Reto Gamma

Early targeted brain COOLing in the cardiac CATHeterisation laboratory following cardiac arrest (COOLCATH).

INTRODUCTION Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill, an intranasal cooling device over Blanketrol, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory. METHODS 70 patients were randomized to TH induction with either Rhinochill or Blanketrol. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge. RESULTS There was no difference in time to reach ≤34 °C between Rhinochill and Blanketrol (Tympanic ≤34 °C, 75 vs. 107 mins; p=0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p=0.151). Tympanic temperature dropped significantly with Rhinochill in the first hour (1.75 vs. 0.94 °C; p<0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%. CONCLUSION In this study, Rhinochill was not found to be more efficient than Blanketrol for TH induction, although there was a non-significant trend in favour of Rhinochill that potentially warrants further investigation with a larger trial.

Chest pain with ST segment elevation in a patient with prosthetic aortic valve infective endocarditis: a case report

IntroductionAcute ST-segment elevation myocardial infarction secondary to atherosclerotic plaque rupture is a common medical emergency. This condition is effectively managed with percutaneous coronary intervention or thrombolysis. We report a rare case of acute myocardial infarction secondary to coronary embolisation of valvular vegetation in a patient with infective endocarditis, and we highlight how the management of this phenomenon may not be the same.Case presentationA 73-year-old British Caucasian man with previous tissue aortic valve replacement was diagnosed with and treated for infective endocarditis of his native mitral valve. His condition deteriorated in hospital and repeat echocardiography revealed migration of vegetation to his aortic valve. Whilst waiting for surgery, our patient developed severe central crushing chest pain with associated anterior ST segment elevation on his electrocardiogram. Our patient had no history or risk factors for ischaemic heart disease. It was likely that coronary embolisation of part of the vegetation had occurred. Thrombolysis or percutaneous coronary intervention treatments were not performed in this setting and a plan was made for urgent surgical intervention. However, our patient deteriorated rapidly and unfortunately died.ConclusionClinicians need to be aware that atherosclerotic plaque rupture is not the only cause of acute myocardial infarction. In the case of septic vegetation embolisation, case report evidence reveals that adopting the current strategies used in the treatment of myocardial infarction can be dangerous. Thrombolysis risks intra-cerebral hemorrhage from mycotic aneurysm rupture. Percutaneous coronary intervention risks coronary mycotic aneurysm formation, stent infections as well as distal septic embolisation. As yet, there remains no defined treatment modality and we feel all cases should be referred to specialist cardiac centers to consider how best to proceed.

Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease

Background Recently, the therapeutic benefits of percutaneous coronary intervention (PCI) have been challenged in patients with stable coronary artery disease (SCD). Objectives The authors examined the impact of PCI on exercise responses in the coronary circulation, the microcirculation, and systemic hemodynamics in patients with SCD. Methods A total of 21 patients (mean age 60.3 ± 8.4 years) with SCD and single-vessel coronary stenosis underwent cardiac catheterization. Pre-PCI, patients exercised on a supine ergometer until rate-limiting angina or exhaustion. Simultaneous trans-stenotic coronary pressure-flow measurements were made throughout exercise. Post-PCI, this process was repeated. Physiological parameters, rate-limiting symptoms, and exercise performance were compared between pre-PCI and post-PCI exercise cycles. Results PCI reduced ischemia as documented by fractional flow reserve value (pre-PCI 0.59 ± 0.18 to post-PCI 0.91 ± 0.07), instantaneous wave-free ratio value (pre-PCI 0.61 ± 0.27 to post-PCI 0.96 ± 0.05) and coronary flow reserve value (pre-PCI 1.7 ± 0.7 to post-PCI 3.1 ± 1.0; p < 0.001 for all). PCI increased peak-exercise average peak coronary flow velocity (p < 0.0001), coronary perfusion pressure (distal coronary pressure; p < 0.0001), systolic blood pressure (p = 0.01), accelerating wave energy (p < 0.001), and myocardial workload (rate-pressure product; p < 0.01). These changes observed immediately following PCI resulted from the abolition of stenosis resistance (p < 0.0001). PCI was also associated with an immediate improvement in exercise time (+67 s; 95% confidence interval: 31 to 102 s; p < 0.0001) and a reduction in rate-limiting angina symptoms (81% reduction in rate-limiting angina symptoms post-PCI; p < 0.001). Conclusions In patients with SCD and severe single-vessel stenosis, objective physiological responses to exercise immediately normalize following PCI. This is seen in the coronary circulation, the microcirculation, and systemic hemodynamics.

TCT-386 Incidence and prevention of contrast induced acute kidney injury in ST elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Contrast-induced acute kidney injury (CI-AKI) is a recognised complication during primary percutaneous coronary intervention (PPCI) that affects short and long term prognosis. Volume of contrast media used is a known predisposing factor for its development. The aim of this study was to determine the

Incidence of left ventricular thrombi in reperfused STEMI patients detected by contrast-enhanced CMR

Background Left ventricular (LV) thrombus formation remains a wellrecognized complication following acute ST-segment elevation myocardial infarction (STEMI) in the primary percutaneous coronary intervention (PPCI) era, with potential devastating consequences such as embolic stroke. Echocardiography-based assessment of anterior STEMI patients, within the first 3 months of presentation, has reported an incidence of LV thrombi ranging from 8 to 15%. CMR not only provides higher resolution anatomical images but also has the ability for tissue characterization. Therefore, we hypothesize the true incidence of LV thrombi in reperfused STEMI patients using contrast-enhanced CE-CMR within one week would be more accurate.

32 The Impact of Haemoglobin Reduction on Short- and Long-Term Mortality Following Primary Percutaneous Coronary Intervention for St-Elevation Myocardial Infarction-analysis from a Real World Stemi Population

Introduction Mortality following ST-elevation myocardial infarction has declined significantly with the advent of primary PCI (PPCI). Concurrent use of antiplatelet agents has further decreased complication rates and mortality; however, these agents confer an increased bleeding risk, an independent risk factor for mortality. This retrospective study assesses the effect of blood loss on short- and long-term mortality and its association with clinical characteristics in a real world population of patients undergoing PPCI at a tertiary referral centre in the UK. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were eligible for inclusion in the study. Patient data were obtained from our Cardiac Services Database System (Phillips CVIS) and mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by one-way ANOVA. Categorical variables were compared using the chi-squared test. A P value of < 0.05 was taken to indicate statistical significance. Results 1403 patients with recorded admission and discharge haemoglobin levels were included in this analysis. Characteristics and clinical outcomes were compared in three groups according to the degree of haemoglobin reduction (Table 1). Patients with a reduction in haemoglobin were more likely to be female, slightly older and have prior history of MI. Patients with a significant reduction in haemoglobin were more likely to have received abciximab. Thirty-day mortality was significantly higher in the group with a haemoglobin drop (Table 1) as was overall mortality (hazard ratio 1.8, 95% CI 1.2–2.5) during a mean follow-up period of 2.1 years (Figure 1). Abstract 32 Figure 1 Kaplan-Meier survival curves Abstract 32 Table 1 Clinical characteristics and outcomes No change in Hb, g/dl (n = 374) Hb reduction 0.1–1 g/dl (n = 517) Hb reduction >1 g/dl (n = 512) p-value Risk factorsMean Age (+/- SD)MaleHypertensionDiabetes MellitusPrevious MIPrevious CABG 64.4 +/- 14290 (77.5%)110 (29.4%)53 (14.2%)59 (15.8%)9 (2.4%) 63.1 +/- 13383 (74%)132 (25.5%)63 (12.2%)61 (11.8%)14 (2.7%) 67.5 +/- 13355 (69.3%)140 (27.3%)64 (12.5%)51 (10%)11 (2.1%) <0.0001*0.021*0.3700.6560.031*0.843 Procedure relatedRadialAbciximab use 113 (30.2%)114 (30.5%) 147 (28.4%)161 (31.1%) 130 (25.4%)208 (40.6%) 0.2630.0001* Clinical outcome30-day mortalityOverall mortality 15 (4%)36 (9.6%) 12 (2.3%)46 (8.9%) 42 (8.2%)79 (15.4%) <0.0001*0.0019* Conclusions Our retrospective analysis in a large cohort of patients confirms recent data suggesting an adverse association between a reduction in haemoglobin following PPCI and long-term mortality. Further work is required on strategies to reduce bleeding risk and hence improve clinical outcome following PPCI.

036 COMPARISON OF CLINICAL CHARACTERISTICS AND OUTCOMES IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK VERSUS ST ELEVATION MYOCARDIAL INFARCTION REFERRED FOR PRIMARY PCI

Aims Current national and international guidelines continue to recommend activation of the primary percutaneous coronary intervention (PPCI) pathway in patients presenting with chest pain and presumed new-onset left bundle branch block (LBBB). Previous research has suggested that a lower proportion of patients presenting with LBBB require emergency intervention. In this study we have compared baseline clinical characteristics, angiographic findings and subsequent outcome in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for PPCI. Table 1 Clinical characteristics Risk factor LBBB (n=155) STEMI (n=1720) p Value Mean age (±SD) 70.35±11.9 64.95±14.0 <0.0001 Male 87 (56.1%) 1228 (71.4%) <0.0001 Hypertension 70 (45.2%) 668 (38.8%) 0.127 Hypercholesterolaemia 52 (33.5%) 512 (29.8%) 0.327 Diabetes mellitus 26 (16.8%) 201 (11.7%) 0.063 Previous MI 36 (23.2%) 205 (11.9%) <0.0001 Previous CABG 10 (6.5%) 44 (2.6%) 0.005 Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were included in the study. Patient data obtained from our Cardiac Services Database System (Phillips CVIS) were analysed and angiographic images reviewed on our Cardiac Image Database (McKesson Horizon). Mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by an unpaired t test. Categorical variables were compared using the χ2 test. A p value of <0.05 was considered to indicate statistical significance. Results During the study period, 1875 patients were referred for PPCI of whom 155 (8.3%) had LBBB. Compared with STEMI, patients with LBBB were significantly older, more likely to be female and have prior history of MI and CABG (table 1). Patients with LBBB had similar door-to-balloon (DTB) and call-to-balloon (CTB) times. PCI was performed in 40 (26%) patients with LBBB although an acutely occluded culprit vessel was found in only 19 (12.2%) patients (table 2). Furthermore, 85 (54.8%) patients had non-flow limiting coronary artery disease and of those with significant disease 12 (7.7%) patients required CABG (figure 1). Overall, an acute coronary syndrome (defined as ischaemic chest pain with positive troponin) was confirmed in only 67 (43.2%) of patients presenting with LBBB. 30-day mortality was similar between LBBB and STEMI patients (table 2). However, during a mean follow-up period of 2.1 years, overall mortality was significantly higher in the LBBB group compared to STEMI (HR 2.01, 95% CI 1.26 to 3.20) (figure 2). Conclusions Our study shows that, in contrast to STEMI, only a small proportion of patients presenting with chest pain and LBBB had an acutely occluded coronary artery. Although short-term mortality was similar between the two groups, long-term outcome was significantly worse in patients with LBBB. Further work is needed to identify those patients presenting with LBBB who are most likely to have an acute coronary occlusion, in order to facilitate the appropriate use of emergency coronary angiography and PPCI. Table 2 Clinical outcomes Outcome LBBB (n=155) STEMI (n=1720) p Value Door-to-balloon time (min±SD) 40±17 37±25 0.710 Call-to-balloon time (min±SD) 128±36 120±47 0.263 Acute coronary occlusion 19 (12.2%) 1096 (63%) <0.0001 PCI performed 40 (26%) 1430 (83%) <0.0001 30-day mortality (all) 8 (5.2%) 120 (6.9%) 0.391 30-day mortality (PCI) 3/40 (7.5%) 94/1430 (6.6%) 0.825 30-day mortality (no PCI) 5/115 (4.3%) 26/290 (8.9%) 0.115 Overall mortality 32 (27.8%) 240 (13.9%) 0.023 Figure 1 Clinical outcome in patients with LBBB. Figure 2 Kaplan-Meier comparison of survival curves.