Maciej Karcz

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.

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.

Impact of Different Re-stenting Strategies on Expansion of a Drug- Eluting Stent Implanted to Treat Bare-Metal Stent Restenosis

We used intravascular ultrasound (IVUS) to compare the expansion of drug-eluting stents (DES) implanted to treat bare-metal stent (BMS) restenosis after 3 common re-stenting strategies. A total of 80 consecutive BMS restenotic targets were re-stented either directly (n = 30, group 1) or after low-pressure (<8 atm) pre-dilation with an undersize regular balloon (n = 16, group 2) or after high-pressure (>12 atm) pre-dilation with a semicompliant balloon the same or greater diameter as the original BMS diameter (n = 34, group 3). More patients from groups 2 and 3 had diabetes mellitus. The targets in group 1 were more proximal and focal. Lesions from groups 2 and 3 were more severe. The size and deployment pressure of the DESs and the achieved angiographic results were all similar. The post-intervention minimum stent area and the percentage of expansion of DES (minimum stent area/distal reference lumen area x 100%) were, however, both significantly larger in group 3 (6.4 +/- 1.5 mm(2) in group 3 vs 5.6 +/- 1.6 mm(2) in group 1 vs 4.4 +/- 1.4 mm(2) in group 2, p <0.001; and 88 +/- 30% in group 3 vs 74 +/- 14% in group 1 vs 73 +/- 23% in group 2, p = 0.021). A post-intervention minimum stent area <5.0 mm(2) was seen in only 3 lesions in group 3 (8.8%) versus 14 in group 1 (46.7%) and 11 in group 2 (68.8%; adjusted odds ratio 0.11, 95% confidence interval 0.03 to 0.38, p <0.001). Overall, the acute lumen gain was mainly from BMS re-expansion; however, the BMS volume increased the most in group 3 (p <0.001). In conclusion, high-pressure pre-dilation leads to superior post-intervention expansion of DESs implanted to treat BMS restenosis, regardless of the original expansion because of the greater BMS re-expansion.

Comparison of Different Methods of ST Segment Resolution Analysis for Prediction of 1-Year Mortality after Primary Angioplasty for Acute Myocardial Infarction

Background: Resolution of ST segment elevation corresponds with myocardial tissue reperfusion and correlates with clinical outcome after ST elevation myocardial infarction. Simpler method evaluating the extent of maximal deviation persisting in a single ECG lead was an even stronger mortality predictor. Our aim was to evaluate and compare prognostic accuracy of different methods of ST segment elevation resolution analysis after primary percutaneous coronary intervention (PCI) in a real‐life setting.

Early stent thrombosis. Aetiology, treatment, and prognosis.

Stent thrombosis (ST) is an uncommon but life-threatening complication after percutaneous coronary intervention (PCI), frequently manifesting as acute coronary syndrome (ACS) or even cardiac death. According to the academic research consortium (ARC), the definition includes definite, probable, or possible ST and is described in detail elsewhere [1]. Traditional classification categorises this complication into early (including acute and subacute ST, within 24 h and from 24 h to 30 days, respectively), late (from 30 days to 1 year), and very late (after 1 year). However, this classification does not include intraprocedural coronary thrombosis, which occurs in nearly 1% of patients [2] and is more common in the setting of ACS [3]. The majority of these events seem to occur within the first month after PCI. Among 21,009 patients treated with bare metal stents or drug eluting stents (DES) from the Dutch Stent Thrombosis Registry, 437 patients experienced ST and only 27% occurred late or very late [4]. Similar results were observed with bioresorbable vessel scaffolding (BVS) within large multicentre GOUST-EU registry (1189 patients included), where ST mostly clustered within 30 days [5]. A shift toward later ST occurrence was observed within the Japanese ST RESTART registry. This included patients treated with sirolimus eluting stents and comprised 611 patients with definite ST. Among them 47% occurred after 1 year [6]. The higher rate of late and very late ST in the Japanese registry may be associated with prolonged healing of the vessel after implantation of DES with potent antiproliferative sirolimus drug. Finally, a completely different pattern of ST timing was observed within the impressive number of 401,662 ACS patients from the CathPCI registry [7]. Among them, definite ST events were identified in 7315. Very late ST constituted as much as 61%, and only 19% of patients presented as early ST. The broad spectrum of risk factor categories is related to the patient (incl. clinical presentation), lesion, stent, and antiplatelet therapy (Table I). Among them, premature cessation of dual antiplatelet therapy (DAPT) seems to be the strongest single risk factor for ST. However, this seems only partially true for early ST, as the majority of patients experiencing ST within the first month remain on DAPT (88% in the Dutch ST Registry) [4]. Furthermore , as shown in the ST-elevation myocardial infarc-tion (STEMI) patient population from the HORIZONS-AMI study, there are differences between ST risk factors for acute, subacute, late, and very late ST …

Risk is not flat. Comprehensive approach to multidimensional risk management in ST-elevation myocardial infarction treated with primary angioplasty (ANIN STEMI Registry).

Introduction Current risk assessment concepts in ST-elevation myocardial infarction (STEMI) are suboptimal for guiding clinical management. Aim To elaborate a composite risk management concept for STEMI, enhancing clinical decision making. Material and methods 1995 unselected, registry patients with STEMI treated with primary percutaneous coronary intervention (pPCI) (mean age 60.1 years, 72.1% men) were included in the study. The independent risk markers were grouped by means of factor analysis, and the appropriate hazards were identified. Results In-hospital death was the primary outcome, observed in 95 (4.7%) patients. Independent predictors of mortality included age, leukocytosis, hyperglycemia, tachycardia, low blood pressure, impaired renal function, Killip > 1, anemia, and history of coronary disease. The factor analysis identified two significant clusters of risk markers: 1. age-anemia- impaired renal function, interpreted as the patient-related hazard; and 2. tachycardia-Killip > 1-hyperglycemia-leukocytosis, interpreted as the event-related (hemodynamic) hazard. The hazard levels (from low to high) were defined based on the number of respective risk markers. Patient-related hazard determined outcomes most significantly within the low hemodynamic hazard group. Conclusions The dissection of the global risk into the combination of patient- and event-related (hemodynamic) hazards allows comprehensive assessment and management of several, often contradictory sources of risk in STEMI. The cohort of high-risk STEMI patients despite hemodynamically trivial infarction face the most suboptimal outcomes under the current invasive management strategy.

Quadrifurcation of the left main coronary artery and acute coronary syndrome.

Percutaneous treatment of the left main coronary artery (LMCA) bifurcation for acute coronary syndrome (ACS) is complex and associated with poorer results as compared to simple lesions. When additional branches take off from the LMCA, percutaneous coronary intervention (PCI) may be challenging. We present two patients with ACS, in whom the culprit lesions were located at the LMCA quadrifurcation. Additionally, we propose modified Medina classification adopted for quadrifurcation lesions. Patient 1: A 65-year-old male patient was admitted due to recurrent chest pain for one week. Electrocardiogram showed ST segment depression in precordial leads. Maximal troponin T rise was 3172 ng/L (UNL < 14). Urgent angiography revealed LMCA quadrifurcation. Eccentric stenosis involved distal LMCA and ostia of the left circumflex coronary (LCx) artery and two intermedial branches (Fig. 1). TIMI 3 flow was preserved. The next day the patient underwent coronary artery by-pass grafting. Patient 2: An 82-year-old male patient with a history of chronic left bundle branch block and ST elevation ACS 12 years ago, treated with primary PCI of the left anterior descending coronary artery (LAD) was admitted due to recurrent chest pain for several hours. Troponin T rise on admission was 1866 ng/L. Angiography revealed LMCA quadrifurcation with critical stenosis in LCx ostium with TIMI 2 flow (Fig. 2). After predilatation of the LCx ostium up to 40 atm., a 2.5 × 12 mm everolimus eluting stent was implanted at 20 atm. Four branches originating from the LMCA are casuistic. Atherosclerotic involvement of the LMCA quadrifurcation makes PCI challenging, although not impossible. Only single reports of PCI for LMCA quadrifurcation are available. Surgical treatment seems to be the gold standard for such lesion location in stable patients. However, ACS may force the operator towards PCI, if the lesion involvement is technically favourable (as in the second patient). Next, classification of the LMCA quadrifurcation may aid the treatment strategy. As adopted from the Medina classification for bifurcation lesions, the quadrifurcation lesions may also be classified in similar way, giving a binary value (0 or 1) according to whether each of the consecutive quadrifurcation segments is compromised or not. The first digit corresponds to the LMCA, the second digit to the LAD, the third and fourth digits to the intermedial branches, and the last digit to LCx (Fig. 3). Theoretically, 32 anatomical scenarios of LMCA quadrifurcation involvement are possible. Finally, such modification of Medina classification may also serve for LMCA trifurcation or pentafurcation assessment (Fig. 4). Figure 1. A–D. Significant stenosis in the left main coronary artery quadrifurcation

Guidelines of the Association of Cardiovascular Interventions of the Polish Cardiac Society for certification of coronary diagnosts and percutaneous coronary intervention operators and invasive cardiology centers in Poland

Wymogi Asocjacji Interwencji Sercowo-Naczyniowych Polskiego Towarzystwa Kardiologicznego dla uzyskania tytułu samodzielnego diagnosty i samodzielnego operatora kardiologii inwazyjnej oraz akredytacji ośrodka kardiologii inwazyjnej w Polsce Stanowisko grupy ekspertów Zarządu Asocjacji Interwencji Sercowo-Naczyniowych Polskiego Towarzystwa Kardiologicznego (PTK) kadencji 2011–2013, zatwierdzone przez Radę Konsultacyjną Asocjacji Interwencji Sercowo-Naczyniowych PTK, Zespół Krajowego Nadzoru Specjalistycznego w Dziedzinie Kardiologii i Zarząd Główny PTK

Relation between coronary plaque calcium deposits as described by computed tomography coronary angiography and acute results of stent deployment as assessed by intravascular ultrasound

Introduction The findings from intravascular ultrasound studies on the impact of calcium deposits on the results of stent implantation are conflicting. Aim To evaluate whether calcium deposits as assessed by (CTCA) influence results of stent deployment. Material and methods The study population comprised 60 patients (43 male; age 64.2 ±8.6 years) who underwent CTCA before stent implantation. Lesion calcium score, total calcium length, and maximal area and maximal thickness of calcium deposits within the lesion segment were assessed. Plaques were divided into those with calcium score ≥ median (group 1), calcium score < median (group 2), and without calcium (group 3). Intravascular ultrasound (IVUS) was performed after attainment of optimal angiographic results of the stent procedure. Focal and diffuse stent expansion was defined as either minimum stent area (MSA) or mean stent area over the length of the stent divided by reference lumen area. Results The proximal reference segments of lesions with higher calcium score contained a larger plaque burden (47 ±12% vs. 41 ±9% vs. 34 ±18%, p = 0.02) – respectively for groups 1, 2, and 3. Positive correlation was observed between lesion calcium score and frequency of post-dilation (R = 0.28, p = 0.03). There was no difference in focal stent expansion (71 ±14% vs. 65 ±15% vs.71 ±15%, p = 0.3) or diffuse stent expansion (92 ±30% vs. 85 ±30% vs. 93 ±38%, p = 0.7) comparing groups 1, 2, and 3. Lesion calcium score, total length of calcium, and maximum area and thickness of calcium deposits did not correlate with focal or diffuse stent expansion. Conclusions Lesions with a higher CTCA calcium score had larger reference plaque burden after stent implantation and more likely required post-dilation, but final stent expansion as assessed by IVUS was not affected by the amount of CTCA calcium provided an angiographically optimal result was achieved.

Comparison of Plaque Burden and Vessel Remodeling in Obstructive Saphenous Vein Graft Lesions as Assessed by Intravascular Ultrasound and Dual-source Computed Tomography.

Purpose: The aim of our study was to compare plaque burden and vessel remodeling of obstructive saphenous vein graft (SVG) lesions as assessed by dual-source computed tomography (DSCT) and intravascular ultrasound (IVUS). Materials and Methods: Preintervention DSCT examination and IVUS were performed in consecutive patients before percutaneous treatment of the SVG lesion. SVG vessel and lumen areas were measured with use of DSCT and IVUS at the minimal lumen area (MLA) site and at proximal and distal reference sites. Plaque burden was defined as the ratio of plaque and vessel area. Remodeling index was defined as the ratio of the SVG area at the MLA site to the mean reference SVG area. Results: Twenty-four obstructive SVG lesions were imaged with DSCT and IVUS before stent implantation in 24 patients. The SVG cross-sectional area at the MLA site measured by IVUS and DSCT was similar (17.0±4.5 vs. 17.3±5.3 mm2, P=0.6) and well correlated (R=0.77, P<0.001). Similarly, plaque burden and remodeling index assessments did not differ significantly between the 2 imaging modalities (79.0%±4.0% vs. 81.0%±8.0%, P=0.18, and 1.09±0.22 vs. 1.07±0.32, P=0.7 for IVUS vs. DSCT for plaque burden and remodeling, respectively). The correlation between IVUS-assessed and DSCT-assessed plaque burden and remodeling index was moderate to good (R=0.55, P=0.01 and R=0.77, P<0.001, respectively, for plaque burden and remodeling index). Conclusions: There is moderate to good correlation between DSCT and IVUS in the assessment of vessel remodeling and plaque burden in obstructive SVG lesions. Noninvasive assessment and monitoring of SVG disease is feasible using DSCT.