Loes P. Hoebers

Effect of Multivessel Coronary Disease With or Without Concurrent Chronic Total Occlusion on One-Year Mortality in Patients Treated With Primary Percutaneous Coronary Intervention for Cardiogenic Shock

Despite early revascularization, mortality remains high in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. It has been shown that the effect of multivessel disease (MVD) on mortality in patients with STEMI treated with primary percutaneous coronary intervention is mainly caused by the presence of chronic total occlusion (CTO) in a noninfarct-related coronary artery. Whether this association also exists in patients with STEMI with cardiogenic shock is unknown. In our institution, 292 consecutive patients with STEMI complicated by cardiogenic shock were admitted from 1997 to 2005 and treated with primary percutaneous coronary intervention. Patients were classified as having single vessel disease, MVD without CTO, and CTO. Cox regression analysis was used for multivariate analysis. The 1-year mortality rate of patients with single-vessel disease, MVD, and CTO was 31%, 47%, and 63%, respectively. After adjustment for possible confounders, MVD alone was not an independent predictor of 1-year mortality (hazard ratio 1.5, 95% confidence interval 0.98 to 2.3, p = 0.07). In contrast, CTO in a noninfarct-related artery was an independent predictor of 1-year mortality (hazard ratio 2.1, 95% confidence interval 1.5 to 3.1, p <0.01). In conclusion, the presence of CTO in a non-infarct-related artery was an independent predictor of 1-year mortality. In contrast, MVD alone lost its predictive significance after multivariate analysis.

Meta-analysis on the impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcome

BACKGROUND Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) may have a beneficial effect on survival through a better-preserved or improved LVEF. Current literature consists of small observational studies therefore we performed a weighted meta-analysis on the impact of revascularization of CTOs on left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and long-term mortality. METHODS We conducted a meta-analysis evaluating LVEF before and after CTO PCI and long-term mortality. No language or time restrictions were applied. References from the identified articles and reviews were examined to find additional relevant manuscripts. RESULTS Of the 812 citations, 34 studies performed between 1987-2014 in 2243 patients were eligible for LVEF and 27 studies performed between 1990-2013 in 11,085 patients with success and 4347 patients that failed CTO PCI were eligible for long-term mortality. After successful CTO PCI, LVEF increased with 4.44% (95% CI: 3.52-5.35, p<0.01) compared to baseline. In a small cohort of ~70 patients, no significant difference in LVEF was observed after non-successful CTO PCI or reocclusion. Additionally, 8 studies reported the change in left ventricular end-diastolic volume (LVEDV) in a total of 412 patients. LVEDV decreased with 6.14 ml/m(2) (95% CI: -9.31 to -2.97, p<0.01). Successful CTO PCI was also associated with reduced mortality in comparison with failed CTO PCI (OR: 0.52, 95% CI: 0.43-0.62, p-value<0.01). CONCLUSIONS The current meta-analysis revealed that successful recanalization of a CTO resulted in an overall improvement of 4.44% absolute LVEF points, reduced adverse remodeling and an improvement of survival (OR: 0.52).

Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

BackgroundIn the setting of primary percutaneous coronary intervention, patients with a chronic total occlusion in a non-infarct related artery were recently identified as a high-risk subgroup. It is unclear whether ST-elevation myocardial infarction patients with a chronic total occlusion in a non-infarct related artery should undergo additional percutaneous coronary intervention of the chronic total occlusion on top of optimal medical therapy shortly after primary percutaneous coronary intervention. Possible beneficial effects include reduction in adverse left ventricular remodeling and preservation of global left ventricular function and improved clinical outcome during future coronary events.Methods/DesignThe Evaluating Xience V and left ventricular function in Percutaneous coronary intervention on occLusiOns afteR ST-Elevation myocardial infarction (EXPLORE) trial is a randomized, prospective, multicenter, two-arm trial with blinded evaluation of endpoints. Three hundred patients after primary percutaneous coronary intervention for ST-elevation myocardial infarction with a chronic total occlusion in a non-infarct related artery are randomized to either elective percutaneous coronary intervention of the chronic total occlusion within seven days or standard medical treatment. When assigned to the invasive arm, an everolimus-eluting coronary stent is used. Primary endpoints are left ventricular ejection fraction and left ventricular end-diastolic volume assessed by cardiac Magnetic Resonance Imaging at four months. Clinical follow-up will continue until five years.DiscussionThe ongoing EXPLORE trial is the first randomized clinical trial powered to investigate whether recanalization of a chronic total occlusion in a non-infarct related artery after primary percutaneous coronary intervention for ST-elevation myocardial infarction results in a better preserved residual left ventricular ejection fraction, reduced end-diastolic volume and enhanced clinical outcome.Trial registrationtrialregister.nl NTR1108.

The impact of multivessel disease with and without a co-existing chronic total occlusion on short- and long-term mortality in ST-elevation myocardial infarction patients with and without cardiogenic shock.

To evaluate the impact of multivessel disease (MVD) with and without a chronic total occlusion (CTO) on early and late mortality in ST‐elevation myocardial infarction (STEMI) patients with and without cardiogenic shock (CS).

Predictive Value of Plasma Glucose Level on Admission for Short and Long Term Mortality in Patients With ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Published reports describe a strong association between plasma glucose levels on admission and mortality in patients who undergo primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. The aim of this study was to assess the predictive value of admission glucose levels for early and late mortality. From 2005 to 2007, 1,646 patients underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and were stratified according to admission plasma glucose level in category 1 (<7.8 mmol/L; n = 747), category 2 (7.8 to 11.0 mmol/L; n = 620), or category 3 (>11 mmol/L; n = 279). Event rates were estimated using the Kaplan-Meier method. A landmark survival analysis to 3-year follow-up was performed, with a landmark set at 30 days. Time-extended Cox regression was used to assess the predictive value of admission glucose levels. Furthermore, a stratified analysis was performed for known diabetes mellitus status at admission. Thirty-day mortality was 2.4% in category 1, 6% in category 2, and 22% in category 3 (p <0.01). Three-year mortality in 30-day survivors was 5.9% in category 1, 8.2% in category 2, and 7.1% in category 3 (p = 0.27). Glucose level on admission was a strong predictor of 30-day mortality: for every 1 mmol/L increase, the hazard increased by 14% (hazard ratio 1.14, 95% confidence interval 1.09 to 1.19, p <0.01) in patients without diabetes, by 12% (hazard ratio 1.12, 95% confidence interval 1.05 to 1.19, p <0.01) in those with diabetes, and by 13% (hazard ratio 1.13, 95% confidence interval 1.09 to 1.17, p <0.01) in the total cohort. After 30 days, glucose level at admission lost its predictive value. In conclusion, in patients with and those without diabetes, glucose level at admission is an independent predictor of early but not late mortality.

Prevalence and impact of a chronic total occlusion in a non-infarct-related artery on long-term mortality in diabetic patients with ST elevation myocardial infarction

Background Recently, a chronic total occlusion (CTO) in a non-infarct-related artery (non-IRA) and not multivessel disease (MVD) alone was identified as an independent predictor of mortality after ST elevation myocardial infarction (STEMI). Patients with diabetes mellitus (DM) constitute a patient group with a high prevalence of MVD and high mortality after STEMI. The prevalence of CTO in a non-IRA was studied and its impact on long-term mortality in STEMI patients with DM was investigated. Methods Between 1997 and 2007 4506 patients with STEMI were admitted and treated with primary percutaneous coronary intervention (PCI). Patients with DM were identified. The patients were categorised as having single vessel disease (SVD), MVD without CTO and CTO based on the angiogram before PCI. Results A total of 539 patients (12%) had DM. MVD with or without a CTO was present in 33% of non-diabetic patients and in 51% of diabetic patients. The prevalence of a CTO in a non-IRA was 21% in STEMI patients with DM and 12% in STEMI patients without DM (p<0.01). Kaplan–Meier estimates for 5-year mortality in STEMI patients with DM were 25%, 21% and 47% in patients with SVD, MVD without a CTO and MVD with a CTO in a non-IRA, respectively. A CTO in a non-IRA was an independent predictor of 5-year mortality (HR 2.2, 95% CI 1.3 to 3.5, p<0.01). Conclusion The prevalence of a CTO in a non-IRA was increased in STEMI patients with DM. The presence of a CTO in a non-IRA was a strong and independent predictor of 5-year mortality. These results suggest that, particularly in the high-risk subgroup of STEMI patients with DM, MVD has prognostic implications only if a concurrent CTO is present.

Chronic Total Occlusions in Sweden - A Report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

Introduction Evidence for the current guidelines for the treatment of patients with chronic total occlusions (CTO) in coronary arteries is limited. In this study we identified all CTO patients registered in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and studied the prevalence, patient characteristics and treatment decisions for CTO in Sweden. Methods and Results Between January 2005 and January 2012, 276,931 procedures (coronary angiography or percutaneous coronary intervention) were performed in 215,836 patients registered in SCAAR. We identified all patients who had 100% luminal diameter stenosis known or assumed to be ≥3 months old. After exclusion of patients with previous coronary artery bypass graft (CABG) surgery or coronary occlusions due to acute coronary syndrome, we identified 16,818 CTO patients. A CTO was present in 10.9% of all coronary angiographies and in 16.0% of patients with coronary artery disease. The majority of CTO patients were treated conservatively and PCI of CTO accounted for only 5.8% of all PCI procedures. CTO patients with diabetes and multivessel disease were more likely to be referred to CABG. Conclusion CTO is a common finding in Swedish patients undergoing coronary angiography but the number of CTO procedures in Sweden is low. Patients with CTO are a high-risk subgroup of patients with coronary artery disease. SCAAR has the largest register of CTO patients and therefore may be valuable for studies of clinical importance of CTO and optimal treatment for CTO patients.

Clinical and Procedural Characteristics Associated With Higher Radiation Exposure During Percutaneous Coronary Interventions and Coronary Angiography

Background—We aim to study the clinical and procedural characteristics associated with higher radiation exposure in patients undergoing percutaneous coronary interventions (PCIs) and coronary angiography. Methods and Results—Our present study included all coronary angiography and PCI procedures in 5 PCI centers in the Western part of Sweden, between January 1, 2008, and January 19, 2012. The radiation exposure and clinical data were collected prospectively in these 5 PCI centers in Sweden as part of the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). A prediction model was made for the radiation exposure (dose–area product) expressed in Gy·cm2. A total of 20 669 procedures were included in the present study, consisting of 9850 PCI and 10 819 coronary angiography procedures. In multivariable analyses, body mass index (&bgr;=1.04; confidence interval [CI], 1.04–1.04; P<0.001); history of coronary artery bypass graft surgery (&bgr;=1.32; CI, 1.28–1.32; P<0.001); 2, 3, or 4 treated lesions (2 treated lesions: &bgr;=1.95; CI, 1.84–2.03; P<0.001; 3 treated lesions: &bgr;=2.34; CI, 2.16–2.53; P<0.001; and 4 treated lesions: &bgr;=2.83; CI, 2.53–3.16; P<0.001); and chronic total occlusion lesions (&bgr;=1.39; CI, 1.31–1.48; P<0.001) were associated with the highest radiation exposure. After adjusting for procedural complexity, radial access route was not associated with increased radiation exposure (&bgr;=1.00; CI, 0.98–1.03; P=0.67). Conclusions—In the largest study population to assess radiation exposure, we found that high body mass index, history of coronary artery bypass graft surgery, number of treated lesions, and chronic total occlusions were associated with the highest patient radiation exposure. Radial access site was not associated with higher radiation exposure when compared with femoral approach.

Long-term safety and sustained left ventricular recovery: long-term results of percutaneous left ventricular support with Impella LP2.5 in ST-elevation myocardial infarction.

AIMS Mechanical left ventricular (LV) unloading may reduce infarct size when combined with primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). The Impella LP2.5 is a novel percutaneous left ventricular assist device. Although the short-term safety and feasibility of this device have been demonstrated, the long-term effects are unknown. The purpose of the current study was to evaluate the long-term effects of the Impella LP2.5 support on the aortic valve and left ventricular ejection fraction (LVEF). METHODS AND RESULTS In 2006, 10 patients with anterior STEMI received 3-day support with the Impella LP2.5 after PCI. The control group consisted of 10 comparable patients, treated according to routine care. For the current study, echocardiography was performed and adverse events were recorded. Mean duration of follow-up was 2.9±0.6 years in the Impella group and 3.0±0.3 years in the control group. No differences in aortic valve abnormalities and LVEF were demonstrated between the groups; nevertheless, LVEF increase from baseline was significantly greater in Impella-treated patients (23.6±8.9% versus 6.7±7.0%, P=0.008). CONCLUSIONS Three-day support with the Impella LP2.5 is not associated with adverse effects on the aortic valve at long-term follow-up. LVEF was similar in both groups; however, recovery was significantly greater in the Impella group.

Long-term mortality after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in patients with insulin-treated versus non-insulin-treated diabetes mellitus

AIMS We investigated the impact of preadmission diabetic status on long-term outcome in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), to improve risk stratification. METHODS AND RESULTS Between 1997 and 2007, 4,402 STEMI patients were admitted to our hospital and stratified as having insulin-treated diabetes mellitus (ITDM) (n=176), non-ITDM (NITDM) (n=354) and non-DM (n=3,872). Five-year mortality was significantly higher in patients with DM compared to non-DM (29% vs. 18%, p<0.01). After stratification for preadmission glucose-lowering therapy, five-year mortality was significantly higher in ITDM patients compared to NITDM (36% vs. 25%, p=0.01) and in NITDM patients compared to non-DM patients (25% vs. 18%, p<0.01). After adjustment for age and gender the mortality risk between patients with NITDM versus non-DM was comparable (HR: 1.1, 95% CI: 0.9-1.4, p=0.38), in contrast to patients with ITDM (HR: 1.9, 95% CI: 1.5-2.5, p<0.01) and ITDM versus NITDM (HR: 1.7, 95% CI: 1.2-2.4, p<0.01). After adjustment for all baseline characteristics, the results were comparable to the age and gender adjusted model. CONCLUSIONS ITDM was a strong predictor for long-term mortality when compared to non-DM and NITDM. The mortality between patients without DM and NITDM was comparable after adjustment for age and gender.