Koo Hui Chan

Everolimus-eluting bioresorbable vascular scaffold (BVS) implantation in patients with ST-segment elevation myocardial infarction (STEMI).

AIMS Recent studies have demonstrated favourable clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease. There are currently no data on its use in patients with ST-segment elevation myocardial infarction (STEMI). We assessed the safety and impact of BVS in the setting of primary percutaneous coronary intervention (PCI) in patients presenting with STEMI to our institution. METHODS AND RESULTS A total of 11 patients who underwent primary PCI with intent for BVS implantation between October 2012 and April 2013 at our institution were included. Median follow-up period was 53.0 ± 45.9 days. One patient presented to the hospital with cardiogenic shock and subsequently died. The other 10 patients did not have any major adverse cardiac events (MACE). There were no acute or subacute stent thromboses at short-term follow-up. CONCLUSIONS These are the first real-world data using BVS in patients with STEMI. The ABSORB™ BVS may be safely used in patients with STEMI undergoing primary PCI with favourable short-term outcome.

Initial experience in the clinical use of everolimus-eluting bioresorbable vascular scaffold (BVS) in a single institution

We read with great interest the recent review article on bioresorbable vascular scaffolds by Bourantas et al. and wish to share our institutions experience with the use of the ABSORB bioresorbable vascular scaffold (BVS; Abbott Vascular, Santa Clara, California) [1]. There is currently limited published data on the use of BVS in routine clinical practice andwehaveundertaken a prospective evaluation of this novel device in our institution. All consecutive patients who underwent percutaneous coronary intervention (PCI) with intent for BVS implantation between July 2011 and September 2012were included in the analysis. All patients received dual anti-platelet therapyprior to PCI and this therapywascontinued for at least a year after implantation. This study fulfilled local ethical requirements and written informed consent was obtained from all patients. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Once a suitable lesion was identified, the pre-procedural reference vessel diameter (RVD) was assessed by quantitative coronary analysis (QCA) using the Pie Medical CAAS QCA (quantitative coronary analysis) package in our Xcelera Workstations (Philips Medical Systems, Veenpluis, The Netherlands). Alternative vessel sizing was via the use of commercially available intravascular ultrasound (IVUS) or optical coherence tomography (OCT). A RVD of 2.0 to 3.8 mm and a lesion length of less than 28 mm were considered suitable for BVS (single or overlapping). The availableABSORBBVSwere2.5×18 mm,2.5×28 mm, 3.0×18 mm, 3.0×28 mm, 3.5×12 mm, 3.5×18 mm, or 3.5×28 mm in size. 6 Fr vascular access was used in all patients with a predominant radial access (77.1%). Mandatory predilation with balloon angioplasty using a balloon with a diameter of 0.5 mm smaller or equivalent to the intended BVS size was performed prior to BVS implantation. Device deployment was performed at a rate of ≤2 atm per 5 s up to 16 atm (rated burst pressure). Postdilation was with a non-compliant balloon with diameter≤0.25 mm beyond the implanted BVS if necessary to avoid scaffold damage. For longer lesions or edge dissections, overlapping scaffolds were used. A total of 35 consecutive patients with 41 lesions underwent attempted ABSORB BVS implantation during the study period. Baseline emographics, indications, procedure and quantitative coronary angiography details are summarized in Table 1. The mean age is 54.7± 11.2 years (range 36–86 years) and 85.7% of the patients (n=30) were male. Diabetes mellitus (type I or II) was present in 17.1% (n=6) of the study population. 51.4% of patients presented with an acute coronary syndrome including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). Overall, 45 BVS were successfully implanted in 33 (93.3%) patients (1.4 BVS/patient). Of the 41 lesions treated, the success rate was 100% (22/22) for the left anterior descending artery (LAD), 100% (11/11) for the right coronary artery (RCA), and 75% (6/8) for the left circumflex artery (LCX). Two patients had circumflex (LCX) stenosis not crossable by the BVS despite aggressive lesion preparation with multiple balloon predilations. An equivalent metallic drug eluting stent crossed without difficulty in both cases. The majority, 31 (75.6%), of lesions treated were complex (B2 or C). Pre-procedure RVD was assessed by QCA in 28 patients (80.0%), IVUS in 4 patients (11.4%), andOCT in 3 patients (8.6%). Themeanpre-procedural RVDwas 2.7±0.4 mm, diameter stenosiswas 77.7±13.0%, and lesion lengthwas 17.2±6.7 mm. Post-procedural RVD was 3.0±0.3 mmwith residual diameter stenosis of 2.4±2.0%.

A single-center experience of transitioning from a routine transfemoral to a transradial intervention approach in ST-elevation myocardial infarction: Impact on door-to-balloon time and clinical outcomes

BACKGROUND In the emergent setting of ST-elevation myocardial infarction (STEMI), transradial intervention (TRI) is less frequently employed than transfemoral intervention (TFI). Because of the greater technical complexity of TRI, a potential compromise in door-to-balloon (DTB) time remains a major concern of centers adopting TRI for STEMI. METHODS We performed a propensity-matched analysis, with 1:1 matching of TRI and TFI patients comparing DTB time, 30-day major adverse cardiac event (MACE), and bleeding outcomes of 1052 consecutive STEMI patients managed at our center during a 2-year transition program from routine TFI to TRI access for STEMI. RESULTS From January 2008 to April 2010, 359 (34.1%) STEMI patients underwent TRI and the remaining 693 (65.9%) STEMI patients underwent TFI. In 283 propensity score matched pairs of TRI and TFI patients, TRI was associated with shorter DTB time (63.6min vs 69.4min, p=0.027) and more patients having DTB time<90min (88.3% vs 82.3%, p=0.043). Thirty-day MACE occurred in 1.0% in the TRI group and 3.0% in the TFI group (p=0.129). There was no significant difference in major (p=0.313) or minor bleeding (p=0.714) between the TRI and TFI groups. There was a twofold greater use of glycoprotein (GP) IIb/IIIa inhibitor in the TRI group (68.5%) compared with the TFI group (36.4%) (p<0.001). CONCLUSION Compared with TFI, TRI was not associated with longer DTB time during our centers transition from routine TFI to TRI in STEMI. Our experience suggests that the transition to TRI in STEMI can be safely achieved with DTB times that are comparable and possibly better than propensity-matched TFI cases.

Risk Reduction Strategies in Early Major Non-Cardiac Surgery after Drug- Eluting Stent Implantation

Percutaneous coronary intervention with stent implantation has become the predominant revascularization strategy for patients with coronary artery disease. To reduce the risk of thrombotic complications, current guideline recommends dual antiplatelet therapy for 12 months after drug-eluting stent implantation. Dilemma arises when post-stent implantation patients have to undergo non-deferrable noncardiac surgery. In this case report, we presented a patient who have received drug-eluting stent implantation to left circumflex artery for myocardial infarction. Before staged percutaneous coronary intervention to a residual high-grade stenosis in the left anterior descending artery, he was diagnosed with renal cell carcinoma requiring nephrectomy. We describe the case of a patient requiring radical nephrectomy after multiple stent implantations and the strategies we adopted to reduce the risks of perioperative complications. The patient subsequently underwent nephrectomy successfully without perioperative myocardial infarction.

Spontaneous Coronary Dissection Masquerading as Benign Fascicular Ventricular Tachycardia

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome. Diagnosis of coronary artery dissection is made on coronary angiogram and prompt revascularisation is the key in management. We present a case of coronary artery dissection with an atypical presentation of cardiac arrhythmia mimicking benign fascicular ventricular tachycardia. A high index of suspicion and early coronary angiogram allowed us to diagnose and treat this potentially life-threatening disease.

Incidence and predictors of target lesion failure in a multiethnic Asian population receiving the SYNERGY coronary stent: A prospective all-comers registry

To evaluate the target lesion failure (TLF) rate of the SYNERGY stent in all‐comers, multiethnic Asian population.