Thibaut Petroni

Intra-aortic balloon pump effects on macrocirculation and microcirculation in cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation

Objectives:This study was designed to assess the effects on macrocirculation and microcirculation of adding an intra-aortic balloon pump to peripheral venoarterial extracorporeal membrane oxygenation in patients with severe cardiogenic shock and little/no residual left ventricular ejection. Design:A prospective, single-center, observational study where macrocirculation and microcirculation were assessed with clinical-, Doppler echocardiography–, and pulmonary artery–derived hemodynamic variables and also cerebral and thenar eminence tissue oxygenation and side-stream dark-field imaging of sublingual microcirculation. Setting:A 26-bed tertiary ICU in a university hospital. Patients:We evaluated 12 consecutive patients before and 30 minutes after interrupting and restarting intra-aortic balloon pump. Interventions:Measurements were performed before, and 30 minutes after interrupting and restarting intra-aortic balloon pump. Measurements and Main Results:Stopping intra-aortic balloon pump was associated with higher pulmonary artery-occlusion pressure (19 ± 10 vs 15 ± 8 mm Hg, p = 0.01), increased left ventricular end-systolic (51 ± 13 vs 50 ± 14 mm, p = 0.05) and end-diastolic (55 ± 13 vs 52 ± 14 mm, p = 0.003) dimensions, and decreased pulse pressure (15 ± 13 vs 29 ± 22 mm Hg, p = 0.02). Maximum pulmonary artery-occlusion pressure reduction when the intra-aortic balloon pump was restarted was observed in the seven patients whose pulmonary artery-occlusion pressure was more than 15 mm Hg when intra-aortic balloon pump was off (–6.6 ± 4.3 vs –0.6 ± 3.4 mm Hg, respectively). Thenar eminence and brain tissue oxygenation and side-stream dark-field–assessed sublingual microcirculation were unchanged by stopping and restarting intra-aortic balloon pump. Conclusions:Restoring pulsatility and decreasing left ventricular afterload with intra-aortic balloon pump was associated with smaller left ventricular dimensions and lower pulmonary artery pressures but did not affect microcirculation variables in cardiogenic shock patients with little/no residual left ventricular ejection while on peripheral venoarterial extracorporeal membrane oxygenation.

Outcomes of primary percutaneous coronary interventions in nonagenarians with acute myocardial infarction

BACKGROUND Few data are available on primary percutaneous coronary intervention (pPCI) in nonagenarians. In a large prospective registry on pPCI for STEMI we compared the demographics, procedural and in-hospital outcomes between nonagenarians (age ≥ 90 years) and patients aged < 90 years. METHODS AND RESULTS We included 26,157 consecutive patients with pPCI in the Greater Paris Area region between 2003 and 2011. Of these, 418 (1.6%) were ≥ 90 years old. Nonagenarians (versus patients < 90 years) were more likely to be female (62.3% versus 22.5%, p < 0.0001), nonsmokers (81.6% versus 36.7%, p < 0.0001), in cardiogenic shock (Killip IV) upon admission (10.5% versus 4.8%, p < 0.001), and had significant co-morbidities. Over two-thirds of patients underwent procedures via the radial artery (61% versus 72.1%, p = 0.007). Both groups had high and similar angiographic success rates (98.1% versus 98.7%, p = 0.33). Drug-eluting stents were used less often in nonagenarians (4.4% versus 16.7%, p < 0.0001). Hospital mortality was significantly much higher in patients over 90 years old (24.9% versus 5.1%, p < 0.001) in univariate analysis. After adjustment for sex, cardiogenic shock, diabetes, triple vessel disease, drug-eluting stent use and glycoprotein IIb/IIIa inhibitors use, mortality remains higher in nonagenarian patients (OR: 4.31; 95% CI: 3.26-5.71, p < 0.0001). CONCLUSIONS In a real-world setting, we found important demographic differences in nonagenarian compared to younger patients. Despite achieving a high rate of reperfusion with pPCI using mainly radial access, similar to that achieved in younger patients, hospital mortality was higher in nonagenarians.

Primary percutaneous coronary intervention for ST elevation myocardial infarction in nonagenarians

Objective To assess outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients. Methods We conducted a multicentre retrospective study between 2006 and 2013 in five international high-volume centres and included consecutive all-comer nonagenarians treated with primary PCI for STEMI. There were no exclusion criteria. We enrolled 145 patients and collected demographic, clinical and procedural data. Severe clinical events and mortality at 6 months and 1 year were assessed. Results Cardiogenic shock was present at admission in 21%. Median (IQR) delay between symptom onset and balloon was 3.7 (2.4–5.6) hours and 60% of procedures were performed through the transradial approach. Successful revascularisation of the culprit vessel was obtained in 86% of the cases (thrombolysis in myocardial infarction flow of 2 or 3). Major or clinically relevant bleeding was observed in 4% of patients. Median left ventricular ejection fraction post PCI was 41.5% (32.0–50.0). The in-hospital mortality was 24%, with 6 months and 1-year survival rates of 61% and 53%, respectively. Conclusions In our study, primary PCI in nonagenarians with STEMI was achieved and feasible through a transradial approach. It is associated with a high rate of reperfusion of the infarct-related artery and 53% survival at 1 year. These results suggest that primary PCI may be offered in selected nonagenarians with acute myocardial infarction.

0513: Bridge to transplantation versus standard heart transplantation: heart transplantation performed after ventricular assistance device is associated with improved survival

Aim Mechanical circulatory support is an alternative strategy as a bridge to transplantation for critical situations such as circulatory shock or graft shortage. The purpose of this study was to evaluate long-term results and outcome after heart transplantation performed in patients with ventricular assistance device (VAD) versus no mechanical circulatory support. Methods All the patients who underwent heart transplantation between 2005 and 2012 were included in this monocentric retrospective study. We compared 52 VAD patients who underwent heart transplantation to 289 patients transplanted without VAD. Results Mean age was 46±11 years in the VAD group vs 51±13 years in the standard group (p=0.01) and 17% of the VAD patients were women vs 25% (p=0.21). Ischemic time was longer in the VAD group (207±54 vs 169±60 min, p 60 years (OR 0.2.35 [1.34-4.14], p 60 years (HR 1.570 [1.05-2.34], p=0.02), recipient creatinin (HR 1.005 [1.002-1.008], p=0.02), and ischemic time (HR 1.004 [1.001-1.007], p=0.01). Conclusion: Bridge to transplantation by ventricular assistance device reduced one-year mortality and improved mid-term survival rate after heart transplantation.

0443: Primary percutaneous coronary intervention for ST elevation myocardial infarction in nonagenarians: a multicentre study

Background There are limited data on outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients. Methods and Results We conducted a multicentre retrospective study between 2006 and 2013 in 5 international high-volume centers and included 145 nonagenarians treated with primary PCI for STEMI. Cardiogenic shock was present at admission in 21%. Mean delay between symptom onset and balloon was 5,8±7,6 hours and 60% of procedures were performed through the transradial approach. Successful revascularization of the culprit vessel was obtained in 86% of the cases (TIMI flow of 2 or 3). Major or clinically-relevant bleeding was observed in 4% of patients. Mean cardiac troponin Ic was 65±79 ng/ml and mean LVEF post-PCI was 42±13%. The in-hospital mortality was 24% with 6 months and 1 year survival of 58% and 49% respectively. Conclusions In our study, primary PCI in nonagenarians with STEMI was successful and feasible through a transradial approach. It is associated with a high rate of successful reperfusion of the infarct-related artery and nearly 50% survival at one year. These results suggest that primary PCI should be offered in selected nonagenarians with acute myocardial infarction (table next page). Abstract 0443 – Table Procedural Findings Time from symtoms to PCI (h) 5.8±7.6 Catheterizzation access (%) Radial 60 Single Vessel Coronary Disease (%) 53 Single Vessel Coronary PCI (%) 74 Infarct-related coronary artery (%) Left main 4 Left anterior descending 41 Circumflex 14 Right 45 CABG 3 Thrombus aspiration (%) 14 TMI flow grade after procedure (%) 0 12 1 1 2 6 3 81 Coronary stenting (%) BMS 75 DES 9 POBA 10 Procedure success (%) Successful PCI 86 Failed PCI 11 Complicated PCI 3 Use of protection device (%) 2 IABP (%) 0 Use of inotropes during procedure (%) 26

0474: The deleterious cardiovascular impact of renal failure varies according to PCI indication

Aim To compare cardiovascular (CV) outcomes after contemporary PCI in patients with vs. without renal failure (RF) according to clinical presentation (ST-elevated myocardial infarction (STEMI), acute coronary syndrome (ACS), and stable coronary artery disease (sCAD)). Methods Consecutive patients undergoing PCI with stent implantation were prospectively included from 2007 to 2012. RF was defined by a CrCl Results Among 5337 patients eligible, 1219 (23%) had PCI for STEMI, 1837 (34%) for ACS and 2281 (43%) for sCAD. There were 1441 (27%) patients with RF. At one year, patients with RF had increased all-cause mortality rates whatever the indication for PCI (Figure), with a 6 fold higher unadjusted all-cause mortality rate in STEMI patients (41% vs. 7.5%) and a 3 fold increase in ACS (19% vs. 6%) and sCAD (10% vs. 3%) patients compared to noRF patients (p 0.05 for both). After multivariable analyses, RF was independently associated with an excess of death with a more than doubled relative risk in STEMI compared to ACS and sCAD patients (OR 5.3: CI 3.627-7.821 in STEMI vs. 2.1: CI 1.465-3.140 and 2.3: CI: 1.507-3.469 in ACS and sCAD, respectively, p Conclusion RF is a stronger independent predictor of death after PCI in patients with STEMI compared to patients with ACS and sCAD. CV prognosis of sCAD-RF patients was found to be comparable to that of STEMI-noRF patients.