass spectrometer (Quattro LC, Micromass, Manchester, United Kingdom). RESULTS Groups of 10 subjects with COPD and 10 healthy controls were analyzed. Carnitine analysis showed that the free carnitine to acylcarnitine ratio (C0/AC ratio) was significantly lower in COPD (0.58 μM/L) compared to the controls (0.73 μM/L; p = 0.002). The mean C8/C2 ratio in the COPD group was significantly higher (0.03 μM/L) - in the control group it was 0 μM/L (p = 0.03). Amino acid analysis showed lower levels of phenylalanine in the COPD group (22.05 μM/L) compared to the controls (30.05 μM/L; p = 0.008). The alanine concentrations were significantly lower in the COPD group (173 μM/L) than in the control group (253 μM/L; p = 0.001). The pyroglutamate levels were higher in COPD (1.58 μM/L) than in the controls (1 μM/L; p = 0.040). CONCLUSIONS The carnitine and acylcarnitine levels in COPD subjects in this study possibly indicate a predisposition to atherosclerosis as a result of inadequate β-oxidation of fatty acids and show the presence of oxidative stress. Furthermore, the high sensitivity to changes in circulating amino acid levels may allow us to detect subclinical malnutrition and take early preventative interventions such as nutritional supplementation and patient education.

Relapse of a pseudoaneurysm of the ascending aorta after coronary artery bypass grafting.

Two months later the patient was admitted with fever and a chest computed tomography (CT) showed a pseudoaneurysm of the ascending aorta (Fig. 1A) near the proximal anastomosis of the SVG to the OMB graft. The patient was treated empirically with intravenous antibiotics (Rifampicin, Linezolid and Gentamicin) and the pseudoaneurysm was closed with an Amplatzer septal occluderTM (St. Jude Medical Inc., St. Paul, Minnesota, USA). Repeat CT-scan showed exclusion of the pseudoaneurysm (Fig. 1B) and the patient was discharged 14 days later without any signs of infection. Three months later, the patient was readmitted due to fever and blood cultures were positive for Pseudomonas aeruginosa. A cardiac and ascending aorta CT-scan revealed recurrence of the pseudoaneurysm of the ascending aorta 39 × 19 × 30 mm (Fig. 2) with a vegetation, near the Amplatzer occluder (both SVG were non-patent). The patient underwent a repeat median sternotomy using cardiopulmonary bypass with deep hypothermia 24°C. Cardiac arrest was instituted with antegrade and retrograde cold blood cardioplegia and the ascending aorta was excised (Fig. 3) and was replaced with aortic homograft tissue. The postoperative course was uneventful. At 3 month follow-up the patient was asymptomatic and the CT-scan showed no recurrent aneurysm (Fig. 4).