Mohaned Egred

Cardiopulmonary exercise testing and its application

Cardiopulmonary exercise testing CPET has become an important clinical tool to evaluate exercise capacity and predict outcome in patients with heart failure and other cardiac conditions. It provides assessment of the integrative exercise responses involving the pulmonary, cardiovascular and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. CPET is being used increasingly in a wide spectrum of clinical applications for evaluation of undiagnosed exercise intolerance and for objective determination of functional capacity and impairment. This review focuses on the exercise physiology and physiological basis for functional exercise testing and discusses the methodology, indications, contraindications and interpretation of CPET in normal people and in patients with heart failure.

Impact of thrombus aspiration during primary percutaneous coronary intervention on mortality in ST-segment elevation myocardial infarction

AIMS To assess the impact of thrombus aspiration during primary percutaneous coronary intervention (PPCI) on the mortality of patients with ST-elevation myocardial infarction (STEMI) patients. METHODS AND RESULTS Retrospective analysis of prospectively collected data on 2567 consecutive PPCI-treated STEMI patients between 2008 and 2011. Cox proportional hazard models and multiple logistic regression analysis were used to adjust for known covariates. Thrombectomy was performed in 1095 patients (42.7%). Post-PPCI thrombolysis in myocardial infarction 3 flow was more frequently achieved in the thrombectomy group [adjusted odds ratio (OR); 1.92, 95% confidence interval (CI): 1.34-2.76, P = 0.0004]. Overall in-hospital and longer term (mean follow-up 9.9 months) mortality rates were 4.5 and 9.0%, respectively. Thrombectomy was associated with a significant reduction in in-hospital (adjusted OR: 0.51, 95% CI: 0.29-0.93, P = 0.027) and longer term mortality [adjusted hazard ratio (HR): 0.69, 95% CI: 0.48-0.96, P = 0.028]. With propensity weighting, the adjusted HR for longer term mortality for thrombectomy was 0.43 (95% CI: 0.19-0.97; P = 0.042). The association between thrombectomy and reduced longer term mortality was only significant in those with a total ischaemic time ≤180min (P = 0.001) but not in patients with a total ischaemic time >180min (P = 0.99). CONCLUSION This study of real-world, unselected STEMI patients demonstrates that thrombus aspiration during PPCI is associated with a significant reduction in mortality, especially in those with a short total ischaemic time. These findings support the use of thrombectomy during PPCI in this group of patients.

Nicorandil may be associated with gastrointestinal ulceration

Nicorandil (Ikorel; Rhone-Poulenc Rorer, Guildford) is associated with mouth and anal ulcers,1–4 but we are not aware of any previous reports of association with gastrointestinal ulceration. A 69 year old woman had had percutaneous coronary intervention and a stent inserted into her left anterior descending artery two years before presentation. She had recurrent angina, and her general practitioner increased her dose of nicorandil to 30 mg twice a …

T lymphocytes and fractalkine contribute to myocardial ischemia/reperfusion injury in patients

BACKGROUND Lymphocytes contribute to ischemia/reperfusion (I/R) injury in several organ systems, but their relevance in ST elevation myocardial infarction (STEMI) is unknown. Our goal was to characterize lymphocyte dynamics in individuals after primary percutaneous coronary intervention (PPCI), assess the prognostic relevance of these cells, and explore mechanisms of lymphocyte-associated injury. METHODS Lymphocyte counts were retrospectively analyzed in 1,377 STEMI patients, and the prognostic relevance of post-PPCI lymphopenia was assessed by Cox proportional hazards regression. Blood from 59 prospectively recruited STEMI patients undergoing PPCI was sampled, and leukocyte subpopulations were quantified. Microvascular obstruction (MVO), a component of I/R injury, was assessed using MRI. RESULTS In the retrospective cohort, lymphopenia was associated with a lower rate of survival at 3 years (82.8% vs. 96.3%, lowest vs. highest tertile; hazard ratio 2.42). In the prospective cohort, lymphocyte counts fell 90 minutes after reperfusion, primarily due to loss of T cells. CD8+ T cells decreased more than CD4+ T cells, and effector subsets exhibited the largest decline. The early decrease in effector T cell levels was greater in individuals that developed substantial MVO. The drop in T cell subsets correlated with expression of the fractalkine receptor CX3CR1 (r2 = 0.99, P = 0.006). Serum fractalkine concentration peaked at 90 minutes after reperfusion, coinciding with the T cell count nadir. CONCLUSIONS Lymphopenia following PPCI is associated with poor prognosis. Our data suggest that fractalkine contributes to lymphocyte shifts, which may influence development of MVO through the action of effector T cells. TRIAL REGISTRATION Not applicable. FUNDING British Heart Foundation (FS/12/31/29533) and National Institute of Health Research (NIHR) Newcastle Biomedical Research Centre.

GuideLiner, a child-in-a-mother catheter for successful retrieval of an entrapped rotablator burr†

Entrapment of the rotablator burr within heavily calcified lesions is a recognized complication, which usually necessitates sternotomy and open surgical intervention to retrieve the trapped burr. In some cases, the trapped burr can be retrieved using simple traction, but this is potentially hazardous with possible trauma and perforation of the vessel. Passing a wire alongside the trapped burr with ballooning to free the burr can be attempted. We describe a novel technique to remove a trapped rotablator burr from a heavily calcified lesion using counter‐traction with a GuideLiner, child‐in‐a‐mother catheter, which successfully removed the entrapped burr without the need for surgery when simple traction alone had been ineffective.

Feasibility and Safety of 7‐Fr Radial Approach for Complex PCI

BACKGROUND Although the transradial approach is well established for percutaneous coronary intervention (PCI), it is perceived as being not suitable for 7-Fr complex PCI, which is traditionally performed from the femoral approach. OBJECTIVE To evaluate the procedural success and outcome of 7-Fr transradial complex PCI. METHOD Retrospective review and analysis of all patients undergoing 7-Fr transradial complex PCI from August 2008 until October 2010 in a tertiary cardiac center setting. RESULTS Transradial 7-Fr complex PCI was performed in 77 patients after manual assessment of the radial pulse and size. The radial access was obtained successfully in all 77 patients. The age range was 39-88 years with 16 patients (23.4%) over 80 years of age and 14 females (18.1%). There were 30 left main stem PCI (39%), 31 (40.2%) chronic total occlusion (CTO), and 13 (16.8%) rotational atherectomy. Intravascular ultrasound (IVUS) was used in 17 (22%) cases, cutting balloons in 16 (20.7%), and LASER PCI in 2 (2.6%) cases. Procedural success was achieved in 76 of 77 (98.7%) with 1 failure to canalize a CTO. There was 1 patient with type I coronary perforation managed conservatively. There was no in-hospital mortality. All radial pulses were present 6 hours after the procedure and only 23 patients were seen for follow-up, and all had patent radial artery 4-6 months following the procedure. CONCLUSION A 7-Fr transradial complex PCI is feasible and can be carried out safely and successfully with excellent results. In suitable patients, male or female, complex PCI need not always be performed from the femoral approach. Background: Although the transradial approach is well established for percutaneous coronary intervention (PCI), it is perceived as being not suitable for 7-Fr complex PCI, which is traditionally performed from the femoral approach. Objective: To evaluate the procedural success and outcome of 7-Fr transradial complex PCI. Method: Retrospective review and analysis of all patients undergoing 7-Fr transradial complex PCI from August 2008 until October 2010 in a tertiary cardiac center setting. Results: Transradial 7-Fr complex PCI was performed in 77 patients after manual assessment of the radial pulse and size. The radial access was obtained successfully in all 77 patients. The age range was 39–88 years with 16 patients (23.4%) over 80 years of age and 14 females (18.1%). There were 30 left main stem PCI (39%), 31 (40.2%) chronic total occlusion (CTO), and 13 (16.8%) rotational atherectomy. Intravascular ultrasound (IVUS) was used in 17 (22%) cases, cutting balloons in 16 (20.7%), and LASER PCI in 2 (2.6%) cases. Procedural success was achieved in 76 of 77 (98.7%) with 1 failure to canalize a CTO. There was 1 patient with type I coronary perforation managed conservatively. There was no in-hospital mortality. All radial pulses were present 6 hours after the procedure and only 23 patients were seen for follow-up, and all had patent radial artery 4–6 months following the procedure. Conclusion: A 7-Fr transradial complex PCI is feasible and can be carried out safely and successfully with excellent results. In suitable patients, male or female, complex PCI need not always be performed from the femoral approach. (J Interven Cardiol 2011;24:383–388)

Mortality outcome of out-of-hours primary percutaneous coronary intervention in the current era

AIMS To assess the impact of the time of primary percutaneous coronary intervention (PPCI) on in-hospital and long-term all-cause mortality in ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS The study retrospectively analyses the prospectively collected data on 2571 consecutive PPCI-treated STEMI patients between March 2008 and June 2011. Of these, 1036 patients (40.3%) underwent PPCI during a weekday between 08:00 and 18:00 (routine-hours group) and 1535 patients (59.7%) underwent PPCI on a weekday between 18:00 and 08:00 or a weekend (out-of-hours group). Compared with the routine-hours group, the out-of-hours group had a lower mean age, fewer patients with previous angina, longer call-to-hospital time, and fewer multivessel PCI. The overall in-hospital mortality rate was 4.5% with no significant difference [0.2%, 95% confidence interval (CI): -1.4 to 1.9%] between the routine-hours group (4.3%) and the out-of-hours group (4.6%) (adjusted odds ratio: 1.33, 95% CI: 0.73-2.40, P = 0.35). During a mean follow-up period of 560 days, 295 patients (11.5%) died, 12.2% in the routine-hours group and 11.0% in the out-of-hours group (difference of -0.1%, 95% CI: -0.4 to 0.2%). In the multiple Cox proportional hazards model, there was no difference in mortality between the two groups (adjusted hazard ratio: 1.09, 95% CI: 0.82-1.46, P = 0.57). Similarly, no increase in mortality was seen in patients who underwent PPCI later at night (22:00-06:00). CONCLUSION This study of real-world, unselected STEMI patients demonstrates that in a large, well-staffed centre, PPCI outside routine-working hours is safe with no difference in outcome of in-hospital and long-term mortality compared with PPCI during routine-working hours.

Shock-index as a novel predictor of long-term outcome following primary percutaneous coronary intervention

Early identification of higher risk patients presenting with ST-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI) will allow a more aggressive strategy and approach. The aim of this study was to evaluate the shock index (ratio of heart rate/systolic blood pressure on admission) as a predictor of mortality post PPCI in addition to other parameters. Methods: We analysed prospectively collected data on 3049 STEMI patients treated with PPCI in a large tertiary centre between March 2008–December 2011, out of which 2424 patients were aged up to 75 years (young) and 625 patients were older than 75 years (elderly). Results: Compared to younger patients, in-hospital mortality rates were four-fold higher in the elderly (11.5% vs 2.8%, odds ratio (OR) 3.5, 95% confidence interval (CI) 2.0–5.9). Cardiogenic shock (OR 8.7 (5.1–14.6)), non-TIMI3 (Thrombosis In Myocardial Infarction) flow post percutaneous coronary intervention (PCI) (OR 5.0 (3.1–7.9)), age over 75 (OR 3.5 (2.3–5.3)) and a positive shock index pre PPCI (OR 3.5 (2.0–5.9)) were the strongest independent predictors of in-hospital mortality. For long-term outcome (median follow-up period 454 days) we excluded 141 (4.6%) patients that died during the initial hospital stay. Previous angina (hazard ratio (HR) 2.9), and previous cerebrovascular events (HR 3.7) were predictors of adverse outcome in the younger patients, while previous myocardial infarction (HR 2.0) and a positive shock index (HR 2.3) were predictors in the elderly. Cardiogenic shock prior to PPCI was not able to predict long-term outcome for in-hospital survivors. Conclusion: Mortality rates following PPCI were higher in elderly patients although remained acceptable. Invasively measured shock index before PPCI is the strongest independent predictor of long-term outcome in elderly patients. In addition, predictors of in-hospital mortality were similar across different age groups but differed significantly in relation to longer-term mortality.

Impact of proctoring on success rates for percutaneous revascularisation of coronary chronic total occlusions.

Objective To assess the impact of proctoring for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in six UK centres. Methods We retrospectively analysed 587 CTO procedures from six UK centres and compared success rates of operators who had received proctorship with success rates of the same operators before proctorship (pre-proctored) and operators in the same institutions who had not been proctored (non-proctored). There were 232 patients in the pre-proctored/non-proctored group and 355 patients in the post-proctored group. Complexity was assessed by calculating the Japanese CTO (JCTO) score for each case. Results CTO PCI success was greater in the post-proctored compared with the pre-proctored/non-proctored group (77.5% vs 62.1%, p<0.0001). In more complex cases where JCTO≥2, the difference in success was greater (70.7% vs 49.5%, p=0.0003). After proctoring, there was an increase in CTO PCI activity in centres from 2.5% to 3.5%, p<0.0001 (as a proportion of total PCI), and the proportion of very difficult cases with JCTO score ≥3 increased from 15.3% (35/229) to 29.7% (105/354), p<0.0001. Conclusions Proctoring resulted in an increase in procedural success for CTO PCI, an increase in complex CTO PCI and an increase in total CTO PCI activity. Proctoring may be a valuable way to improve access to CTO PCI and the likelihood of procedural success.

Myocardial Ischemia and Reperfusion Leads to Transient CD8 Immune Deficiency and Accelerated Immunosenescence in CMV-Seropositive Patients

Rationale: There is mounting evidence of a higher incidence of coronary heart disease in cytomegalovirus-seropositive individuals. Objective: The aim of this study was to investigate whether acute myocardial infarction triggers an inflammatory T-cell response that might lead to accelerated immunosenescence in cytomegalovirus-seropositive patients. Methods and Results: Thirty-four patients with acute myocardial infarction undergoing primary percutaneous coronary intervention were longitudinally studied within 3 months after reperfusion (Cohort A). In addition, 54 patients with acute myocardial infarction and chronic myocardial infarction were analyzed in a cross-sectional study (Cohort B). Cytomegalovirus-seropositive patients demonstrated a greater fall in the concentration of terminally differentiated CD8 effector memory T cells (TEMRA) in peripheral blood during the first 30 minutes of reperfusion compared with cytomegalovirus-seronegative patients (−192 versus −63 cells/&mgr;L; P=0.008), correlating with the expression of programmed cell death-1 before primary percutaneous coronary intervention (r=0.8; P=0.0002). A significant proportion of TEMRA cells remained depleted for ≥3 months in cytomegalovirus-seropositive patients. Using high-throughput 13-parameter flow cytometry and human leukocyte antigen class I cytomegalovirus-specific dextramers, we confirmed an acute and persistent depletion of terminally differentiated TEMRA and cytomegalovirus-specific CD8+ cells in cytomegalovirus-seropositive patients. Long-term reconstitution of the TEMRA pool in chronic cytomegalovirus-seropositive postmyocardial infarction patients was associated with signs of terminal differentiation including an increase in killer cell lectin-like receptor subfamily G member 1 and shorter telomere length in CD8+ T cells (2225 versus 3397 bp; P<0.001). Conclusions: Myocardial ischemia and reperfusion in cytomegalovirus-seropositive patients undergoing primary percutaneous coronary intervention leads to acute loss of antigen-specific, terminally differentiated CD8 T cells, possibly through programmed cell death-1–dependent programmed cell death. Our results suggest that acute myocardial infarction and reperfusion accelerate immunosenescence in cytomegalovirus-seropositive patients.