Nurit Shor

The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures

The ACIST injection system is an automatic power injection device that allows for online control of injection rate and volume of contrast. Limited data is available whether this technology allows reducing use of contrast and fluoroscopy time. Accordingly, we compared the use of this system to manual injection among 450 consecutive patients who underwent diagnostic coronary angiography and/or angioplasty who were randomly assigned to either manual contrast injection (control; n = 198) or to the ACIST system (study group; n = 252). The amount of contrast, fluoroscopy and total procedural times were recorded for each patient. In the diagnostic group, the mean total amount of contrast (including wasted) was reduced by 63% when the ACIST was used compared to control (100±42 ml versus 163±56 ml; P<0.001, respectively). When only the net amount of contrast delivered to the patient was considered, the differences were smaller (20%, P = 0.004). During angioplasty, the amount of contrast was also lower in the ACIST group (206±65 versus 230±69, P = 0.008), whereas no difference were noted in net amount of contrast. Fluoroscopy time was significantly shorter in the ACIST group compared to control both during diagnostic catheterization (4.7±3.5 min versus 6.3±5.5 min, respectively; P = 0.014), and angioplasty (16.7±9.1 min versus 19.6±12.4 min, respectively; P = 0.05). Routine utilization of the ACIST system during diagnostic and interventional procedure significantly reduced the total amount of contrast media used and fluoroscopy time.

Coronary stent deployment without predilation in acute myocardial infarction : A feasible, safe, and effective technique

Direct percutaneous transcatheter revascularization (PTCR) is becoming an acceptable therapy for acute myocardial infarction (AMI). Stenting in the setting of AMI, once consid ered contraindicated, is emerging as a suitable option in this situation. Coronary stenting without predilation (SWOP) may potentially shorten the procedure and radiation time, reduce costs, and decrease procedural complications such as coronary dissection and distal embolization. It is expected to cause less vascular injury, with a reduction in the rate of in-stent restenosis. In this preliminary study the authors evaluated the feasibility of the SWOP procedure in 22 selected patients with AMI. Indications for catheter-based myocardial reperfusion were the following: extensive anterior wall MI (68%), inferior wall and right ventricular MI (23%), and inferior wall MI with contraindication for thrombolytic therapy (9%). Patients with cardiogenic shock or with contraindications for aspirin or ticlopidine were excluded. SWOP was successful in 21 attempts (95%), and final procedural success was achieved in all. Proximal or distal dissections were seen in three cases and were treated by additional three stents. Thrombolysis in myocardial infarction (TIMI) flow 3 was restored in all patients. There were no distal embolizations, side branch occlusions, coronary perforations, procedure-related emergency bypass operations, or deaths. It is concluded that in selected patients with AMI, coronary artery stenting without predilation is feasible and safe and does not introduce additional risk to the patients.

Effectiveness of coronary stent deployment without predilation.

The feasibility of coronary stenting without predilation is demonstrated in 240 patients. In all, 249 stents were placed. Primary implantation was successful in 93% of cases. In 17 lesions the stents could not be advanced through the stenotic lesion. The unexpanded stents were removed through the guiding catheter, and stenting was performed after prediction. Minor complications (side branch compromise and intimal dissection), which were successfully treated, occurred in 26 patients (10.6%).

Acute and intermediate‐term results of percutaneous coronary stenting in octogenarian patients

BACKGROUND: Percutaneous coronary intervention (PCI) in octogenarian patients has been associated with increased cardiovascular morbidity and mortality. This study aimed to assess acute and intermediate‐term clinical outcomes among octogenarians undergoing PCI. METHODS: The authors identified 97 consecutive patients aged ≥80 years who underwent PCI using stents between November 2000 and February 2002 at their institution. The patients were divided into three groups according to clinical presentation: (1) acute myocardial infarction (AMI, n = 31); (2) unstable angina pectoris (UAP, n = 28); and (3) stable angina pectoris (SAP, n = 38). Procedural data, and in‐hospital and six‐month clinical outcomes were obtained and adjudicated for all patients. RESULTS: Overall mean age was 84 ± 3 years, 67% of patients were males and 73% had multivessel coronary disease. In‐hospital outcomes varied according to clinical presentation: procedural success was 78% in AMI patients (including shock patients), 93% in UAP, and 95% in SAP patients. Likewise, hospital mortality was 26% in AMI, 3.6% in UAP, and 0% in SAP patients (p = 0.0003). Among AMI patients, hospital mortality was extremely high in patients with cardiogenic shock (67% versus 4.6% in AMI without shock, p < 0.0001). Cumulative event rate at six months also varied according to clinical presentation: mortality/MI and target vessel revascularization (TVR) rates were 29%, 3.6%, and 0% in AMI, 7.1%, 7.4%, and 11% in UAP and 0%, 5.3%, and 7.9% in SAP patients. Multivariate analysis identified cardiogenic shock as the most powerful risk factor for predicting mortality (odds ratio = 42, p = 0.03). CONCLUSIONS: These results show that clinically stable octogenarian patients undergoing PCI have favorable procedural and intermediate‐term prognosis. In contrast, cardiogenic shock has a profound negative prognostic impact on octogenarians despite ‘aggressive’ PCI attempts. (Int J Cardiovasc Intervent 2003; 5: 195–199)

Coronary Stent Deployment Without Predilation: Prevention of Complications of Venous Graft Angioplasty

Saphenous vein graft stenting without predilation may potentially decrease procedural complications such as distal embolization and no-reflow phenomenon. In this report the authors describe the deployment of stents (three Wallstents, one Palmaz-Schatz, one Multilink, and one NIR) without predilation in five patients with unstable angina pectoris due to high-grade stenosis in old saphenous vein grafts. Stent deployment was successful in all patients without procedure-related complications. Stenting without predilation appears to be feasible in old bypass grafts with significant stenosis. The potential of this new stenting technique to reduce the risk of stenting complications should be tested by a randomized trial.

Characteristics and clinical outcomes of patients with cardiogenic shock complicating acute myocardial infarction treated by emergent coronary angioplasty

BACKGROUND: Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines. AIM: To evaluate the in‐hospital and 30‐day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS. METHODS AND RESULTS: Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co‐morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In‐hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non‐cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48 hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age ⩾75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0–1.24, P = 0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95–1.0, P = 0.05), were independent predictors of all cause mortality at 30 days. CONCLUSION: Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.

The impact of adjunctive eptifibatide therapy with percutaneous coronary intervention for acute myocardial infarction

The role of small molecules anti‐glycoprotein (GP) IIb/IIIa pharmacotherapy during acute myocardial infarction (AMI) has not been established. The purpose of our study was to evaluate the clinical outcomes of patients sustaining AMI who underwent emergent percutaneous coronary intervention (PCI) and who were distinguished by the use of the anti‐GP IIb/IIIa agent eptifibatide. We studied a consecutive group of 216 patients who underwent PCI for acute ST‐elevation myocardial infarction and compared the outcomes of patients who received eptifibatide just prior and following the procedure (n = 167) to those who were not on anti GP IIb/IIIa inhibitors (n = 49). On average, patients treated using eptifibatide were younger and were more likely to be men, hypertensive, and smokers. The eptifibatide treated patients were less likely to have diabetes and renal failure and had worse angiographic characteristics. There were no significant differences between the groups in any of the clinical outcomes, including the composite endpoint (e.g. death, MI, repeat revascularization) and the rate of sub‐acute stent thrombosis. Nonetheless, there was a non‐significant trend towards lower 30 day mortality in the eptifibatide group (4.8% versus 12%, P = 0.09). We concluded that in our comparative study of periprocedural administration of eptifibatide during emergent AMI angioplasty, there was a non‐significant trend towards better short‐term survival among eptifibatide treated patients although the composite endpoint did not differ between patients distinguished by the use of anti GP IIb/IIIa small molecule pharmacotherapy.

Acute and intermediate‐term clinical outcomes following Heparin coated BX coronary stent implantation in patients with thrombus containing lesions

BACKGROUND: Coronary stenting in acute coronary syndromes might be associated with increased procedural complications and stent thrombosis risk. Heparin‐coated stent (HCS) may improve procedural outcomes when treating these high‐risk lesions. The purpose of this study was to determine the safety and efficacy of HCS in patients with acute coronary syndromes and thrombus containing lesions. METHODS: Between January 2001 and January 2002, 49 patients (42 male) with thrombus containing lesions (32 sustained acute myocardial infarction) received HC BX stents (HepaCoat) at our hospital. Procedural, hospital and six‐month outcomes and quantitative angiographic analysis data were obtained from all patients. RESULTS: The mean age of patients was 58 ± 14 years, 45% had multi‐vessel disease and 24% were diabetics. Fifteen patients (31%) received a second HCS for sub‐optimal results or threatened closure. Procedural success was achieved in 94% of patients. The mean stent diameter and length was 3.2 ± 0.2 mm and 18.2 ± 7.4 mm. The mean TIMI flow increased from 1.3 ± 1.3 to 2.9 ± 0.3 and the mean diameter stenosis before and after intervention was 84 ± 21% and 12 ± 14%. In‐hospital and 30‐day follow‐up were eventually without occurrence of death, myocardial infarction, stent thrombosis, coronary bypass. At six‐months follow‐up, cardiac event‐free survival was 89.8%, target vessel revascularization was 6.1 and 90% of patients were free of angina. CONCLUSION: In this series of patients with acute ischemic syndromes associated with visible thrombus, the use of HCS resulted in (1) favorable procedural and six‐month outcomes, (2) no incidence of stent thrombosis, and (3) overall good cardiac prognosis at six‐month follow‐up. (Int J Cardiovasc Intervent 2004; 2: 77–81)

Coronary Wallstent Implantation by the Transradial Artery Approach A Case Report

The authors report the implantation of two wallstents in a patient by use of the transra dial artery approach. This approach for coronary wallstent implantation allows for intensive anticoagulation therapy with less risk of bleeding.