Roshan Weerackody

Successful Recanalization of Chronic Total Occlusions Is Associated With Improved Long-Term Survival

OBJECTIVES This study investigated the impact of procedural success on mortality following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a large cohort of patients in the drug-eluting stent era. BACKGROUND Despite advances in expertise and technologies, many patients with CTO are not offered PCI. METHODS A total of 6,996 patients underwent elective PCI for stable angina at a single center (2003 to 2010), 836 (11.9%) for CTO. All-cause mortality was obtained to 5 years (median: 3.8 years; interquartile range: 2.0 to 5.4 years) and stratified according to successful chronic total occlusion (sCTO) or unsuccessful chronic total occlusion (uCTO) recanalization. Major adverse cardiac events (MACE) included myocardial infarction (MI), urgent revascularization, stroke, or death. RESULTS A total of 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting). Prior revascularization was more frequent among uCTO patients: coronary artery bypass grafting (CABG) (16.5% vs. 7.4%; p < 0.0001), PCI (36.0% vs. 21.2%; p < 0.0001). Baseline characteristics were otherwise similar. Intraprocedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but did not affect in-hospital MACE (3% vs. 2.1%; p = NS). All-cause mortality was 17.2% for uCTO and 4.5% for sCTO at 5 years (p < 0.0001). The need for CABG was reduced following sCTO (3.1% vs. 22.1%; p < 0.0001). Multivariate analysis demonstrated that procedural success was independently predictive of mortality (hazard ratio [HR]: 0.32 [95% confidence interval (CI): 0.18 to 0.58]), which persisted when incorporating a propensity score (HR: 0.28 [95% CI: 0.15 to 0.52]). CONCLUSIONS Successful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis.

Atypical risk factor profile and excellent long-term outcomes of young patients treated with primary percutaneous coronary intervention for ST-elevation myocardial infarction

Introduction: Several studies have examined the relationship between age and clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI). The majority of studies have concentrated on describing elderly patients and there has been less focus on the profile and outcome of young patients suffering from STEMI. The aim of this study was to describe the clinical profile and outcomes of young patients compared with an older cohort and to establish what risk factors were associated with young patients having PPCI for STEMI. Methods: This was an observational cohort study of 3618 patients with STEMI treated by PPCI at a regional heart attack centre in London between January 2004 and September 2012. Clinical characteristics and outcomes in (young) patients aged ≤45 years were compared with those in (older) patients aged >45 years. The primary and main secondary outcomes were all-cause mortality and major adverse cardiovascular event rates, respectively, at a median follow-up of 3.0 (interquartile range 1.2–4.6) years. Results: Of the 3618 patients, 367 (10.1%) were aged ≤45 years and 3251 (89.9%) were aged >45 years. The proportion of patients aged ≤45 years increased from 8.5% to 11.5% (p=0.04) during the study period. Compared with older patients, those aged ≤45 years were more likely to be male, smokers, of South Asian ethnicity and to have a family history of premature coronary artery disease. Young patients were less likely to have a history of hypertension, hypercholesterolaemia, diabetes mellitus, previous myocardial infarction, myocardial revascularisation, or to have left ventricular systolic impairment or renal impairment. Over the follow-up period, mortality (2.7% vs. 7.6%; p<0.0001) and major adverse cardiovascular event rates (7.0% vs. 13.5%; p<0.0001) were significantly lower in patients aged ≤45 years compared with older patients. After adjustment for potential confounding factors, young age remained a predictor of reduced all cause mortality when compared with older patients (hazard ratio 0.12 (95% confidence interval 0.04–0.38)), including after incorporation of a propensity score (hazard ratio: 0.14 (95% confidence interval 0.04–0.36)). Conclusions: In this cohort of patients with STEMI treated by PPCI there was an increasing incidence of young patients aged ≤45 years throughout the study period. These patients were more often male, smokers and of South Asian ethnicity. Outcomes in younger patients was good. Focusing preventative strategies on smokers and high risk ethnic groups may help reduce the incidence of premature coronary artery disease.

35 Successful recanalisation of chronic total occlusions is associated with increased long term survival

Introduction Chronic total occlusion (CTO) remains a challenging lesion subset. Despite advances in equipment and expertise, many CTO patients may not be offered PCI as physicians perceive procedural success may be lower, and the anatomy is stable. The aim of this study was to investigate the impact of procedural success on mortality following CTO-PCI in a large cohort of patients in the drug eluting stent era. Methods 6122 consecutive patients underwent elective PCI at a single centre (October 2003–May 2010), 836 (13.7%) for CTO. Demographic and procedural data were collected at the time of intervention (Abstract 35 table 1). In-hospital MACE (myocardial infarction, urgent revascularisation, stroke or death) was documented at discharge. All cause mortality data was obtained from the Office of National Statistics via the BCIS/CCAD national audit out to 4 years (mean 2.9±1.6) and stratified according to successful or unsuccessful CTO recanalisation.Abstract 35 Table 1 Successful (n=572) Unsuccessful (n=264) p value Age 62.4±0.47 63.7±0.69 0.1 Male 433 (75.7%) 209 (79.2%) 0.3 Diabetes 151 (26.9%) 74 (28.6%) 0.6 Hypertension 320 (63.8%) 160 (66.6%) 0.5 Hypercholesterolaemia 281 (56.0%) 147 (61.2%) 0.2 Previous MI 174 (31.7%) 94 (36.4%) 0.2 Radial access 123 (21.5%) 47 (17.8%) 0.3 Femoral access 416 (72.7%) 193 (73.1%) 0.6 Dual site access (bilateral femoral or radial + femoral) 23 (4.0%) 18 (6.8%) 0.5 Results 572 (68.4%) CTO procedures were successful. Coronary stents were implanted in 96.9% (mean 2.3±0.1 stents per patient, 70% drug eluting). Prior revascularisation was more frequent among patients with unsuccessful CTO-PCI than successful; prior CABG 16.5% unsuccessful vs 7.4% successful, (p<0.0001), PCI 36.0% vs 21.2%, (p<0.0001). Baseline characteristics were otherwise similar (Abstract 35 table 1). Intra-procedural complications (coronary dissection, perforation, access site (dissection, haematoma) were more frequent in unsuccessful cases (19% (52) vs 4.1% (20) (p<0.0001) but did not have an impact on in-hospital MACE (2% vs 1.8%, p=0.6). All cause mortality was 8% (21) in the unsuccessful group and 3% (17) in the successful group out to 4 years, (Abstract 35 figure 1). Mortality following successful CTO-PCI was similar to that of the non-CTO elective PCI group (5.1%, p=NS).Abstract 35 Figure 1 All cause mortality after PCI for elective patients. Conclusion A successful angiographic outcome following CTO-PCI is associated with a survival advantage out to 4 years following intervention. These data suggest that the adoption of new techniques and technologies to improve procedural success may improve prognosis.

Prevention of thrombus embolization during primary percutaneous intervention using a novel mesh covered stent

Embolization of athero‐thrombotic material during primary percutaneous coronary intervention is a common cause of periprocedural complication. Methods developed to reduce embolization include thrombus aspiration, and distal protection. We report five cases of primary percutaneous intervention to coronary arteries that contain large amounts of thrombus, using a novel mesh covered stent. The mesh covering of the stent is designed such that it is theoretically able to ensnare thrombus and thus prevent distal migration of embolic material. In all cases, TIMI grade III flow was achieved at the end of the procedure, despite the extensive thrombus burden.

Percutaneous balloon aortic valvuloplasty in the era of transcatheter aortic valve implantation: a narrative review

The role of percutaneous balloon aortic valvuloplasty (BAV) in the management of severe symptomatic aortic stenosis has come under the spotlight following the development of the transcatheter aortic valve implantation (TAVI) technique. Previous indications for BAV were limited to symptom palliation and as a bridge to definitive therapy for patients undergoing conventional surgical aortic valve replacement (AVR). In the TAVI era, BAV may also be undertaken to assess the ‘therapeutic response’ of a reduction in aortic gradient in borderline patients often with multiple comorbidities, to assess symptomatic improvement prior to consideration of definitive TAVI intervention. This narrative review aims to update the reader on the current indications and practical techniques involved in undertaking a BAV procedure. In addition, a summary of the haemodynamic and clinical outcomes, as well as the frequently encountered procedural complications is presented for BAV procedures conducted during both the pre-TAVI and post-TAVI era.

Deployment of drug-eluting stents for isolated proximal lad disease is associated with lower major adverse cardiac events and no increase in stent thrombosis when compared with bare metal stents: A 5-year observational cohort study

Drug‐eluting stents (DES) may be associated with an increased risk of late stent thrombosis (ST) compared with bare metal stents (BMS). We compared major adverse cardiac events (MACE) and long term all cause mortality in patients with isolated proximal LAD disease treated with DES or BMS.

Importance of primary percutaneous coronary intervention for reducing mortality in ST-elevation myocardial infarction complicated by out of hospital cardiac arrest

Background: Current recommendations are for primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI) complicated by out of hospital cardiac arrest (OHCA). However, information about longer-term outcomes is sparse, particularly among high-risk patients who do not regain consciousness promptly after resuscitation. Methods and results: Of 1836 consecutive patients admitted with STEMI for pPCI between April 2008–October 2011, 132 (7.2%) who had suffered OHCA with recovery of spontaneous circulation (ROSC) form the study population. 101 patients survived to hospital discharge (76.5%) with only one further death in the first year. Prognosis was worse for the 62 patients who were unconscious on arrival and required admission to the intensive therapy unit (ITU), only 54% of whom survived. Every additional minute in the time to ROSC increased the hazard of death by 1.7% while alertness upon ROSC and successful reperfusion in response to pPCI reduced the hazard of death by 90% and 65% respectively. Full neurological recovery was recorded in 85.1% of those who survived to be discharged but in only 30.6% of the 34 survivors who were admitted unconscious and received ITU treatment. Every additional minute in the time to ROSC increased the odds of neurological deficit by 7.0%. Conclusions: In patients with STEMI who are conscious after OHCA, high rates of survival can be achieved with pPCI, depending in part on the time it takes for ROSC. Prognosis is less good in the subgroup brought to hospital unconscious but even in this high risk group neurologically intact survival can be achieved in about one-third of cases, suggesting the benefit of immediate pPCI in STEMI patients successfully resuscitated after OHCA.

Simulation of cardiac emergencies with real patients.

Simulation training with manikin simulators for medical emergencies is increasingly used in medical training. The assessment of a manikin, in particular history and examination, is very different to that of a real patient. We sought to combine aspects of traditional simulation training with the assessment of real hospital in‐patients.

Glycoprotein IIb/IIIa inhibitors use and outcome after percutaneous coronary intervention for non-ST elevation myocardial infarction.

Aims. We investigate the effect of glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors on long-term outcomes following percutaneous coronary intervention (PCI) after non-ST elevation myocardial infarction (NSTEMI). Meta-analyses indicate that these agents are associated with improved short-term outcomes. However, many trials were undertaken before the routine use of P2Y12 inhibitors. Recent studies yield conflicting results and registry data have suggested that GP IIb/IIIa inhibitors may cause more bleeding than what trials indicate. Methods and Results. This retrospective observational study involves 3047 patients receiving dual-antiplatelet therapy who underwent PCI for NSTEMI. Primary outcome was all-cause mortality. Major adverse cardiac events (MACE) were a secondary outcome. Mean follow-up was 4.6 years. Patients treated with GP IIb/IIIa inhibitors were younger with fewer comorbidities. Although the unadjusted Kaplan-Meier analysis suggested that GP IIb/IIIa inhibitor use was associated with improved outcomes, multivariate analysis (including propensity scoring) showed no benefit for either survival (P = 0.136) or MACE (P = 0.614). GP IIb/IIIa inhibitor use was associated with an increased risk of major bleeding (P = 0.021). Conclusion. Although GP IIb/IIIa inhibitor use appeared to improve outcomes after PCI for NSTEMI, patients who received GP IIb/IIIa inhibitors tended to be at lower risk. After multivariate adjustment we observed no improvement in MACE or survival and an increased risk of major bleeding.

Cardiac magnetic resonance myocardial feature tracking: feasibility for use in left ventricular non-compaction

Background Cardiac magnetic resonance (CMR) myocardial feature tracking (FT) is emerging as a sensitive and reproducible method for measuring myocardial strain parameters without the need to acquire additional images. Up until now adult CMRFT studies have primarily focussed on the reproducibility of the software,with very few studies addressing disease states beyond ischaemic cardiomyopathy. The aim of this pilot study was to assess the feasibility of cine-images derived quantitative CMR FT strain parameters to differentiate between normal individuals and patients with Left ventricular non-compaction (LVNC). Methods Patients were identified retrospectively from an established clinical CMR database. 8 LVNC patients with negative invasive angiography or stress CMR myocardial perfusion imaging were compared to 21 normal controls. LVNC was defined according to the Petersen criteria,with an end-diastolic ratio of non-compacted to compacted layer (NC/C) >2.3. LV morphological and functional parameters were performed off-line on a dedicated workstation. CMR 4chamber(4CH) and mid-ventricular short axis(SAX) cineimages were analysed in systole(S) and diastole(D) using dedicated FT software(Diogenes MRI,TomTec Imaging Systems,Munich Germany).