Michał Chyrchel

Association of plasma miR-223 and platelet reactivity in patients with coronary artery disease on dual antiplatelet therapy: A preliminary report

Abstract Decreased plasma levels of microRNA-223 (miR-223), predominantly of platelet origin, were proposed as a surrogate marker of efficacy of antiplatelet therapy. However, higher on-treatment platelet reactivity was associated with lower plasma miR-223 in patients with coronary artery disease (CAD) on dual antiplatelet therapy (DAPT) including clopidogrel and aspirin. Our aim was to compare plasma miR-223 and platelet reactivity in CAD patients on DAPT with newer P2Y12 antagonists vs. clopidogrel. We studied 21 men with CAD admitted to our centre owing to a non-ST-elevation acute coronary syndrome, and with an uncomplicated hospital course. From the day of admission, the patients were receiving either clopidogrel (n = 11) or prasugrel/ticagrelor (n = 10) in addition to aspirin. Before discharge, miR-223 expression in plasma was estimated by quantitative polymerase chain reaction using the comparative Ct method relative to miR-16 as an endogenous control. Multiple electrode aggregometry was used to assess platelet aggregation in response to adenosine diphosphate (ADP). ADP-induced platelet reactivity was decreased in the patients treated with prasugrel or ticagrelor compared with those on clopidogrel (mean ± SD: 139 ± 71 vs. 313 ± 162 arbitrary units [AU]*min, p = 0.006), due to a more potent antiplatelet activity of the novel P2Y12 antagonists. Consequently, six out of seven patients in the lower tertile of the ADP-induced platelet aggregation were treated with the newer P2Y12 blockers, whereas six out of seven patients in the upper tertile were on clopidogrel. Plasma miR-223 was elevated with decreasing platelet reactivity (Spearman’s rho = –0.52; p = 0.015 for trend), being significantly higher in the lower tertile of the ADP-induced platelet aggregation (median [range]: 1.06 [0.25–2.31]) vs. the upper tertile (0.20 [0.13–2.30]) (p = 0.04). In conclusion, our preliminary results argue against the notion of low plasma miR-223 as a marker of platelet responsiveness to DAPT. On the contrary, more potent platelet inhibition associated mainly with newer P2Y12 antagonists appears to coincide with higher miR-223 relative to the subjects with attenuated responsiveness to DAPT.

Assessment of Culprit Plaque Temperature by Intracoronary Thermography Appears Inconclusive in Patients With Acute Coronary Syndromes

Objective—Safety and feasibility evaluation of intracoronary temperature measurements in patients with acute coronary syndromes (ACS) using a catheter based thermography system. Methods and Results—Thermography was performed in 40 patients with ACS. A 3.5-F thermography catheter containing 5 thermocouples measuring vessel wall temperature, and 1 thermocouple measuring blood temperature (accuracy 0.05°C) was used. Gradient (&Dgr;Tmax) between blood temperature (Tbl) and the maximum wall temperature during pullback was measured. The device showed satisfactory safety in ACS. Only in 16 patients (40%) &Dgr;Tmax was ≥0.1°C. In 23 patients (57.5%) the highest &Dgr;Tmax was found in the culprit segment. &Dgr;Tmax between culprit and adjacent non-culprit segments was observed in patients with transient blood flow interruption during thermography (0.11±0.03 versus 0.08±0.01; P=0.04), in contrast to patients with preserved flow (0.07±0.03 versus 0.06±0.02; P=0.058). Conclusions—The novel, technically sophisticated intracoronary thermography proved its safety and feasibility. However, we were not able to convincingly and consistently differentiate between different lesions at risk, despite a selection of lesions that should appear most distinct to differentiate. A systematic interruption of flow may be necessary to achieve diagnostic results consistently, although such requirement may unfavorably change the risk-to-benefit ratio of this developing technology.

Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in elderly patients transferred with ST-elevation myocardial infarction: Data from the EUROTRANSFER registry

BACKGROUND Limited data are available concerning benefits and risks of early abciximab (EA) administration before primary percutaneous coronary intervention (PPCI) in elderly ST-segment elevation myocardial infarction (STEMI) patients. The objective of the study was to assess the impact of EA before PPCI in elderly (>or=65 years) patients. METHODS AND RESULTS We identified 545 patients <65 years (354 with EA administration (>30 min before PPCI), 191 late abciximab (LA)), and 541 patients >or=65 years of age (373 EA, 168 LA) in the EUROTRANSFER Registry database. Elderly patients were more likely to have comorbidities, angiographic PCI complications, and bleeding events. EA promotes infarct-related artery patency before PPCI and improves myocardial reperfusion after PPCI in both age groups, but the risk of 30-day death (EA vs. LA: <65 years, 2.0% vs. 1.6%; p=0.999; >or=65 years, 5.9% vs. 14.3%; p=0.001) and 30-day death+reinfarction (EA vs. LA: <65 years, 2.5% vs. 2.1%; p=0.999; >or=65 years, 7.5% vs. 17.3%; p=0.001) was reduced in elderly patients only. There was no difference in bleedings, especially major bleedings requiring transfusion (EA vs. LA: patients <65 years, 2.3% vs. 0%, p=0.055; >or=65 years, 2.4% vs. 3%; p=0.448) between groups. CONCLUSIONS Patients >or=65 years of age have a substantially increased risk of angiographic PCI complications, death and bleeding events compared with their younger counterparts. Strategy of EA before PPCI improves reperfusion parameters and clinical outcome in elderly patients and is not associated with elevated risk of major bleeding.

Effects of short-term anti-inflammatory therapy on endothelial function in patients with non-ST-segment elevation acute coronary syndrome

The aim was to assess the impact of the short-term anti-inflammatory therapy on coronary endothelial function in non-ST-segment elevation acute coronary syndrome patients. In 30 patients, coronary endothelial function was assessed by acetylcholine test. Vessel response was calculated as a percent change of mean lumen diameter (MLD). Then patients were randomized into three groups: A (n = 11) placebo, B (n = 11) 80 mg atorvastatin, C (n = 8) 80 mg atorvastatin and 25 mg rofecoxib. After 7 days control test was performed. Recovery of coronary endothelial function was calculated as delta in percent changes of MLD between Days 1 and 7. On Day 1, percent change of MLD between baseline and maximum acetylcholine did not differentiate the groups: -20 ± 3.5% in A, -25 ± 3.9% in B and -26 ± 3.7% in C, P = .20. On Day 7, percentage changes in MLD were as follows: -21 ± 3.9% in A, -15 ± 3.0% in B and -10 ± 4.0% in C, P=.002. The delta in percentage change in MLD between Days 1 and 7 were as follows: -1% in A, + 10% in B and +16% in C, P = .02. In conclusion, short-term, anti-inflammatory therapy with high-dose atorvastatin and selective cyclooxygenase-2 inhibitor improves coronary endothelial function within 7 days in non-ST-segment elevation acute coronary syndrome patients.

Endovascular retrieval of ruptured and dislocated vascular catheter

A 61-year-old female patient was admitted to the cardiology department due to dyspnea and atypical chest pain. She had cervical cancer with metastasis to the lungs which was diagnosed 2 years earlier. The patient was undergoing palliative chemotherapy (vinorelbine) administered through a silicone catheter (Celsite – implantable access port system; B Braun Medical, France) localized in the right subclavian vein. On admission, the patient was hemodynamically stable (blood pressure: 120/80 mm Hg, heart rate: 80 bpm, saturation 98%). Laboratory tests revealed anemia (Hb: 10.1 g/dl, Ht: 31.1%) and elevated serum creatinine (1.2 mg/dl, eGFR 47.0 ml/min/1.73 m2). Pulmonary embolism was excluded using echocardiography and D-Dimer measurement. In echocardiography a longitudinal shadow was found in the heart protruding to the inferior vena cava. Therefore an abdominal X-ray was performed (Figure 1 A). Examination confirmed the presence of a ruptured chemotherapy catheter. A 17.5 cm long catheter was located in the inferior vena cava and right atrium. Due to the risk of thrombus-embolic complications the patient was qualified for endovascular removal of the catheter. After local anesthesia the right femoral vein was punctured. A 7 Fr vascular sheath was introduced and a 7 Fr Judkins right guiding catheter (Medtronic, USA) was located below the lower tip of the catheter. An Andrasnare AS-10 device with atraumatic 10 mm nitinol loop (Andramed GmbH, Germany) was introduced through the guiding catheter. The device loop was positioned at the very end of the catheter, which enabled coaxially pulling out the ruptured catheter through the 7 Fr sheath (Figures 1 B–D). Fluoroscopy time was 9 min 12 s with a radiation dose of 0.2 Gy. A total of 20 ml of contrast media was used. There were no periprocedural complications. The next day, the remaining part of the broken vascular port chamber was removed surgically from subcutaneous tissue in the right subclavian vein region. The patient was discharged home on the fifth day. Subcutaneous venous catheters are commonly used in patients with cancer. Located in big veins, they are used for fluid infusion, parenteral nutrition, and administration of chemotherapy agents [1–3]. Early complications associated with catheters occur immediately after the implantation. They can be related to clinical conditions of the patient or to surgical factors. These include skin or vascular perforation, hemothorax, incorrect positioning of the catheter, and improper anchoring of the catheter with early dislocation. The rate of early complications is below 4.5% [4]. The late complications include infection of the subcutaneous pocket or the port system, skin infection, sepsis, drug extravasation, mechanical malfunction, skin necrosis, catheter thrombosis, catheter disconnection and embolization, and venous thrombosis. The rate of migration of the ruptured catheter ranges from 0.2% to 8% [4]. The mechanism and the exact time of catheter rupture in the present case is unknown. Dislocation of the separated catheter fragment to the cardiovascular system is not frequent. It is associated with possible severe clinical consequences (life-threatening arrhythmias, sepsis, thrombus formation, endocarditis, heart perforation or even death) [2, 4]. Therefore the dislocated catheter should be urgently removed from vascular circulation. The recommended approach for foreign body removal is minimally invasive endovascular treatment under fluoroscopy with snaring devices [3, 5]. Minimally invasive techniques present outstanding results and may minimize morbidity and mortality [3]. The remaining catheter part in the subcutaneous tissue can be easily removed surgically under local anesthesia.

Twelve months follow-up after retrograde recanalization of superficial femoral artery chronic total occlusion

INTRODUCTION Fifty percent of cases of peripheral artery disease are caused by chronic total occlusion (CTO) of the superficial femoral artery (SFA). Ten-fifteen percent of percutaneous SFA recanalization procedures are unsuccessful. In those cases the retrograde technique can increase the success rate of the procedure, but the long-term follow-up of such procedures is still unknown. AIM To assess the efficacy and clinical outcomes during long-term follow-up after retrograde recanalization of the SFA. MATERIAL AND METHODS We included patients after at least one unsuccessful percutaneous antegrade recanalization of the SFA. Patients were evaluated for the procedural and clinical follow-up of mean time 13.9 months. RESULTS The study included 17 patients (7 females, 10 males) who underwent percutaneous retrograde recanalization of the SFA from June 2011 to June 2015. The mean age of patients was 63 ±7 years. Retrograde puncture of the distal SFA was successful in all cases. A retrograde procedure was performed immediately after antegrade failure in 4 (23.5%) patients and after a previously failed attempt in 13 (76.5%) patients. The procedure was successful in 15 (88.2%) patients, and unsuccessful in 2 (11.8%) patients. Periprocedural complications included 1 peripheral distal embolization (successfully treated with aspiration thrombectomy), 1 bleeding event from the puncture site and 7 puncture site hematomas. During follow-up the all-cause mortality rate was 5.8% (1 patient, non-cardiac death). The primary patency rate at 12 months was 88.2% and secondary patency 100%. CONCLUSIONS The retrograde SFA puncture seems to be a safe and successful technique for CTO recanalization and is associated with a low rate of perioperative and long-term follow-up complications.

Impact of coronary artery disease presence on the long-term follow-up of carotid artery stenting

BACKGROUND Carotid artery stenting (CAS) has become an alternative for carotid endarterectomy in the treatment of carotid artery atherosclerosis, due to limited injury and comparable periprocedural risk. The impact of coronary artery disease (CAD) on long-term follow-up after CAS needs to be reconsidered due to the intensification of aggressive pharmacotherapy in CAD in recent years. AIM To assess the impact of CAD presence on the long-term follow-up of patients after CAS. METHODS Data of 130 symptomatic and asymptomatic patients undergoing CAS with cerebral protection systems from December 2002 to December 2010 were divided into two groups: those with and those without CAD. Major adverse cardio- and cerebrovascular events (MACCE) during follow-up were defined as the combination of death (cardiac and non-cardiac), myocardial infarction (MI) and stroke or transient ischaemic attack (TIA). Long-term outcomes of patients were stratified based on the history of CAD. RESULTS The mean age of patients was 66 ± 9 years, and the majority of patients were male (80.2%). Long-term follow-up data were available in 86.2% of patients. During mean follow-up of 71.9 ± 31.7 months the all-cause mortality rate was 19.3%. The rates of MI, stroke/TIA, and MACCE were 16.7%, 12.3%, and 36.3%, respectively. The frequency of MACCE during long-term follow-up was higher in patients with CAD vs. without CAD (40.8% vs. 6.7%, p = 0.01), and the mortality rate in the two groups was 22.2% vs. 0%, (p = 0.07), respectively. CONCLUSIONS Patients with symptomatic or asymptomatic carotid stenosis are high-risk individuals. The presence of CAD increases the risk of MACCE in such patients during long-term follow-up.

Transradial percutaneous coronary intervention for unprotected left main closure during acute myocardial infarction.

An 87-year-old female patient was admitted to the emergency unit with the diagnosis of non-ST-elevation myocardial infarction (MI). She complained of dyspnea and easy fatigue for 2 days. On admission she was without chest pain and hemodynamically stable (RR 105/65 mm Hg). The electrocardiogram revealed ST-segment depression in leads II, III, aVF and V4–V6 and ST-segment elevation in leads aVR and V1–V2. In the angiography performed from the right radial artery, acute left main coronary artery (LMCA) occlusion was found (Figures 1A, ​,B).B). During catheterization the patient developed cardiogenic shock with arterial pressure drop to 60/20 mm Hg. Immediate percutaneous coronary intervention (PCI) of LMCA was started. Due to severe spasm of the right radial artery, the introduction of a regular guiding catheter was impossible. Then sheathless 3.5JL catheter was effectively positioned in the ostium of the LMCA. After passing the occlusion with the BMW Universal wire (Abbott Vascular, USA), aspiration thrombectomy was unsuccessfully attempted. Predilatation with a small balloon (2.0 × 15 mm; Sprinter Legend, Medtronic, USA) was performed and complete flow through the LMCA was restored. Two zotarolimus-eluting coronary stents (3.0 × 26 mm and 2.5 × 18 mm; Resolute Integrity, Medtronic, USA) were implanted from the LMCA ostium to the proximal left anterior descending artery (Figure 1C). After implantation of the stents her systolic blood pressure stabilized at about 110 mm Hg without pharmacological support. She was transferred to the cardiac intensive care unit. After 30 min she developed severe pulmonary edema which was successfully treated with the standard pharmacological regimen. There were no further complications during the hospitalization. She was discharged home on the sixth day. Left ventricular ejection fraction at discharge was 45%. There were no cardiovascular events during 4-month follow-up. Figure 1 Coronary angiography: A – coronary angiogram in the left cranial oblique view showing total occlusion of the left main coronary artery, B – coronary angiogram in the epicranial oblique view showing the right coronary artery without significant ... Acute MI (AMI) due to LMCA occlusion is a rare situation but very often associated with severe clinical consequences (cardiogenic shock, life-threatening arrhythmias, sudden cardiac death) [1]. There have been no randomized trials comparing revascularization strategies (PCI vs. coronary artery bypass grafting) in this group of patients. However, according to certain assumptions (less invasive procedure, fast access, better acute results) PCI may be superior to cardiac surgery in this clinical scenario. Recent data show effectiveness of PCI of the LMCA in AMI even in centers without on-site cardiac surgical backup [2]. However, due to high probability of cardiogenic shock (from 16% to 69%) among patients with AMI due to an occlusion of the LMCA, hemodynamic support with an intra-aortic balloon pump or left ventricle assist device during the procedure is frequently required (from 23% to 89%) [3, 4]. The transradial approach for unprotected LMCA disease is a reasonable option also in patients with AMI, as the rate of procedural complications is similar to that reported for the femoral access [5]. Ostial/mid-shaft LMCA lesions are relatively straightforward to treat. Distal bifurcation lesions could be more tricky but treatable through the transradial approach. The transradial approach is also useful in patients with hemodynamic instability (pulmonary edema) after PCI, when a patient can be safely placed in a sitting position and effectively treated with pharmacotherapy only.

Letter by Chyrchel et al Regarding Article, “Unexpected Effect of Proton Pump Inhibitors: Elevation of the Cardiovascular Risk Factor Asymmetric Dimethylarginine”

Ghebremariam et al1 brilliantly demonstrated that proton pump inhibitors (PPIs) inhibit dimethylarginine dimethylaminohydrolase, a key enzyme metabolizing the endogenous nitric oxide synthase antagonist asymmetrical dimethylarginine. This finding offers a novel mechanism for the putative ability of PPIs to attenuate benefits of antiplatelet agents, an effect initially attributed to the interaction of PPIs with clopidogrel activation by a hepatic enzyme (CYP2C19).2 …

Rescue removal of disrupted balloon catheter from right coronary artery and aortic arch

We present the case of a 70-year-old female patient diagnosed with unstable angina, who was qualified to coronarography in a peripheral interventional cardiology department. Critical stenosis of right posterior descending artery was found. During percutaneous coronary intervention, after-stent balloon catheter interrupted and was left partially in the right coronary artery sticking out of the aortic arch. In a second attempt at removal, using an Amplatz GooseNeck snare, operators managed to take the broken balloon out of the intravascular space.