Robert Pyo

Impact of the everolimus-eluting stent on stent thrombosis: a meta-analysis of 13 randomized trials

OBJECTIVES We evaluated the impact of the everolimus-eluting stent (EES) on the frequency of stent thrombosis (ST), target vessel revascularization (TVR), myocardial infarction (MI), and cardiac death in randomized controlled trials comparing the EES to non-everolimus-eluting drug-eluting stents (EE-DES). BACKGROUND Whether or not the unique properties of the EES translate into reductions in ST remains unknown. METHODS We searched MEDLINE, Scopus, the Cochrane Library, and Internet sources for articles comparing outcomes between EES and non-EE-DES without language or date restriction. Randomized controlled trials reporting the frequency of ST were included. Variables relating to patient and study characteristics and clinical endpoints were extracted. RESULTS We identified 13 randomized trials (n = 17,101) with a weighted mean follow-up of 21.7 months. Compared with non-EE-DES, the EES significantly reduced ST (relative risk [RR]: 0.55; 95% confidence interval [CI]: 0.38 to 0.78; p = 0.001), TVR (RR: 0.77; 95% CI: 0.64 to 0.92; p = 0.004), and MI (RR: 0.78; 95% CI: 0.64 to 0.96; p = 0.02). There was no difference in cardiac mortality between the groups (RR: 0.92; 95% CI: 0.74 to 1.16; p = 0.38). The treatment effect was consistent by different follow-up times and duration of clopidogrel use. The treatment effects increased with higher baseline risks of the respective control groups with the strongest correlation observed for ST (R(2) = 0.89, p < 0.001). CONCLUSIONS Intracoronary implantation of the EES is associated with highly significant reductions in ST with concordant reductions in TVR and MI compared to non-EE-DES. Whether these effects apply to different patient subgroups and DES types merits further investigation.

High platelet reactivity on clopidogrel therapy correlates with increased coronary atherosclerosis and calcification: a volumetric intravascular ultrasound study.

OBJECTIVES This study sought to evaluate the relationship between platelet reactivity and atherosclerotic burden in patients undergoing percutaneous coronary intervention (PCI) with pre-intervention volumetric intravascular ultrasound (IVUS) imaging. BACKGROUND Atherosclerosis progresses by the pathologic sequence of subclinical plaque rupture, thrombosis, and healing. In this setting, increased platelet reactivity may lead to more extensive arterial thrombosis at the time of plaque rupture, leading to a more rapid progression of the disease. Alternatively, abnormal vessel wall biology with advanced atherosclerosis is known to enhance platelet reactivity. Therefore, it is possible that by either mechanism, increased platelet reactivity may be associated with greater atherosclerotic burden. METHODS This study included patients who underwent PCI with pre-intervention IVUS imaging and platelet reactivity functional assay (P2Y(12) reaction units) performed >16 h after PCI, after the stabilization of clopidogrel therapy (administered before PCI). Platelet reactivity >230 P2Y(12) reaction units defined high on-treatment platelet reactivity (HPR). RESULTS Among 335 patients (mean age 65.0 years, 71% men), there were 109 patients with HPR (32.5%) and 226 without HPR (67.5%), with HPR being associated with diabetes and chronic renal insufficiency. By IVUS analysis, patients with HPR had significantly greater target lesion calcium lengths, calcium arcs, and calcium indexes. Furthermore, patients with HPR tended to have longer lesions and greater volumetric dimensions, indicating higher plaque volume, larger total vessel volume, and also greater luminal volume, despite similar plaque burden. By multivariate analysis controlling for baseline clinical variables, HPR was the single consistent predictor of all IVUS parameters examined, including plaque volume, calcium length, and calcium arc. CONCLUSIONS Increased platelet reactivity on clopidogrel treatment, defined as >230 P2Y(12) reaction units, is associated with greater coronary artery atherosclerotic disease burden and plaque calcification.

TCT-159 Impact of Staged versus One-Time Multivessel Percutaneous Intervention in ST-elevation Myocardial Infarction: A Meta-analysis

RESULTS The total of 31,760 patients were included in the study of which 12,951 (41%) were pretreated with UH/LMWH and 1,154 (4%) were pretreated with GP. The number of treated segments was 61,011 of which 32,446 (53%) were occluded prior to primary PCI. Non-patent IRA was associated with higher risk of death at 30 days (adjusted OR 1.6; 95% CI 1.47 to 1.89; P<0.000). Pretreatment with UH/LMWH (adjusted OR 0.82; 95% CI 0.79 to 0.86; P<0.001) and/or GP (adjusted OR 0.86; 95% CI 0.77 to 0.95; P1⁄40.003) was associated with higher probability for patent IRA.

Coronary Artery Spasm: Is ST Elevation Key for Diagnosis?

Coronary vasospasm is uncommon in pregnancy and the post-partum period. We present a very rare case about an acute coronary vasospasm in a 36-year-old woman, 2 weeks postpartum. The coronary arteriograms showed a coronary vasospasm in the distal left anterior descending and circumflex coronary arteries. EKG presentation was atypical, with T-wave inversions in leads I, aVl, V2-V6. To our knowledge, this is the first case with a welldocumented coronary artery vasospasm in a postpartum woman, without the classic ST elevation on EKG. Management should follow the usual principles of care for acute coronary vasospasm.

Vascular Closure Devices and Complications

When compared to manual compression, utilization of vascular closure devices (VCDs) in an appropriate patient population has the potential to reduce time to post procedure mobility and thereby improve patient comfort after percutaneous procedures. Additionally, reduced time to ambulation is important as more hospitals adopt same-day discharge strategies. However it has not been clearly established if VCDs reduce overall complication rates when compared to manual compression. When utilizing these devices, one must weigh the potential complications associated with these devices against their potential benefits. This chapter will review VCDs commonly used with respect to their specific indications for use, specific contraindications, and safe deployment practices.

Radial Coronary Interventions

The radial artery access is gaining popularity due to decreased rates of access site complications and improved patient comfort. This chapter is an overview on radial interventions.

Achieving Perfect Vascular Access

The femoral artery is the most commonly used arterial site of access in the United States (>90 % in 2011). The radial artery access is currently gaining popularity [1]. The brachial artery, axillary artery, ulnar artery, and femoral artery cutdown for access are rarely used now.

TCT-886 Predictors of Vascular complications in patients undergoing Balloon Aortic Valvuloplasty

Gill Buchanan, Alaide Chieffo, Matteo Montorfano, Francesco Maisano, Azeem Latib, Micaela Cioni, Filippo Figini, Francesco Giannini, Chiara Bernelli, Alessandro Durante, Santo Ferrarello, Mauro Carlino, Pietro Spagnolo, Annalisa Franco, Chiara Gerli, Remo Covello, Eustachio Agricola, Giovanni La Canna, Ottavio Alfieri, Antonio Colombo San Raffaele Scientific Institute, Milan, Italy, San Raffaele Scientific Institute, Milan, N/A

CLINICALLY-BASED PATIENT RISK SCORES AND THE ‘TARGET LESION REVASCULARIZATION PARADOX’ IN PATIENTS WITH MULTI-VESSEL CAD UNDERGOING PCI

Background: Various risk scores predict clinical events. However, the criteria used in these scores vary widely, ranging from purely angiographic (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], New York State Risk Score [NYSRS]). With such disparity, we sought to clarify the utility of these 6 scores for predicting clinical events in pts with multi-vessel CAD undergoing PCI.