Roger K. Philipp

The ability to achieve complete revascularization is associated with improved in-hospital survival in cardiogenic shock due to myocardial infarction: Manitoba cardiogenic SHOCK Registry investigators.

Objectives: To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort. Background: Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization. Methods: A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in‐hospital survival were identified utilizing logistic regression. Results: ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09–0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002–1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04–11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73–39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1–6.2)) and peak lactate (P = 0.02). Conclusions: The ability to achieve complete revascularization may be strongly associated with improved in‐hospital survival in patients with cardiogenic shock.

The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients

OBJECTIVE Since the introduction of telemetry over a half century ago, it has expanded to various units and wards within health care institutions outside of the traditional critical care setting. Little is known on whether routine telemetry use is beneficial in this patient population. The aim of this study was to determine the impact of telemetry monitoring on survival of in-hospital cardiac arrests in patients admitted to non-critical care units. METHODS A retrospective study of cardiac arrests in patients admitted to non-critical care units within the Winnipeg Regional Health Authority from 2002 to 2006 inclusive was performed. Baseline demographic, cardiac arrest, and outcome data were collected. RESULTS Of the total 668 patients, the mean age was 70±14 years with 404 (61%) males. Patients presenting with asystole or pulseless electrical activity (PEA) demonstrated an increased mortality as compared to those presenting with ventricular tachycardia (VT) or ventricular fibrillation (VF). Overall, 268 of 668 patients (40%) survived their initial arrest, 66 (10%) survived to hospital discharge and 49 (7%) survived transfer to another facility. Patients on telemetry vs. no telemetry had higher survival rates immediately following cardiac arrest (66% vs. 34%, OR=3.67, p=0.02), as well as higher survival to hospital discharge (30% vs. 6%, OR=7.17, p=0.01). Finally, patients with cardiac arrest during the night and early morning benefited proportionally the greatest from telemetry use. CONCLUSION Regardless of whether cardiac arrest was witnessed or unwitnessed, telemetry use was an independent and strong predictor of survival to hospital discharge.

Cardiac Outcomes Through Digital Evaluation (CODE) STEMI Project: Prehospital Digitally-Assisted Reperfusion Strategies

BACKGROUND Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times. METHODS In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physicians hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room. RESULTS From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%. CONCLUSIONS Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.

The presence of ST-elevation in lead aVR predicts significant left main coronary artery stenosis in cardiogenic shock resulting from myocardial infarction: The Manitoba cardiogenic shock registry

INTRODUCTION Electrocardiographic (ECG) predictors of significant angiographic left main coronary artery stenosis (LMCS>50%) have been described in acute myocardial infarction using ST-segment elevation in lead aVR (aVR-STE). However, there is a paucity of data on its association with LMCS>50% in the setting of cardiogemic shock (CGS). METHODS We investigated 210 consecutive, unselected, patients from Sept. 2002-2006 with CGS due to acute myocardial infarction undergoing cardiac catheterization. Of those, 191 patients with interpretable ECG tracings for aVR-STE analysis formed our study sample. aVR-STE was defined as ST-segment elevation≥1mm in aVR while LMCS>50% on coronary angiogram was defined as any left main lesion that demonstrated >50% lumen narrowing or equivalent by direct visualization or quantitative coronary angiography analysis. RESULTS There was 59% survival to discharge of this predominantly male cohort (median age 68±12years; 31% females). Fifty three (28%) cases had aVR-STE while 27 (14%) had LMCS>50%. Of those, 16 patients who had aVR-STE also had LMCS>50% (sensitivity 59%, specificity 77%, positive predictive value 30%, negative predictive value 92% for predicting LMCS>50%). Multivariate analysis revealed that aVR-STE was the only significant predictor of LMCS>50% was (p=0.014; Odds Ratio=3.06; 95% Confidence Interval 1.26-7.47). CONCLUSION In CGS due to acute myocardial infarction, aVR-STE>1mm proves to be an important predictor of LMCS>50%. Such data could be helpful in further risk stratification for optimal management during CGS.

The acutely occluded left main coronary artery culprit in cardiogenic shock and initial percutaneous coronary intervention: a substudy of the Manitoba "no option" left main PCI registry.

We aim to describe the in-hospital outcomes of the first reported Canadian cohort of patients with cardiogenic shock and acute myocardial infarction (MI) due to acute and total occlusion of the left main coronary artery, treated with initial percutaneous coronary intervention (PCI). Acute left main thromboses with cardiogenic shock were identified (N = 8) from a retrospective consecutive cohort of high risk left main PCI (N = 56) performed at our institution from 2004-2009. The mean age was 62.3 ± 13.2 years, with 6 (75%) male patients. Successful PCI was performed in all patients, with thrombectomy utilized in 4 patients (50%), stenting in 7 patients (88%), and intra-aortic balloon pump augmentation in 7 patients (88%). Two patients (25%) required extracorporeal membrane oxygenation (ECMO) and 2 other patients required ventricular assist devices. Post-PCI coronary artery bypass grafting (CABG) was performed for 2 patients (25%). The mean SYNTAX score was 26.6 ± 10.5. The mean logistic EuroSCORE was 30.4 ± 12.6%. In-hospital mortality occurred in 3 patients (38%). Acute left main occlusion is a rare but devastating presentation of myocardial infarction, invariably with cardiogenic shock. Emergent PCI may be an effective method to acutely revascularize this subset of patients; however, aggressive post-PCI care including ECMO, CABG, and ventricular support may be required to improve patient survival.

Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo-sternotomy: A case report

An 85‐year‐old gentlemen with a history of previous triple vessel coronary bypass grafting presented with severe aortic stenosis and occlusion of the previous saphenous vein grafts but with patent left internal mammary artery (LIMA)–left anterior descending. The patient underwent uncomplicated repeat sternotomy and aortic valve replacement with repeated coronary bypass. On post‐operative day 21 the patient was successfully resuscitated from a pulseless electrical activity (PEA) arrest, and was found to have a 1‐cm pseudoaneurysm of the left internal mammary artery at the level of sternomanubrial junction with associated hemothorax. The LIMA remained patent and a pinhole source of extravasation was discovered by angiography at the aneurysmal site. The defect was successfully repaired by endovascular implant of a 3.5 mm × 12 mm Graft Master covered stent (Abbott Vascular). The patient recovered well from the procedure without further complications and was discharged after a total of 48 days of hospital stay. Our experience confirms the feasibility of repairing post‐operative pseudoaneurysm in the internal mammary artery by endovascular stent grafting, thereby avoiding the risks and complications of a repeat open chest procedure.

Multimodality imaging of a right saphenous vein graft pseudoaneurysm

A 74-year-old man with a history that was significant for two-vessel coronary artery bypass grafting (CABG) surgery, underwent magnetic resonance cholangiopancreatography for evaluation of chronic pancreatitis. A complex cystic mass, measuring 2 cm × 2 cm was incidentally observed anterior to the right atrium on the axial T2-weighted magnetic resonance cholangiopancreatography half-Fourier acquisition single-shot turbo spin-echo (HASTE) image (Figure 1A). A subsequent transthoracic echocardiography confirmed the cystic mass, extrinsic to the right atrium, with no intracardiac communication following administration of agitated saline contrast (Figure 1B). Multidetector computed tomography identified a pseudoaneurysm of the right saphenous vein graft from previous CABG (Figure 1C). A three-dimensional, volume-rendered multidetector computed tomography image of the graft arising from the aorta and the pseudoaneurysm is shown in Figure 1D. Cardiac catheterization confirmed the presence of a discrete inlet communication into the saphenous vein graft pseudoaneurysm (Figure 1E). The patient underwent successful occlusion of the ostium of the pseudoaneurysm by a covered stent graft (JOSTENT [Abbott Laboratories, USA] 4.00 mm × 8 mm) and disappearance of the jet of contrast (Figure 1F). Figure 1) A A complex cystic mass (arrow) measuring 3 cm × 3 cm × 4 cm was incidentally observed anterior to the right atrium on the axial T2-weighted magnetic resonance cholangiopancreatography half-Fourier acquisition single-shot turbo spin-echo ... Saphenous vein graft pseudoaneurysms are a rare complication following CABG and warrant prompt recognition due to potential fatal complications (1). They are often asymptomatic, discovered as an incidental paracardiac or mediastinal mass using complementary cardiac imaging including echocardiography, computed tomography and cardiac magnetic resonance imaging (2). Although surgery has traditionally been the treatment of choice (3), percutaneous techniques such as coiled embolization or self-expanding stents are emerging alternative options (4).

A “no-option” left main PCI registry: Outcomes and predictors of in hospital mortality—utility of the logistic EuroSCORE

Although high‐risk left main PCI populations have been previously described, there is little data describing outcomes and the role of the logistic EuroSCORE in surgical turndown cohorts or patients in extremis due to acute infarction or cardiogenic shock from left main ischemia.