Pietro Pascotto

Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction

OBJECTIVES We sought to evaluate the effects of mechanical thrombectomy on myocardial reperfusion during direct angioplasty for acute myocardial infarction (AMI). BACKGROUND Embolization of thrombus and plaque debris may occur during direct angioplasty for AMI. This may lead to distal vessel or side branch occlusion and to obstructions in the microvascular system, resulting in impaired myocardial reperfusion. Mechanical thrombectomy is used to reduce distal embolization. METHODS Ninety-two patients with AMI and angiographic evidence of intraluminal thrombus were randomized to either intracoronary thrombectomy followed by stenting or to a conventional strategy of stenting. Thrombectomy was performed using the X-Sizer catheter (EndiCOR Inc., San Clemente, California). Myocardial reperfusion was assessed by myocardial blush and ST resolution. RESULTS Postprocedure Thrombolysis in Myocardial Infarction-3 flow was not different between groups (93.5% vs. 95.7%, p = 0.39). Myocardial blush-3 was observed in 71.7% of patients undergoing thrombectomy and in 36.9% of patients undergoing conventional strategy (p = 0.006). ST-segment resolution >or=50% occurred more often in patients undergoing thrombectomy (82.6% vs. 52.2%, p = 0.001). By multivariate analysis, adjunctive thrombectomy was an independent predictor of blush-3 (odds ratio, 3.27; 95% confidence interval, 1.06 to 10.05; p = 0.039). CONCLUSIONS Intracoronary thrombectomy as adjunct to stenting during direct angioplasty for AMI improves myocardial reperfusion as assessed by myocardial blush and ST resolution.

Predictive Value of Early Atrial Tachyarrhythmias Recurrence After Circumferential Anatomical Pulmonary Vein Ablation

Objective: Radiofrequency (RF) ablation at the ostia of the pulmonary veins (PVs) to cure atrial fibrillation (AF) is often followed by early AF recurrence. The aims of this study were to determine the rate of early atrial tachyarrhythmia as recurrence after circumferential anatomical PV ablation; to evaluate whether the early recurrence of atrial tachyarrhythmias correlates with the long‐term outcome of ablation; and to identify the predictors of early atrial tachyarrhythmias relapse.

Long term follow up of radiofrequency catheter ablation of atrial flutter: clinical course and predictors of atrial fibrillation occurrence

Objectives: To evaluate the time to onset and the predictors of atrial fibrillation (AF) during long term follow up of patients with typical atrial flutter (AFL) treated with transisthmic ablation. Design: Prospective multicentre study. Methods and results: 383 patients (75.4% men, mean (SD) age 61.7 (11.1) years) who underwent transisthmic ablation for typical AFL were investigated. In 239 patients (62.4%) AF was present before ablation. Ablation proved successful in 367 patients (95.8%). During a mean (SD) follow up of 20.5 (12.4) months, 41.5% of patients reported AF. The cumulative probability of postablation AF increased continuously as time passed: it was 22% at six months, 36% at one year, 50% at two years, 58% at three years, and 63% at four years. Conclusions: AF occurred in a large proportion of patients after transisthmic catheter ablation of typical AFL. The occurrence of AF was progressive during follow up. Preablation AF, age < 65 years, and left atrial size > 50 mm are associated with postablation AF occurrence.

Integration of three-dimensional left atrial magnetic resonance images into a real-time electroanatomic mapping system: validation of a registration method.

Background: The alignment of three‐dimensional (3D) left atrial images acquired by magnetic resonance (MR) with the anatomical information yielded by 3D mapping systems is one of the most critical issues in image integration techniques for catheter ablation of atrial fibrillation (AF). We assessed the accuracy of a simplified method of superimposing 3D MR left atrial images on real‐time left atrial electroanatomic maps (registration).

Antibiotic prophylaxis with a single dose of cefazolin during pacemaker implantation : Incidence of long-term infective complications

Objective: Systemic and localized infections related to permanent pacemaker implantation are not common, but are serious and potentially life‐threatening complications. The aims of this prospective observational study were: (1) to assess the safety and long‐term efficacy of a simplified scheme of antibiotic prophylaxis, and (2) to identify the predictors of long‐term infective complications, in patients undergoing pacemaker implantation or replacement.

Long-Term Outcome of Right and Left Atrial Radiofrequency Ablation in Patients with Persistent Atrial Fibrillation

Objectives: To investigate the clinical outcome of right and left atrial radiofrequency ablation after the first 12 months in patients with drug‐refractory persistent atrial fibrillation (AF), and to identify predictors of long‐term success.

Different Clinical Courses and Predictors of Atrial Fibrillation Occurrence After Transisthmic Ablation in Patients with Preablation Lone Atrial Flutter, Coexistent Atrial Fibrillation, and Drug Induced Atrial Flutter

The aim of this prospective study was to compare the long‐term follow‐up after transisthmic ablation of patients with preablation lone atrial flutter, coexistent AF, and drug induced atrial flutter to determine if postablation AF followed a different clinical course and displayed different predictors in these groups. The study evaluated 357 patients who underwent transisthmic ablation for typical atrial flutter. These were divided into four groups according to their preablation history. Group A included patients with typical atrial flutter and without preablation AF (n = 120, 33.6%). Group B included patients with preablation AF and spontaneous atrial flutter (n = 132, 37.0%). Group C patients had preablation AF and atrial flutter induced by treatment with IC drugs (propafenone or flecainide) (n = 63, 17.6%) Group D included patients with preablation AF and atrial flutter induced by treatment with amiodarone (n = 42, 11.8%). During a mean follow‐up of 15.2 ‡ 10.6 months (range 6–55 months) AF occurred more frequently in groups B (56.1%) and C (57.1%) patients than in groups A (20.8%, P < 0.0001) and D (31.0%, P < 0.0001) patients. The results of multivariate analysis revealed that different clinical and echocardiographical variables were correlated with postablation AF occurrence in the different groups. Patients with atrial flutter induced by amiodarone have a significantly lower risk of postablation AF than patients with spontaneous atrial flutter and AF, and those with atrial flutter induced by IC drugs. Different clinical and echocardiographical variables predict postablation AF occurrence in different subgroups of patients.

Feasibility of Pulmonary Vein Ostia Radiofrequency Ablation in Patients with Atrial Fibrillation: A Multicenter Study (CACAF Pilot Study)

STABILE, G., et al.: Feasibility of Pulmonary Vein Ostia Radiofrequency Ablation in Patients with Atrial Fibrillation: A Multicenter Study (CACAF Pilot Study) Radiofrequency (RF) catheter ablation has been proposed as a treatment of atrial fibrillation (AF). Several approaches have been reported and success rates have been dependent on procedural volume and operators experience. This is the first report of a multicenter study of RF ablation of AF. We treated 44 men and 25 women with paroxysmal (n = 40) or persistent (n = 29) , drug refractory AF. Circular pulmonary vein (PV) ostial lesions were deployed transseptally, during sinus rhythm(n = 42)or AF(n = 26), under three‐dimensional electroanatomic guidance. Cavo‐tricuspid isthmus ablation was performed in 27 (40%) patients. The mean procedure time was215 ± 76minutes (93–530), mean fluoroscopic exposure32 ± 14minutes (12–79), and mean number of RF pulses per patient56 ± 29(18–166). The mean numbers of separate PV ostia mapped and isolated per patient were3.9 ± 0.5, and3.8 ± 0.7, respectively. Major complications were observed in 3 (4%) patients, including pericardial effusion, transient ischemic attack, and tamponade. At 1‐month follow‐up, 21 of 68 (31%) patients had had AF recurrences, of whom 8 required electrical cardioversion. After the first month, over a mean period of9 ± 3(5–14) months, 57 (84%) patients remained free of atrial arrhythmias. RF ablation of AF by circumferential PV ostial ablation is feasible with a high short‐term success rate. While the procedure and fluoroscopic exposure duration were short, the incidence of major cardiac complications was not negligible. (PACE 2003; 26[Pt. II]:284–287)

Percutaneous interventions in patients with acute ischemic stroke related to obstructive atherosclerotic disease or dissection of the extracranial carotid artery.

Purpose: To determine the safety, feasibility, and efficacy of carotid artery stenting (CAS) in patients with acute stroke who underwent angioplasty of the extracranial internal carotid artery (ICA). Methods: Patients were eligible for CAS if they presented within 6 hours of symptom onset and had a National Institutes of Health Stroke Scale (NIHSS) score >4. The records of all 18 acute stroke patients (11 men; mean age 68.3±14.3 years) who underwent endovascular intervention in the stroke-related extracranial ICA between May 2003 and February 2006 were reviewed. Fourteen (77.8%) had atheromatous obstructions and 4 (22.2%) had dissection of the extracranial ICA. Major adverse cerebral and cardiac events (MACCEs) and neurological status, including NIHSS and the modified Rankin Scale (mRS) scores, were recorded for all patients. Results: Successful revascularization was achieved in 83.3% (15/18) of the patients. Cerebral protection devices were applied successfully in 13 (72.2%). At discharge, a neurological improvement (NIHSS reduction ≥4) was observed in 77.8% (14/18) of patients. The clinical success rate was 72.2% (13/18). The median NIHSS was 8.5 on admission versus 4.5 at discharge (p<0.01). The 30-day death and stroke rate was 11.1%. During the 14.6±9.3-month followup, the MACCE and the death/stroke rates were 33.3% and 27.8%, respectively. The median mRS scores at 30 days and at midterm followup were 1 and 2.5, respectively (p=NS). Conclusion: Endovascular revascularization of the extracranial ICA in patients with acute ischemic stroke is associated with high procedural success rates and favorable midterm outcome.

Prevalence of conduction delay of the right atrium in patients with SSS: Implications for pacing site selection

Objectives To evaluate the prevalence of severe right atrial conduction delay in patients with sinus node dysfunction (SND) and atrial fibrillation (AF) and the effects of pacing in the right atrial appendage (RAA) and in the inter-atrial septum (IAS). Methods Forty-two patients (15 male, 72 ± 7 years) underwent electrophysiologic study to measure the difference between the conduction time from RAA to coronary sinus ostium during stimulation at 600 ms and after extrastimulus (ΔCTos). Patients were classified as group A if ΔCTos > 60 ms and group B if < 60 ms. Each Group was randomized to RAA/IAS pacing and algorithms ON/OFF. Results Fifteen patients (36%, group A) had ΔCTos = 76 ± 11 ms and 27 patients (64%, group B) had ΔCTos = 36 ± 20 ms. Twenty-two patients were paced at the RAA and 20 at the IAS. During the study, no AF recurrences were reported in 11 of 42 (26%) patients, independently of RAA or IAS pacing. Patients from group A and RAA pacing had 0.79 ± 0.81 episodes of AF/day during DDD, which increased to 1.52 ± 1.41 episodes of AF/day during DDDR + Alg (P = 0.046). Those with IAS pacing had 0.5 ± 0.24 episodes of AF/day during DDD, which decreased to 0.06 ± 0.08 episodes of AF/day during DDDR + Alg (P = 0.06). In group B, no differences were reported between pacing sites and pacing modes. Conclusions Severe right atrial conduction delay is present in one-third of patients with SND and AF: continuous pacing at the IAS is superior to RAA for AF recurrences. In patients without severe conduction delay, no differences between pacing site or mode were observed.