Philoktimon Plastaras

Recording of quality indicators in the management of acute coronary syndromes: Predictors of reperfusion times

Background: There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion. Methods: Single-centre, retrospective study of all consecutive patients admitted for primary PCI from June 2009 to October 2010. Door-to-artery (D2A) and Door-to-balloon (D2B) times were calculated from times noted by cathlab. nurses and compared with times from digital recordings of PCI procedures. Predictors of time to reperfusion were identified by logistic regression. Results: 300 patients were included. Median (interquartile range) D2B time recorded by cathlab. nurses (D2B-CN) was 35.5 (24; 52) minutes, 32 (20; 51) min from PCI recordings (D2B-PCI). Average difference between D2B-CN and D2B-PCI was 6.2 min (P < 0.0001). Concordance of percent patients with a D2B time < 90 and < 45 min was mediocre, kappa coefficients 0.44 (95% CI: 0.10–0.79) and 0.68 (95% CI: 0.57–0.80) respectively. By multivariate analysis, older patients had longest D2A times (P = 0.04); patients with longest D2A and D2B times more frequently had elevated creatinine (P = 0.002 (D2A), P = 0.0003 (D2B). Organizational aspects did not influence reperfusion times. Conclusion: Data regarding reperfusion times are unreliable when recorded by nurses. Age and creatinine levels are significantly associated with reperfusion times, whereas organizational aspects are not.

CAN THE “BLEEDING ACADEMIC RESEARCH CONSORTIUM” (BARC) CLASSIFICATION BE APPLIED TO PULMONARY EMBOLISM?

Study Aim: To investigate whether the BARC classification of bleeding events is applicable in the context of PE, where no standard definition exists Anticoagulant and thrombolytic agents form the cornerstone of PE management, but their use is associated with an increased risk of bleeding. Bleeding complications are associated with an increased risk of subsequent adverse outcomes in pulmonary embolism (PE). The “Bleeding Academic Research Consortium” (BARC) developed a classification of bleeding events combining laboratory and clinical parameters, but this classification was developed in ACS patients, and its applicability to other settings remains unknown.

013: Association between inflammatory markers, mean platelet volume and traditional risk factors in patients with documented coronary artery spasm

Objectives Coronary artery spasm is an important physiopathological mechanism in some forms of myocardial ischemic disease. Increased levels of inflammatory markers and mean platelet volume (MPV) are associated with increased risk thromboembolism, but the relationship between these parameters and coronary artery spasm is unclear. Methods During coronary angiography, iv methylergometrin was injected to 345 patients with chest pain and normal coronary angiograms to provoke coronary artery spasm. Pts were divided into 2 groups according to results: spasm group (60 pts) and non-spasm group (285 pts). We compared between groups: 1) inflammatory markers including C-reactive protein (CRP), white blood cells (WBC), polymorphonuclear neutrophils (PMN), monocytes (MO), and lymphocytes (LY); 2) hemostasis markers including mean platelet volume (MPV), platelet count, fibrinogen (FIB) and D-Dimers (DD); 3) traditional risk factors for vascular disease, ie. hyperlipidemia, triglycerides (TG), total cholesterol (TC), LDL and HDL cholesterol (LDL-C, HDL-C) and uric acid (UA). Results Compared with females, more males with chest pain suffered spasm during the provocation test (23.56% vs 11.11%, p 0.05). Serum levels of CRP and blood counts of PMN and MO were signicantly higher in the spasm group (P Conclusions Inflammation may contribute to pathogenesis of coronary artery spasm. Smoking, PMN count and MO count appear to be clinical risk factors for coronary artery spasm. Conversely, spasm does not seem to be associated with abnormalities in thrombogenesis.

006: Impact of successful thrombus retrieval during primary percutaneous coronary intervention with thrombus aspiration on the infarct size and microvascular obstruction: Insight from contrast-enhanced mag

Background hromboaspiration (TA) during primary percutaneous intervention (PPCI) is effective in opening the infarct-related artery in patients with ST-segment elevation myocardial infarction (STEMI), leading to better reperfusion and improved outcome. However, the effect of positive macroscopic efficiency of TA remains unknown. We aimed to evaluate the impact of positive thrombus retrieval during PPCI with manual TA on infarct size (IS) and microvascular obstruction (MVO) as assessed by contrast-enhanced magnetic resonance imaging (CE-MRI) in a subset of patients with STEMI. Methods Inclusion criteria were patients aged Results 88patients were enrolled, mean age 55±10years; 43.1% in the positive TA group. Main results are presented in the table. Clinical and procedural characteristics (90-min total ischemic time, ST-segment resolution, post-procedural TIMI flow grade and post-stenting myocardial blush grade, and peak troponin) did not differ significantly between groups. Independent predictors of final IS were: positive TA (OR 0.34, 95%CI 0.03-0.71), MVO (OR 1.75, 95%CI 1.28-0.71) and IS at 5days (OR 2.06, 95%CI 1.87-3.32). Conclusion Positive thrombus retrieval during primary PPCI with manual TA in STEMI reduces MVO and in the acute phase and at 6 months and represents a powerful predictor of final infarct size. Table – Main results Negative TA (N=50) Positive TA (N+38) p MVO (%) 7.6±5.1 3.8±3.1 0.003 IS in the acute phase (%) 28.2±20.8 14.9±8.7 0.004 Final IS at 6 months (%) 22.3±19.3 12.0±8.3 0.002

166: Assessment of doubtful aortic stenosis by measuring simultaneous transaortic pressure: A pilot study with fractional flow reserve guidewire

Background Transthoracic echocardiography (TTE) is the reference technique for evaluating aortic stenosis (AS), but in certain cases, estimation of the average gradient and aortic valve area can be difficult. We aimed to assess the feasibility and utility of measuring simultaneous transaortic pressure using a fractional flow reserve (FFR) guidewire in doubtful aortic stenosis. Method Between January 2009 and December 2011, 57 patients with symptoms possibly related to severe AS that was poorly evaluated by echocardiography underwent right and left heart catheterization for assessment of aortic valve area with the Gorlin & Gorlin formula. Transaortic pressure was obtained by 2 invasive methods, namely conventional pullback method from the left ventricle (LV) towards the aorta (PM) with subsequent computerized superposition of the pressure curves, and (2) simultaneous method using a FFR wire introduced into the LV (SM). Results Reasons for inaccurate assessment by echocardiography were atrial fibrillation (75%) and/or low LV ejection fraction (38%). Results of evaluation of mean aortic valve gradient and aortic valve area are summarized in the table below. Agreement between methods (using the kappa coefficient) for severe aortic stenosis defined by an aortic-valve area Conclusions Simultaneous measurement of trans-aortic pressure using a FFR guidewire is feasible and may be an attractive and accurate method for evaluation of doubtful aortic stenosis. Table . Results SM PM TTE Mean aortic valve gradient, mmHg 30.5±14.4 23.6±9.9 28.8±8.0 p vs PM – 0.0002 p vs TTE 0.241 – – Aortic valve area, cm/m2 0.46±0.2 0.48±0.15 0.49±0.1 p vs PM 0.003 – 0.529 p vs TTE 0.074 – –

Invasive Assessment of Doubtful Aortic Stenosis by Measuring Simultaneous Transaortic Gradient With a Pressure Wire

Two-dimensional transthoracic echocardiography (2D-TTE) is the reference technique for evaluating aortic stenosis (AS) but may be unreliable in some cases. We aimed to assess whether the use of a pressure wire to measure simultaneous transaortic gradient and aortic valve area (AVA) could be helpful in patients in whom initial noninvasive evaluations were considered doubtful for AS. Fifty-seven patients (mean age 76 years; 39 men) underwent cardiac catheterization with single arterial access for assessment of AVA with the Gorlin and Gorlin formula. Transaortic pressure was obtained by 2 invasive methods: (1) conventional pullback method (PM) from the left ventricle toward the aorta and (2) simultaneous method (SM) with transaortic pressure simultaneously recorded with a 0.014-inch pressure wire introduced into the left ventricle and with a diagnostic catheter placed in the ascending aorta. Reasons for inaccurate assessment by 2D-TTE were low flow states (88%) and/or atrial fibrillation (79%). Agreement for severe AS defined by AVA <0.6 cm²/m² between SM and 2D-TTE and between SM and PM was fair, with kappa coefficients of 0.38 (95% confidence interval [CI] 0.14-0.75) and 0.36 (95% CI 0.22-0.7) respectively; agreement was poor between 2D-TTE and PM (kappa: 0.23; 95% CI 0.002-0.36). SM led to a reclassification of the severity of AS in 9 patients (15.8%) compared with 2D-TTE and in 11 patients (19.3%) compared with PM. In conclusion, invasive evaluation of doubtful AS by measuring simultaneous transaortic gradient using a pressure wire may provide an attractive method that can lead to a change in therapeutic strategy in a substantial proportion of patients.

TCT-468 Impact of Successful Thrombus Retrieval During Primary Percutaneous Coronary Intervention With Thrombus Aspiration on Infarct Size and Microvascular Obstruction: Insight From Contrast-Enhanced Magnetic Resonance Imaging

Thromboaspiration (TA) during primary percutaneous intervention (PPCI) is effective in opening the infarct-related artery in patients with ST-segment elevation myocardial infarction (STEMI), leading to better reperfusion and improved outcome. However, the effect of positive macroscopic efficiency of