Radosław Pracoń

Aspiration coronary thrombectomy for acute myocardial infarction increases myocardial salvage: single center randomized study.

Objectives: The aim of the study was to assess if aspiration thrombectomy in high risk patients with STEMI and angiographic evidence of thrombus may improve myocardial salvage. Background: It is unclear if thrombus aspiration before percutaneous intervention (PCI) improves myocardial salvage. Methods: The trial was a prospective randomized study. The inclusion criteria were: first STEMI within 12 hr from symptoms onset, culprit lesion in left anterior descending or right coronary artery, culprit artery TIMI flow ≤ 2 and angiographic evidence of thrombus. The primary endpoint was myocardial salvage index (MSI) as assessed by 99mTc‐sestamibi SPECT imaging. Results: We randomized 137 patients (98 male, mean age 64.1 ± 12.5 years) either to aspiration thrombectomy followed by standard PCI with stent implantation (n = 67) or to standard primary PCI (n = 70). Index perfusion defect was similar in both study groups: 34.2% ± 13.1% in thrombectomy group versus 37.1% ± 12.0% in primary PCI group (P = 0.2). MSI was larger in aspiration thrombectomy group than in control patients [25.4% (IQR 13.5–44) vs. 18.5% (IQR 7.7–30.3) respectively, P = 0.02]. The final infarct size was smaller in patients treated with aspiration thrombectomy (23.1% ± 13.3% vs. 28.9% ± 10.2% in the control group, P = 0.002). Conclusions: Aspiration thrombectomy improves myocardial salvage in high risk STEMI patients with angiographic evidence of thrombus.

What is the optimal cut-off point for low coronary artery calcium score assessed by computed tomography? Multi-Detector Computed Tomography ANIN Registry.

Aim This prospective study was conducted to evaluate the incidence and predictors of coronary artery disease (CAD) in relation to the low coronary artery calcium (CAC) score among patients with intermediate probability of CAD. Material and methods A total of 1132 consecutive patients were included in the analysis (58.7 ±10.9 years, 46.7% males). Coronary computed tomography (CCT) angiography was performed in a multi-detector computed tomography scanner. Coronary artery calcium score was calculated by the Agatston method. Obstructive CAD was defined as the presence of coronary artery stenosis ≥ 50% on CCT angiography. Results Coronary artery disease was diagnosed in nearly one-fourth of patients (n = 272, 24%). In the receiver operating characteristics (ROC) curve analysis a CAC score of 10 was used as an optimal cut-off point for discriminating obstructive CAD (sensitivity: 0.79, specificity: 0.75, p < 0.0001) whereas for a CAC score of 100 the sensitivity and specificity were 0.48 and 0.92, respectively. On multivariate analysis after adjustment for age, gender, hypertension, hyperlipidemia, creatinine levels, only in patients with CAC score ≤ 10 age (OR = 1.05, 95% CI: 1.02-1.08, p = 0.0005, OR = 1.05, 95% CI: 1.03-1.08, p < 0.0001) and male gender (OR = 3.45, 95% CI: 1.92-6.22, p < 0.0001), likewise in group with CAC score ≤ 100 age (OR = 1.05, 95% CI: 1.03-1.08, p < 0.0001) and male gender (OR = 3.31, 95% CI: 1.88-5.81, p < 0.0001) were independent predictors of obstructive CAD. Conclusions The cut-off point of 10 for CAC score determined patients with CAD with the best sensitivity and specificity. Therefore, a total CAC score < 10 should be classified as “low”. In patients with a low CAC score obstructive high risk plaques prone to rupture are presented and are associated with increasing age and male gender.

Device Thrombosis After Percutaneous Left Atrial Appendage Occlusion Is Related to Patient and Procedural Characteristics but Not to Duration of Postimplantation Dual Antiplatelet Therapy

Background— Device-related thrombus (DRT) after left atrial appendage occlusion is a worrisome finding with little knowledge about when to expect it and how to prevent it. This study sought to investigate correlates of DRT after left atrial appendage occlusion, its time of diagnosis, and particularly, association with postimplantation dual antiplatelet therapy duration. Methods and Results— Consecutive patients (n=102) after left atrial appendage occlusion with AMPLATZER Cardiac Plug/Amulet (n=59) or WATCHMAN (n=43) were included in a prospective registry (October 2011–May 2016). Follow-up was done at 1.5, 3 to 6, and 12 months postimplantation. DRT was classified as early (at 1.5 month), late (at 3–6 month), or very late (at 12-month follow-up). Postimplantation dual antiplatelet therapy was recommended for 30 to 180 days and decided independently by attending physicians. Final analysis included 99 patients, 42 (42.4%) females, with median CHA2DS2-VASc of 4.0 (interquartile range [IQR], 3.0–5.0) and median HAS-BLED score of 2.0 (IQR, 1.0–3.0). DRTs were observed in 7 (7.1%) patients: 2 (28.6%) early, 2 (28.6%) late, and 3 (42.9%) very late. When compared with patients without DRT, those with DRT presented more often with a history of prior thromboembolism (5 [71.4%] versus 28 [30.4%]; P=0.04), had lower left ventricular ejection fraction (50.0 [IQR, 35.0–55.0] versus 60.0 [IQR, 55.0–66.0]; P<0.01), and had greater proportion of patients with deep device implantation (6 [85.7%] versus 36 [39.1%]; P=0.04) and with larger devices implanted (30.0 mm [IQR, 27.0–33.0] versus 25.0 mm [IQR, 24.0–28.0]; P<0.01). Postimplantation dual antiplatelet therapy duration was not different between the 2 groups (12.4 weeks [IQR, 6.0–49.7] with DRT versus 13.0 weeks [IQR, 7.3–26.0] without DRT; P=0.77). Conclusions— In this real-world series, DRT was observed early, late, and very late after left atrial appendage occlusion. It was related to patient and procedural characteristics but not to postimplantation dual antiplatelet therapy duration.

Pulmonary artery rupture as a complication of Swan-Ganz catheter application. Diagnosis and endovascular treatment: a single centre's experience.

Introduction The placement of a Swan-Ganz catheter into the pulmonary artery may lead to a number of complications (2–17%). In less than 0.2% of cases Swan-Ganz catheterization results in serious vascular damage – pulmonary artery rupture (PAR). This paper presents two distinct forms of iatrogenic PAR treated endovascularly using different vascular devices. Aim To evaluate the effectiveness of endovascular treatment and the application of different types of vascular devices in the management of pulmonary artery rupture caused by Swan-Ganz catheterization. Material and methods In this retrospective study we evaluated 2 patients in whom Swan-Ganz catheter application was used for perioperative monitoring and resulted in pulmonary artery rupture. This complication was treated endovascularly by means of interventional cardiology. Results We report the cases of 2 patients with a pulmonary artery pseudoaneurysm formed in the perioperative period. In case 1, a single, 4-loop, 3 mm diameter coil was implanted. In case 2, a 5 mm Amplatzer Vascular Plug IV was applied. In both cases, the endovascular approach resulted in total occlusion of the feeding artery and reduced further extravasation of the blood. Conclusions Despite its extremely low incidence, iatrogenic PAR is a serious, life-threatening complication of Swan-Ganz catheterization that requires urgent attention. Among available methods of treatment, percutaneous embolization is a relatively quick, safe, accurate and highly effective alternative to traumatizing surgery.

Lumen and calcium characteristics within calcified coronary lesions. Comparison of computed tomography coronary angiography versus intravascular ultrasound

Introduction Computed tomography coronary angiography (CTCA) is a diagnostic method used for exclusion of coronary artery disease. However, lower accuracy of CTCA in assessment of calcified lesions is a significant factor impeding applicability of CTCA for assessment of coronary atherosclerosis. Aim To provide insight into lumen and calcium characteristics assessed with CTCA, we compared these parameters to the reference of intravascular ultrasound (IVUS). Material and methods Two hundred and fifty-two calcified lesions within 97 arteries of 60 patients (19 women, age 63 ±10 years) underwent assessment with both 2 × 64 slice CT (Somatom Definition, Siemens) and IVUS (s5, Volcano Corp.). Coronary lumen and calcium dimensions within calcified lesions were assessed with CTCA and compared to the reference measurements made with IVUS. Results On average CTCA underestimated mean lumen diameter (2.8 ±0.7 mm vs. 2.9 ±0.8 mm for IVUS), lumen area (6.4 ±3.4 mm2 vs. 7.0 ±3.7 mm2 for IVUS, p < 0.001) and total calcium arc (52 ±35° vs. 83 ±54°). However, analysis of tertiles of the examined parameters revealed that the mean lumen diameter, lumen area and calcium arc did not significantly differ between CTCA and IVUS within the smallest lumens (1st tertile of mean lumen diameter at 2.1 mm, and 1st tertile of lumen area at 3.7 mm2) and lowest calcium arc (mean of 40°). Conclusions Although, on average, CTCA underestimates lumen diameter and area as well as calcium arc within calcified lesions, the differences are not significant within the smallest vessels and calcium arcs. The low diagnostic accuracy of CTCA within calcified lesions may be attributed to high variance and not to systematic error of measurements.

Use of troponin assay 99th percentile as the decision level for myocardial infarction diagnosis

Background The Universal Definition of Myocardial Infarction recommends the 99th percentile concentration of cardiac troponin in a normal reference population as part of the decision threshold to diagnose type 1 spontaneous myocardial infarction. Adoption of this recommendation in contemporary worldwide practice is not well known. Methods We performed a cohort study of 276 hospital laboratories in 31 countries participating in the National Heart, Lung, and Blood Institute–sponsored International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial. Each hospital laboratorys troponin assay manufacturer and model, the recommended assays 99th percentile upper reference limit (URL) from the manufacturers package insert, and the troponin concentration used locally as the decision level to diagnose myocardial infarction were ascertained. Results Twenty‐one unique troponin assays from 9 manufacturers were used by the surveyed hospital laboratories. The ratio of the troponin concentration used locally to diagnose myocardial infarction to the assay manufacturer–determined 99th percentile URL was <1 at 19 (6.6%) laboratories, equal to 1 at 91 (31.6%) laboratories, >1 to ≤5 at 101 (35.1%) laboratories, >5 to ≤10 at 34 (11.8%) laboratories, and >10 at 43 (14.9%) laboratories. The variability in troponin decision level for myocardial infarction relative to the assay 99th percentile URL was present for laboratories in and outside of the United States, as well as for high‐ and standard‐sensitivity assays. Conclusions There is substantial hospital‐level variation in the troponin threshold used to diagnose myocardial infarction; only one‐third of hospital laboratories currently follow the Universal Definition of Myocardial Infarction consensus recommendation for use of troponin concentration at the 99th percentile of a normal reference population as the decision level to diagnose myocardial infarction. This variability across laboratories has important implications for both the diagnosis of myocardial infarction in clinical practice as well as adjudication of myocardial infarction in clinical trials.

SUBSTANTIAL VARIABILITY BETWEEN LABORATORIES IN TROPONIN DECISION LEVEL FOR DIAGNOSIS OF MYOCARDIAL INFARCTION AND ASSAY 99TH PERCENTILE: FINDINGS FROM THE INTERNATIONAL STUDY OF COMPARATIVE HEALTH EFFECTIVENESS WITH MEDICAL AND INVASIVE APPROACHES (ISCHEMIA) TRIAL

The Third Universal Definition of Myocardial Infarction (MI) designates an increase in cardiac troponin concentration (cTn) > 99th percentile of a normal reference population as the decision level for MI diagnosis. The variability among hospitals in the lab-determined cTn level to diagnose MI [cTn

Computed tomography to predict surgical revascularization of a left anterior descending artery occlusion incompletely visualized by conventional angiography.

Purpose Previous studies demonstrated that failure to visualize distal chronic total occlusion in conventional coronary angiography (CCA) does not preclude procedural success of coronary artery bypass grafting (CABG). We assessed the utility of computed tomography angiography (CTA) in guiding CABG to the occluded left anterior descending artery (LAD) incompletely visualized by CCA. Materials and Methods Twenty-four symptomatic patients rejected for revascularization of an occluded LAD on the basis of CCA underwent a preoperative CTA before intended transmyocardial laser revascularization. Off-pump CABG to the LAD was attempted in all patients depending on the intraoperative findings. The primary outcome was defined as procedural success of CABG to the LAD. Results The success rate for CABG was 79.2%. By CCA, Rentrop 0/1 was present in 6 patients (25%), whereas Rentrop 2 was present in 18 patients (75%). By CTA, Rentrop 3 was seen in all patients. Compared with the CABG-failure group, the CABG-success group showed a larger mean distal LAD diameter (1.7±0.2 mm vs. 1.3±0.1 mm; P=0.001). By receiver-operating curve analysis, a cutoff value of 1.5 mm for the mean distal LAD diameter predicted CABG availability with 100% specificity and 95% sensitivity. The distal LAD short length and intramyocardial course were other significant correlates of CABG failure compared with CABG success (60% vs. 5.3%, P=0.018; 80% vs. 0%, P<0.001). Conclusions Noninvasive CTA is not only superior to CCA in delineating distal coronary occlusion but also very precisely predicts the procedural success of CABG. CTA represents a robust evaluation tool for coronary mapping of chronic total occlusion with doubtful distal anatomy in CCA.

A randomized comparison of modified subcutaneous “Z”-stitch versus manual compression to achieve hemostasis after large caliber femoral venous sheath removal: “Z”-Stitch vs. Manual Compression

To compare subcutaneous “Z”‐stitch versus manual compression in attaining hemostasis after large bore femoral venous access, and to assess its impact on venous patency.

How to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion.

The left atrial appendage (LAA) conceals 90% of thrombi found in the left atrium in patients with atrial fibrillation (AF), and thus has been declared the main villain responsible for thromboembolic events associated with AF [1]. Systemic anticoagulation cuts the risk of stroke and peripheral embolism associated with AF by more than 60% [2, 3]. However, it is a double-edged sword, as it carries a substantial bleeding risk [4]. The bleedings affect tissues and organs located far from the LAA – innocent bystanders, one could say. Hence, it seems perfectly reasonable to call for a local solution to a local problem, without putting patients at risk of systemic complications. In response to this call the concept of mechanical closure of the LAA (LAAC) has appeared [5, 6]. The concept proved to be at least as effective as anticoagulation with vitamin K antagonists in randomised and non-randomised studies with the two CE marked left atrial appendage occluders available on the market: the WATCHMAN Device and the Amplatzer Cardiac Plug (ACP) Device [7–13]. It was suggested that LAAC would show its full potential in delivering net clinical benefit over vitamin K antagonists at longer-term follow-ups, after having left behind early hazards of the implantation procedure and with continuous accumulation of adverse events with anticoagulation. Indeed, in a very recent landmark report with 3.8-years follow-up of patients from the initial PROTECT AF trial, the WATCHMAN device has met superiority criteria over warfarin in reducing combined outcome, including thromboembolic events. What is even more momentous, WATCHMAN proved superior in reducing cardiovascular as well as all-cause mortality [14]. Still, the body of evidence on this relatively novel technology is scarce when compared to extensive data on the efficacy and safety of oral anticoagulation, including novel drugs. Furthermore, the technology itself is still young and the procedure carries inherent risks that are partly mitigated with growing operators’ experience. The current European guidelines recommend that this procedure should be limited to AF patients at high stroke risk and with contraindications to anticoagulation [15].