Marek Grygier

New Method of Intracoronary Adenosine Injection to Prevent Microvascular Reperfusion Injury in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

The aim of our study was to examine the role of a new, simple protocol of intracoronary adenosine administration performed during primary angioplasty on the immediate angiographic results and clinical course. A prospective, single-center, randomized, placebo-controlled trial of 70 consecutive patients (64 ± 14 years, 54 men) with acute myocardial infarction with ST-segment elevation undergoing primary percutaneous coronary intervention (PCI) was conducted. Patients were randomized to 2 groups. Group 1 (n = 35) received intracoronary adenosine (1 to 2 mg) with a hand injection through the guiding catheter 2 times: immediately after crossing the lesion of the infarct-related artery with guidewire and then after the first balloon inflation. Group 2 (n = 35) received placebo. The baseline clinical and angiographic characteristics of the 2 groups were similar. Percutaneous coronary intervention resulted in Thrombolysis In Myocardial Infarction grade 3 flow after PCI in 32 patients (91.4%) in the adenosine group and 27 patients (77.1%) in the placebo group (p = 0.059). Myocardial blush grade 3 was observed at the end of PCI in 23 patients (65.7%) in the adenosine group and 13 (37.1%) in the placebo group (p < 0.05). Resolution of ST-segment elevation (> 50%) was more frequently observed in the adenosine than in the placebo group: 27 (77%) versus 15 (43%), respectively (p < 0.01). In conclusion, intracoronary adenosine administration improved the angiographic and electrocardiographic results in patients with acute myocardial infarction with ST-segment elevation undergoing PCI. Adenosine administration seemed to be associated with a more favorable clinical course.

Postconditioning Reduces Enzymatic Infarct Size and Improves Microvascular Reperfusion in Patients with ST-Segment Elevation Myocardial Infarction

Objectives: Postconditioning has been reported to reduce infarct size in ST-segment myocardial infarction (STEMI). However, recently, few other studies did not show any effect of postconditioning and suggested that it may be even harmful. We sought to assess whether postconditioning could reduce infarct size and improve myocardial reperfusion in early presenters with STEMI. Methods: 72 STEMI patients treated with primary percutaneous coronary intervention (PCI) were randomly assigned to either the postconditioning (n = 35) or the standard PCI group (control group; n = 37). Blood samples were obtained for creatine kinase (CK) and its MB isoform (CK-MB) within 36 h. The angiographic (myocardial blush grade, MBG) and electrocardiographic (ST-segment resolution, STR) data were evaluated and compared between groups. Results: The areas under the curve of CK and CK-MB release were significantly reduced in the postconditioning group compared with the control group (38,612.91 ± 25,028.42 vs. 60,547.30 ± 25,264.63 for CK and 5,498.23 ± 3,787.91 vs. 7,443.12 ± 3,561.13 for CK-MB, p < 0.0001). MBG was significantly better in the postconditioning group than in the control group (MBG 3: 82.3 vs. 47.1%, p = 0.0023). In the postconditioning group, STR >70% was more often observed (97.1 vs. 64.1%, p = 0.0007). Conclusions: In patients with STEMI, postconditioning could significantly reduce enzymatic infarct size and improve myocardial reperfusion.

Effect of restoration of AV synchrony on stroke volume, exercise capacity, and quality-of-life: can we predict the beneficial effect of a pacemaker upgrade?

PRECH, M., et al.: Effect of Restoration of AV Synchrony on Stroke Volume, Exercise Capacity, and Quality‐of‐Life: Can We Predict the Beneficial Effect of a Pacemaker Upgrade? The aim of this study was to assess to what extent patients with VVIR pacemakers and without overt symptoms of a pacemaker syndrome benefit from a pacemaker upgrade, and if a preoperative noninvasive measurement of the change in stroke volume (SV) could predict the effect of a pacemaker upgrade. The study group consisted of 20 (12 women, 8 men) VVIR patients with a mean age of 60 years. The indication for the first implantation was AV block in 13 patients and SSS in 7. The mean time of a ventricular pacing was 77 months. The objective (echocardiography, an exercise capacity) and the subjective (the quality‐of‐life) parameters investigated in patients during ventricular pacing were compared to results obtained 2 months and 1 year after a pacemaker upgrade. To assess preoperatively a change in a SV expected after upgrading, attempts were made to restore AV synchronization by the use of a transesophageal pacemaker. An increase in SV (from 5% to > 35%) during temporary AV resynchronization was observed in each patient. Values of SV increase correlated with those obtained 2 months (r = 0. 65; P < 0.01) and 1 year (r = 0.66; P < 0.01) after an upgrade. Superior hemodynamics was associated with a significant improvement of an exercise capacity in both subgroups of patients. The most significant improvement in the quality‐of‐life was observed in patients with SSS. We did not find correlations between SV and the quality‐of‐life assessed 2 months (r = 0.043; NS) or 1 year (r = 0.02; NS) after an upgrade. In conclusion, a pacemaker upgrade performed after a long‐term ventricular pacing resulted almost consistently in the improvement of hemodynamics and was associated with an increase of exercise capacity. In patients with SSS it was followed by the significant improvement of their quality‐of‐life. Such a relation was not observed in patients with AV block as some of them (especially those with VVIR pacemakers) felt quite well during ventricular pacing. The proposed preoperative echocardiographic evaluation may precisely predict the degree of hemodynamic improvement expected after a pacemaker upgrade.

Role of adenosine as an adjunct therapy in the prevention and treatment of no-reflow phenomenon in acute myocardial infarction with ST segment elevation: review of the current data

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Percutaneous coronary intervention for chronic total occlusion of the coronary artery with the implantation of bioresorbable everolimus-eluting scaffolds. Poznan CTO-Absorb Pilot Registry.

AIMS Data concerning the use of bioresorbable vascular scaffolds (BVS) for chronic total occlusion (CTO) lesions are limited. The aim of this study was to evaluate the early and midterm clinical outcomes of CTO stenting with BVS. METHODS AND RESULTS Forty consecutive patients (male 78%, mean age 59.9±8.3 years, diabetics 30%) with CTO treated with BVS were enrolled. Patients with a reference vessel diameter >4 mm, metallic stents, excessive calcium and tortuosity were excluded. Mean J-CTO score was 1.6. A total of 63 BVS were implanted with an average number of 1.6 per patient, and an average scaffold length of 42.4±21.5 mm. Procedural success was achieved in all patients with no device-related complications. At follow-up (median time 556 days), there were no deaths, one patient experienced subacute and late scaffold thrombosis (ST), and another one developed symptomatic in-scaffold focal restenosis treated with repeat PCI. At control angiography, performed at a median time of 329 days in 27 patients (68%), no more restenosis or vessel reocclusion was found. CONCLUSIONS CTO stenting with BVS is feasible with good acute performance, and good early and midterm clinical outcomes.

The impact of ischemia-reperfusion injury on the effectiveness of primary angioplasty in ST-segment elevation myocardial infarction.

The most effective method of reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (PCI), assisted by aspiration thrombectomy and administration of antiplatelet agents and anticoagulants. However, effective restoration of blood flow in the infarct-related artery may paradoxically result in further damage to the heart muscle. This phenomenon, called ischemia-reperfusion injury (IRI), can significantly reduce the beneficial effects of reperfusion therapy. The rapid restoration of blood flow to the previously ischemic area causes a number of pathophysiological mechanisms leading to increased necrosis of myocytes still viable at the end of the ischemic period. It has been postulated that there are several strategies that can reduce damage to the heart muscle. Attempts to translate the results of experimental trials has been disappointing. More recently, however, some of the clinical benefits of ischemic postconditioning in which reperfusion in patients with STEMI who are undergoing PCI is interrupted with short episodes of ischemia were demonstrated. This renewed the interest in the reperfusion phase as a target for cardioprotective therapy. Research in this field has also been reinforced by the discovery of new potential targets for treatment that protects against IRI, such as the kinase pathway to protect against damage (reperfusion injury salvage kinases – RISK) and mitochondrial permeability transition pore. It seems that these findings will help to develop strategies that will improve the efficiency of mechanical reperfusion and may translate into long-term clinical effects.

Pre-procedural dual antiplatelet therapy and bleeding events following transcatheter aortic valve implantation (TAVI)

INTRODUCTION Transcatheter aortic valve implantation (TAVI) is associated with bleeding that increases mortality. Dual antiplatelet therapy (DAPT) is recommended in TAVI, however little is known about pre-procedural DAPT use and its impact on hemostasis. We sought to determine the frequency, predictors and bleeding events in patients receiving DAPT before TAVI. METHODS Three-hundred-and-three (n=303, 78.6±7.6years, 49% female, EuroScore 23.1±16.9) consecutive patients undergoing TAVI were prospectively analyzed and followed for in-hospital events. According to pre-procedural antiplatelet status study population was divided into 2 groups: patients receiving aspirin and clopidogrel (DAPT) and those on aspirin only or no antiplatelet therapy (noDAPT). RESULTS Pre-procedural DAPT was used in 139 cases (46%). Previous PCI (OR 4.8, [2.8-8.3], p<0.0001), implantation of self-expandable prosthesis (OR 2.2, [1.2-4], p=0.007) femoral access (OR 2.2, [1.1-4.5], p=0.029) and platelet count (OR 1.006, [1.002-1.01], p=0.002) were identified as independent predictors of pre-procedural DAPT. No difference was observed in the rates of any bleeding (23% in DAPT vs. 24.4% in noDAPT, p=0.930) or major/life-threatening bleeding (12.2% in DAPT vs. 14.7% in noDAPT, p=0.715). Propensity-score matching analysis did not alter the results. GFR <30ml/min was the strongest predictor of bleeding (OR 4.3, [1.9-9.9], p=0.0005). There was a trend towards lower frequency of MI and stroke/TIA in DAPT as compared with noDAPT (3.6% vs. 9.8%, p=0.082). CONCLUSIONS Pre-procedural DAPT is frequent and does not increase short-term bleeding complications or need for transfusion following TAVI. Possible impact of DAPT use before TAVI on ischemic complications needs to be investigated in larger populations.

Percutaneous interventions in cardiology in Poland in the year 2014. Summary report of the Association of Cardiovascular Interventions of the Polish Cardiac Society AISN PTK.

Introduction The Board of the Association of Cardiovascular Interventions of the Polish Cardiac Society (AISN PTK) publishes annual data from the National PCI Registry (ORPKI) operated by the Jagiellonian University Medical College in Krakow. Aim For the first time the AISN PTK report is based on the new electronic database implemented in Poland on January 1st, 2014. Material and methods In 2014, there were 155 invasive cardiology centers registered in the ORPKI database (an increase by 1 center in comparison to 2013) and 92% of them had 24/7 percutaneous (PCI) duty. For the first time the number of catheterization laboratories (cath labs) in Poland remained stable, and even though there was an increase by 1 in absolute numbers, 2 cath labs ceased to admit patients in 2014. This means that the number of active cath labs per 1 million inhabitants is similar to last year and equals 4. Results In comparison to 2013, there was a significant increase in the total number of coronary angiographies. There were 226 713 angiographies in 2014. The total number of PCI procedures was 126 241, which is 5.1% more than in 2013. Conclusions There was a significant increase in the overall number of coronary angiographies and PCIs in Poland in 2014. The use of attributes of modern interventional cardiology such as drug-eluting stents and bioabsorbable vascular stents is growing as well as more frequent choice of a radial access site by PCI operators even in ST-elevation myocardial infarction patients. One should also note a significant rise in the use of additional imaging or diagnostic tools such as fractional flow reserve, intravascular ultrasound and optical coherent tomography.

Effect of new method of intracoronary adenosine injection during primary percutaneous coronary intervention on microvascular reperfusion injury - clinical outcome and 1-year follow-up.

Objectives: The aim of this single-center, randomized placebo-controlled trial in 70 consecutive patients (64 ± 14 years) with acute myocardial infarction was to examine the role of a new protocol of adenosine administration during primary angioplasty on immediate electrocardiographic and angiographic results, clinical outcome and 1-year follow-up. Methods: Group A (n = 35) twice received intracoronary adenosine through the guiding catheter: immediately after crossing the lesion of the infarct-related artery with guidewire and then after first balloon inflation. Group B (n = 35) received placebo. Results: Resolution of ST segment elevation was more frequently observed in the adenosine than in the placebo group (p < 0.01). Percutaneous coronary intervention (PCI) resulted in borderline better TIMI 3 flow after the procedure in the adenosine group than in the placebo group. Myocardial blush grade 3 at the end of the procedure was significantly improved in the adenosine compared to the placebo group (p < 0.05). At 1-year the composite end-point of death, recurrent myocardial infarction, heart failure and clinically driven target vessel revascularization was present in 8 patients in the adenosine group and 16 patients in placebo group (p < 0.05). Conclusions: Intracoronary adenosine improved electrocardiographic and angiographic results in patients undergoing primary PCI and seemed to be associated with more favorable clinical course.

QT Interval Dispersion as a New Marker of Restenosis after Percutaneous Transluminal Coronary Angioplasty of Isolated Single-Vessel Coronary Artery Stenosis

Background: There are no reliable non-invasive markers of restenosis after percutaneous transluminal coronary angioplasty (PTCA). The aim of our study was to measure changes in QT interval dispersion after PTCA and to determine whether restenosis subsequently affects QT interval dispersion. Methods and Results: Fifty-six consecutive patients – 41 men and 15 women (mean age: 56.2 ±8.3 years) – with isolated stenosis of the left anterior descending artery who underwent successful PTCA were studied. A symptom-limited treadmill exercise test was performed within 7 days after PTCA and then again before repeated angiography. Repeated coronary angiography revealed restenosis in 15 patients (26.8%) and no signs of significant stenosis in 41 patients (73.2%). QT interval dispersion in the group of patients with restenosis measured before exercise increased from baseline 34 ± 7 to 49 ± 15 ms after 6 months (p < 0.01) and QT interval dispersion measured immediately after exercise increased from baseline 38 ± 4 to 68 ± 21 ms after 6 months (p < 0.001). In contrast, patients without restenosis showed no significant changes in QT interval dispersion measured before (baseline: 34 ± 9 ms; after 6 months 33 ± 12 ms; p = NS) and immediately after exercise (baseline: 34 ± 12 ms; after 6 months: 33 ± 10; p = NS). When QT interval dispersion ≧60 ms (measured 6 months after PTCA procedure) was considered as a potential marker of restenosis, this indicator had very high sensitivity and specificity when measured immediately after exercise (80 and 95% respectively). Conclusions: QT interval dispersion significantly increases in the group of patients with documented restenosis and may be a simple, non-invasive marker of restenosis. However, further studies are needed to confirm this observation.