R. Clugston

Left atrial appendage closure with Amplatzer cardiac plug for stroke prevention in atrial fibrillation: Initial Asia‐Pacific experience

Background: Left atrial appendage (LAA) is the main source of left atrial thrombus that causes stroke in patients with non‐valvular atrial fibrillation (NVAF). This study reported the initial safety, feasibility, and 1‐yr clinical outcomes following AMPLATZER cardiac plug (ACP) implantation in Asia‐Pacific region.Methods: Twenty NVAF patients (16 males, age 68 ± 9 yr) with high risk for developing cardioembolic stroke (CHADS2 score: 2.3 ± 1.3) and contraindications to warfarin received ACP implants from June 2009 to May 2010. Patients received general anesthesia (n = 9) or controlled propofol sedation (n = 11) and the procedures were guided by fluoroscopy and transesophageal echocardiography (TEE). Clinical follow‐up was arranged at 1 month and then every 3 months after implantation, whereas, a TEE was scheduled at 1 month upon completion of dual anti‐platelet therapy.Results: The LAA was successfully occluded in 19/20 patients (95%) at two Asian centers. One procedure was abandoned because of catheter‐related thrombus formation. Other complications included coronary artery air embolism (n = 1) and TEE‐attributed esophageal injury (n = 1). The median procedural and fluoroscopic times were 79 (IQR: 59–100) and 18 (IQR 12–27) minutes, respectively. The mean size of implant was 23.6 ± 3.1 mm. The average hospital stay was 1.8 ± 1.1 days. Follow‐up TEE showed all the LAA orifices were sealed without device‐related thrombus formation. No stroke or death occurred at a mean follow‐up of 12.7 ± 3.1 months. Conclusions: Our preliminary data suggested LAA closure with ACP is safe, feasible with encouraging 1‐yr clinical outcomes. Further large‐scaled trials are needed to confirm the efficacy of this device.

Four-Year Follow-Up of TYPHOON (Trial to Assess the Use of the CYPHer Sirolimus-Eluting Coronary Stent in Acute Myocardial Infarction Treated With BallOON Angioplasty)

OBJECTIVES The aim of this study was to assess the long-term safety and efficacy of the CYPHER (Cordis, Johnson and Johnson, Bridgewater, New Jersey) sirolimus-eluting coronary stent (SES) in percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). BACKGROUND Concern over the safety of drug-eluting stents implanted during PCI for STEMI remains, and long-term follow-up from randomized trials are necessary. TYPHOON (Trial to assess the use of the cYPHer sirolimus-eluting stent in acute myocardial infarction treated with ballOON angioplasty) randomized 712 patients with STEMI treated by primary PCI to receive either SES (n = 355) or bare-metal stents (BMS) (n = 357). The primary end point, target vessel failure at 1 year, was significantly lower in the SES group than in the BMS group (7.3% vs. 14.3%, p = 0.004) with no increase in adverse events. METHODS A 4-year follow-up was performed. Complete data were available in 501 patients (70%), and the survival status is known in 580 patients (81%). RESULTS Freedom from target lesion revascularization (TLR) at 4 years was significantly better in the SES group (92.4% vs. 85.1%; p = 0.002); there were no significant differences in freedom from cardiac death (97.6% and 95.9%; p = 0.37) or freedom from repeat myocardial infarction (94.8% and 95.6%; p = 0.85) between the SES and BMS groups. No difference in definite/probable stent thrombosis was noted at 4 years (SES: 4.4%, BMS: 4.8%, p = 0.83). In the 580 patients with known survival status at 4 years, the all-cause death rate was 5.8% in the SES and 7.0% in the BMS group (p = 0.61). CONCLUSIONS In the 70% of patients with complete follow-up at 4 years, SES demonstrated sustained efficacy to reduce TLR with no difference in death, repeat myocardial infarction or stent thrombosis. (The Study to Assess AMI Treated With Balloon Angioplasty [TYPHOON]; NCT00232830).

Balloon expandable stents to treat central venous stenoses in hemodialysis patients.

Vascular access failure in hemodialysis patients remains a significant problem. The use of thrombolytic agents and balloon angioplasty instead of or in conjunction with surgical revision, has been helpful in increasing the life span of vascular access in these patients. The application of newer endovascular therapies, such as vascular stents, may further improve the salvage rate of hemodialysis access sites. These stents may be particularly valuable in treating stenoses in large central veins. We present 2 cases in which a balloon-expandable Palmaz stent was used to treat a central venous stenosis causing signs of vascular access failure.

Internal Mammary Artery Graft Fistulae to the Pulmonary Arteries as a cause of Myocardial Ischaemia after Coronary Artery Bypass Graft

Internal mammary artery (IMA) graft fistula to the pulmonary arteries is a cause of myocardial ischaemia after coronary artery bypass grafting (CABG). Surgical and percutaneous interventional treatments are available, both with their inherent risk and benefits. Optimised medical management is therefore essential. A pre CABG IMA angiographic image may assist surgeons to ligate identifiable accessory branches, which may contribute to fistula formation.