Miroslav Brtko

ST-Segment Elevation Myocardial Infarction Treated by Radial or Femoral Approach in a Multicenter Randomized Clinical Trial The STEMI-RADIAL Trial

OBJECTIVES This study sought to compare radial and femoral approaches in patients presenting with ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI) by high-volume operators experienced in both access sites. BACKGROUND The exact clinical benefit of the radial compared to the femoral approach remains controversial. METHODS STEMI-RADIAL (ST Elevation Myocardial Infarction treated by RADIAL or femoral approach) was a randomized, multicenter trial. A total of 707 patients referred for STEMI <12 h of symptom onset were randomized in 4 high-volume radial centers. The primary endpoint was the cumulative incidence of major bleeding and vascular access site complications at 30 days. The rate of net adverse clinical events (NACE) was defined as a composite of death, myocardial infarction, stroke, and major bleeding/vascular complications. Access site crossover, contrast volume, duration of intensive care stay, and death at 6 months were secondary endpoints. RESULTS The primary endpoint occurred in 1.4% of the radial group (n = 348) and 7.2% of the femoral group (n = 359; p = 0.0001). The NACE rate was 4.6% versus 11.0% (p = 0.0028), respectively. Crossover from radial to femoral approach was 3.7%. Intensive care stay (2.5 ± 1.7 days vs. 3.0 ± 2.9 days, p = 0.0038) as well as contrast utilization (170 ± 71 ml vs. 182 ± 60 ml, p = 0.01) were significantly reduced in the radial group. Mortality in the radial and femoral groups was 2.3% versus 3.1% (p = 0.64) at 30 days and 2.3% versus 3.6% (p = 0.31) at 6 months, respectively. CONCLUSIONS In patients with STEMI undergoing primary PCI by operators experienced in both access sites, the radial approach was associated with significantly lower incidence of major bleeding and access site complications and superior net clinical benefit. These findings support the use of the radial approach in primary PCI as first choice after proper training. (Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention [PCI] [STEMI-RADIAL]; NCT01136187).

Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium.

Whats known on the subject? and What does the study add?

The percutaneous closure of a large pseudoaneurysm of the ascending aorta with an atrial septal defect Amplatzer occluder: Two-year follow-up

Pseudoaneurysm of the ascending aorta is a high-risk complication following cardiac surgery. The present report describes excellent two-year follow-up results after the percutaneous closure of a very large pseudoaneurysm with an Amplatzer atrial septal defect occluder. The original cavity in the anterior mediastinum with maximal diameter 15 cm remained as only a small scar. The patient was without serious health problems both early and after two years.

A Foreign Body in the Heart Due to an Unusual Injury

Penetrating heart injuries are immediate life-threatening situations. We present a case report of a 44-year-old man with a foreign body in his right heart. The injury happened while the man was working with a circular saw 15 months prior to the actual diagnosis. With respect to the size of the foreign body, its close proximity to the right coronary artery, the potential risk of bleeding, embolization, endocarditis or pericarditis, surgical therapy was indicated in spite of the fact that the patient was asymptomatic. The foreign body (a spring-segment of a roller blind) was successfully removed.

Safety and efficacy of cangrelor, an intravenous, short-acting platelet inhibitor in patients requiring coronary artery bypass surgery.

OBJECTIVE Oral P2Y₁₂ platelet receptor inhibitors are a cornerstone of reducing complications in patients with acute coronary syndromes or coronary stents. Guidelines advocate discontinuing treatment with P2Y₁₂ platelet receptor inhibitors before surgery. Cangrelor, a short-acting, reversible, intravenously administered P2Y₁₂ platelet inhibitor is effective in achieving appropriate platelet inhibition in patients who are awaiting coronary artery bypass grafting (CABG) and require P2Y₁₂ inhibition. The objective of this study was to assess the effects of preoperative cangrelor on the incidence of perioperative complications, which are currently unknown. METHODS Patients (n = 210) requiring preoperative clinical administration of thienopyridine therapy were randomized in a multicenter, double-blinded study to receive cangrelor or placebo while awaiting CABG after discontinuation of the thienopyridine. Optimal platelet reactivity, which was defined as <240 P2Y₁₂ platelet reaction units, was measured with serial point-of-care testing (VerifyNow). Pre- and postoperative outcomes, bleeding values, and transfusion rates were compared. To quantify potential risk factors for bleeding, we developed a multivariate logistic model. RESULTS The differences between the groups in bleeding and perioperative transfusion rates were not significantly different. The rate of CABG-related bleeding was 11.8% (12/102) in cangrelor-treated patients and 10.4% (10/96) in the placebo group (P = .763). Transfusion rates for the groups were similar. Serious postoperative adverse events for the cangrelor and placebo groups were 7.8% (8/102) and 5.2% (5/96), respectively (P = .454). CONCLUSIONS Compared with placebo, bridging patients with cangrelor prior to CABG effectively maintains platelet inhibition without increasing post-CABG complications, including bleeding and the need for transfusions. These data suggest cangrelor treatment is a potential strategy for bridging patients requiring P2Y₁₂ receptor inhibition while they await surgery.

Transcatheter Aortic Valve Implantation (TAVI)

Transcatheter aortic valve implantation (TAVI or TAVR) was developed as an alternative to surgical aortic valve replacement (SAVR) for inoperable or high-risk patients. Originally, this method was intended for the treatment of patients with aortic stenosis. Currently, there are several types of valves implanted percutaneously. The periprocedural complications of TAVI are not frequent. Using the second-generation or third-generation valves, the results of TAVI are improving and therefore TAVI is currently recommended also for intermediate-risk patients. For several reasons, TAVI in patients with AR is still problematic and is a subject of clinical research.

Recommendation for Outpatient Follow-Up After Aortic Valve Surgery

The patient after aortic valve surgery does not become a healthy person. He or she should be regularly followed-up by a cardiologist, preferably in a cardiac care centre. On the outpatient visit, the patient’s history is taken, chest X-ray, ECG and echocardiography are performed and the patient is clinically examined. The drug therapy is also checked. According to the type of performed surgery (aortic valve replacement with mechanical valve, bioprosthesis, pulmonary autograft or aortic allograft, or aortic valve sparing procedure), the anticoagulation or antiplatelet therapy is prescribed for a short- or long term postoperatively. According to guidelines, the prophylaxis of infective endocarditis is recommended for patients at highest risk of infective endocarditis only. From practical point of view, it applies to patients with mechanical prosthesis or bioprosthesis or to patients with the history of infective endocarditis.

Echocardiography of the Aortic Valve

Echocardiography (TTE, TEE) is currently the leading method in diagnostics of valve diseases. It is an initial examination in suspicion of valve disease due to its accessibility, simplicity, and non-invasivity. Echocardiography is a highly reliable method in the disease aetiology and significance assessment and it is important in treatment decision. It does not use radiation and so it is arbitrarily repeatable and optimal in monitoring of patients with valve disease. Together with clinical examination, it precisely determines timing and type of surgery. Perioperative TEE is indispensable in the assessment of the result of surgery, particularly in valve-sparing procedures. Early post-operative echocardiography is the first examination in the assessment of post-operative complications. In the long-term follow-up, echocardiography is used for follow-up of patients with residual valve disease.

Aortic Regurgitation: From Diagnosis to Indication

Aortic regurgitation is the third most frequent valve disease in adults. Approximately 20–30% of the aortic valve operations are performed for AR. AR may be caused either by aortic valve leaflets pathology themselves or by aortic valve annulus and aortic root pathology. Echocardiography, chest X-ray and ECG are the basic diagnostic methods in patients with AR. Ergometry is used to verify symptoms and to evaluate long-term development of physical fitness of patients. CT angiography is indicated to evaluate precisely the ascending aorta anatomy and to diagnose the presence and extent of eventual aortic dissection. Catheterization is not particularly useful in AR. The assessment of AR is difficult, in real life mostly semiquantitative. The patients with AR are indicated to the operation according to their symptoms and echo parameters. Drug therapy does not improve the fate of patients with significant AR. An acute AR is a serious condition mostly with urgent indication to surgery.

Recombinant Activated Factor VII Administration after Pulmonary Embolectomy: Case Report

Bleeding management in cardiac surgery could be a great challenge for the surgeon and a life-threatening moment for the patient. Despite the fact that recombinant activated factor VII is now widely accepted as a useful adjunct in the management of postcardiotomy coagulopathy, its use in the course of recent thromboembolic event is rarely described. We hereby present a case of rescue recombinant activated factor VII administration to manage a severe coagulation disorder during surgical pulmonary embolectomy performed under cardiopulmonary bypass.