Tomas Ondrus

Age – related treatment strategy and long-term outcome in acute myocardial infarction patients in the PCI era

BackgroundOlder age, as a factor we cannot affect, is consistently one of the main negative prognostic values in patients with acute myocardial infarction. One of the most powerful factors that improves outcomes in patients with acute coronary syndromes is the revascularization preferably performed by percutaneous coronary intervention. No data is currently available for the role of age in large groups of consecutive patients with PCI as the nearly sole method of revascularization in AMI patients. The aim of this study was to analyze age-related differences in treatment strategies, results of PCI procedures and both in-hospital and long-term outcomes of consecutive patients with acute myocardial infarction.MethodsRetrospective multicenter analysis of 3814 consecutive acute myocardial infarction patients divided into two groups according to age (1800 patients ≤ 65 years and 2014 patients > 65 years). Significantly more older patients had a history of diabetes mellitus and previous myocardial infarctions.ResultsThe older population had a significantly lower rate of coronary angiographies (1726; 95.9% vs. 1860; 92.4%, p < 0.0001), PCI (1541; 85.6% vs. 1505; 74.7%, p < 0.001), achievement of optimal final TIMI flow 3 (1434; 79.7% vs. 1343; 66.7%, p < 0.001) and higher rate of unsuccessful reperfusion with final TIMI flow 0-1 (46; 2.6% vs. 78; 3.9%, p = 0.022). A total of 217 patients (5.7%) died during hospitalization, significantly more often in the older population (46; 2.6% vs. 171; 8.5%, p < 0.001). The long-term mortality (data for 2847 patients from 2 centers) was higher in the older population as well (5 years survival: 86.1% vs. 59.8%). Though not significantly different and in contrast with PCI, the presence of diabetes mellitus, previous MI, final TIMI flow and LAD, as the infarct-related artery, had relatively lower impact on the older patients. Severe heart failure on admission (Killip III-IV) was associated with the worst prognosis in the whole group of patients, though its significance was higher in the youngers (HR 6.04 vs. 3.14, p = 0.051 for Killip III and 12.24 vs. 5.65, p = 0.030 for Killip IV). We clearly demonstrated age as a strong discriminator for the whole population of AMI patients.ConclusionsIn a consecutive AMI population, the older group (>65 years) was associated with a less pronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomy by coronary angiography and proceed to PCI if suitable regardless of age is crucial in all patients, though the primary success rate of PCI in the older age is lower. Age, when viewed as a risk factor, was a dominant discriminating factor in all patients.

Acute myocardial infarction complicated by shock: outcome analysis based on initial electrocardiogram

Abstract Objectives. To assess the relation between initial ECG findings, presence of risk factors, coronary angiography findings, and clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS). Design. Data from a total of 5572 acute myocardial infarction patients admitted to the four tertiary hospitals during a period of 3 years were analyzed. CS on admission was present in 358 patients (6.4%). They were divided into four groups based on the admission ECG: ST-segment elevation (STEMI), ST-segment depression (STDMI), bundle branch block (BBBMI), and other ECG acute myocardial infarction. Results. CS developed most frequently among BBBMI patients (in 12.1% of all BBBMIs, p < 0.001 vs. STEMI), followed by STEMI (6.7%), STDMI (4.4%), and other ECG acute myocardial infarction (2.3%). The risk of CS development was similar in patients with left bundle branch block (LBBB) (13.3%) and right bundle branch block (RBBB) (11.2%). The one-year mortality was highest among RBBBMI patients (66.7%, p < 0.001), followed by LBBBMI (48.6%), other ECG (47.1%), STEMI (41.7%), and STDMI patients (38.1%). Conclusions. RBBB on admission ECG is associated with the highest risk of CS development, frequent left main coronary artery affection, and unsuccessful revascularization. It is also an independent predictor of one-year mortality.

Association of the right ventricle impairment with electrocardiographic localization and related artery in patients with ST-elevation myocardial infarction

INTRODUCTION The right ventricular myocardial infarction (RVMI) has traditionally been mainly related to inferior wall ST elevation myocardial infarction (STEMI). This study assessed the RVMI electrocardiographic (ECG-RVMI) signs in relationship to ECG-based STEMI localization and to the infarct related artery in patients treated with primary percutaneous coronary intervention (pPCI). METHODS Three hundred consecutive adult patients (107 females) were referred to catheterization laboratory with the acute STEMI diagnosis. In all patients, both the standard 12-lead ECGs and the right-sided precordial leads (V1R-V6R) were recorded. ECG-RVMI was diagnosed by ST segment elevation above 100μV in V4R. RESULTS ECG signs of RVMI were found in 35 and 31 (23.8% for both) patients with inferior and anterior wall STEMI, respectively. In 32 ECG-RVMI patients, the right coronary artery (RCA) was occluded while in 34 patients, the occlusions were in the left anterior descending (LAD) or the left circumflex artery. No statistically significant differences were found in ECG-RVMI patients when comparing clinical variables between those with anterior and inferior wall STEMI. CONCLUSIONS ECG signs of RVMI during acute STEMI are not uncommon. RCA was the infarction-related artery in only one half of these patients. Anterior wall STEMI and the LAD were associated with a significant proportion of ECG-RVMI cases.

Radial artery neointimal hyperplasia after transradial PCI-Serial optical coherence tomography volumetric study

Aims Transradial catheterization (TRC) is a dominant access site for coronary catheterization and percutaneous coronary interventions (PCI) in many centers. Previous studies reported higher intimal thickness of the radial artery (RA) wall in patients with a previous history of TRC. In this investigation the aim was to assess the intimal changes of RA using the optical coherence tomography (OCT) intravascular imaging in a serial manner. Methods and results 100 patients with the diagnosis of non-ST-elevation myocardial infarction (nSTEMI) treated by PCI were enrolled (6 patients were excluded from this analysis because of occluded RA at follow-up [2 patients] and insufficient quality of OCT images [4 patients]). An 54mm long OCT run of the RA was performed immediately after the index PCI and repeated 9 months later. Volumetric analyses of the intimal layer and lumen changes were conducted. Median intimal volume at baseline versus 9 months was 33.9mm3 (19.0; 69.4) versus 39.0mm3 (21.7; 72.6) (p<0.001); and median arterial lumen volume was 356.3mm3 (227.8; 645.3) versus 304.7mm3 (186.1; 582.7) (p<0.001). There was no significant difference in the effect of any clinical factor on the RA volume changes. Conclusions OCT volumetric analyses at baseline and 9 months showed a significant increase in the radial artery intimal layer volume and a decrease in lumen volume after transradial PCI. No significant factors affecting this process were identified.

Higher incidence of hypotension episodes in women during the sub-acute phase of ST elevation myocardial infarction and relationship to covariates

Objective The introduction of primary percutaneous coronary intervention (PPCI) has modified the profile of ST elevation myocardial infarction (STEMI) patients. Occurrence and prognostic significance of hypotension episodes are not known in PPCI treated STEMI patients. It is also not known whether and/or how the hypotension episodes correlate with the degree of myocardial damage and whether there are any sex differences. Methods Data of 293 consecutive STEMI patients (189 males) treated by PPCI and without cardiogenic shock were analyzed. Blood pressure was measured noninvasively. A hypotensive episode was defined as a systolic blood pressure below 90 mmHg over a period of at least 30 minutes. Results A hypotensive episode was observed in 92 patients (31.4%). Female sex was the strongest independent predictor of hypotension episodes (p < 0.0001), while there was no relationship to electrocardiographic STEMI localization. Hypotensive patients had significantly higher levels of troponin T and brain natriuretic peptide; hypotensive episodes were particularly frequent in women with increased troponin T. Treatment with angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB) and betablockers was less frequent in hypotensive patients. After a mean 20-month follow-up, all-cause mortality did not differ between hypotensive patients and others. However, mortality in hypotensive patients who did not tolerate ACEI/ARB therapy was significantly higher compared to other hypotensive patients (p = 0.016). Conclusion Hypotension episodes are not uncommon in the sub-acute phase of contemporarily treated STEMI patients with a striking difference between sexes—female sex was the strongest independent predictor of hypotension episodes. Hypotensive episodes may lead to a delay in pharmacotherapy which influences prognosis. Higher incidence of hypotension in women could at least partially explain the sex-related differences in the use of cardiovascular pharmacotherapy which was repeatedly observed in various studies.

Minimally invasive mitral valve annuloplasty confers a long-term survival benefit compared with state-of-the-art treatment in heart failure with functional mitral regurgitation

BACKGROUND Clinical impact of the minimally invasive surgical mitral valve annuloplasty (MVA) of functional mitral regurgitation (FMR) in systolic heart failure on top of the state-of-the-art standards of care remains controversial. Therefore, we aimed to compare clinical outcomes of isolated MVA using the mini-invasive videothoracoscopic approach versus the state-of-the-art (CON=conservative) treatment in patients with chronic systolic heart failure and symptomatic FMR. METHODS The study population consisted of 379 patients (age 68.9±11.0years, 62.8% males) with left ventricular (LV) systolic dysfunction, symptomatic FMR and previous heart failure hospitalization. A total of 167 patients underwent undersized MVA and 212 patients were treated conservatively. A concomitant MAZE was performed in 53 (31.7%) patients. RESULTS In the MVA group, the periprocedural and the 30-day mortality were 1.2% and 4.8%, respectively. During the median follow-up of 7.1years (IQR 3.5-9.8years) a total of 74 (44.3%) and 138 (65.1%) died in the MVA and the CON group, respectively (p<0.001). The lowest mortality was observed in MVA combined with MAZE (22.6%; p<0.01). In Cox regression analysis, age, MVA with MAZE emerged as independent predictors of both all-cause mortality and rehospitalizations for heart failure (all p<0.05). MVA was associated with significantly greater symptomatic improvement and reduction of FMR than the conservative treatment (both p<0.001). Reverse LV remodeling was observed only in the MVA combined with MAZE group (p<0.01). CONCLUSIONS In patients with symptomatic FMR, minimally invasive MVA, in particular in combination with MAZE, confers an independent long-term survival benefit compared with the state-of-the-art treatment.

Quantification of aortic annulus in computed tomography angiography: Validation of a fully automatic methodology

BACKGROUND Automatic accurate measuring of the aortic annulus and determination of the optimal angulation of X-ray projection are important for the trans-catheter aortic valve replacement (TAVR) procedure. The objective of this study was to present a novel fully automatic methodology for the quantification of the aortic annulus in computed tomography angiography (CTA) images. METHODS CTA datasets of 26 patients were analyzed retrospectively with the proposed methodology, which consists of a knowledge-based segmentation of the aortic root and detection of the orientation and size of the aortic annulus. The accuracy of the methodology was determined by comparing the automatically derived results with the reference standard obtained by semi-automatic delineation of the aortic root and manual definition of the annulus plane. RESULTS The difference between the automatic annulus diameter and the reference standard by observer 1 was 0.2±1.0mm, with an inter-observer variability of 1.2±0.6mm. The Pearson correlation coefficient for the diameter was good (0.92 for observer 1). For the first time, a fully automatic tool to assess the optimal projection curves was presented and validated. The mean difference between the optimal projection curves calculated based on the automatically defined annulus plane and the reference standard was 6.4° in the cranial/caudal (CRA/CAU) direction. The mean computation time was short with around 60s per dataset. CONCLUSION The new fully automatic and fast methodology described in this manuscript not only provided precise measurements about the aortic annulus size with results comparable to experienced observers, but also predicted optimal X-ray projection curves from CTA images.

Resolving Apparent Inconsistencies Between Area, Flow, and Gradient Measurements in Patients With Aortic Valve Stenosis and Preserved Left Ventricular Ejection Fraction

Inconsistencies between area (aortic valve area [AVA])-flow-gradient are common during the echocardiographic assessment of aortic stenosis (AS). This study was conducted to investigate the importance of these inconsistencies and the impact of 3 methods to resolve these inconsistencies. The study population consisted of 327 patients (age: 76.3 ± 8.6 years, 49.5% males) with severe AS (SAS) (AVA ≤ 1 cm2) and preserved left ventricular ejection fraction (≥50%). Inconsistent findings between AVA, flow, and mean gradient (MG) were observed in 78 (23.9%) patients with low flow and a high MG, 52 (15.9%) patients with normal flow and a low MG, and 37 (11.3%) patients with a low flow and a low MG. Using stroke volume index by catheterization for AVA recalculation showed the greatest effect to resolve inconsistencies in the low flow and a high MG group (85%). Decreasing the AVA cut-off values for SAS to ≤0.8 cm2 resulted in a shift from SAS to moderate AS in 36 patients (69%) in the normal flow and a low MG. Indexing AVA to body surface area had only a minor impact on reclassification. In conclusion, in patients with SAS and preserved left ventricular ejection fraction, the majority of area-flow-gradient inconsistencies at echocardiography can be resolved by correcting errors in stroke volume index measurements by alternative techniques and by redefining the cut-off value for SAS to ≤0.8 cm2.

TCT-547 Radial artery changes after transradial PCI – A serial optical coherence tomography volumetric study

Transradial catheterization (TRC) is a dominant access site for coronary catheterization and percutaneous coronary interventions (PCI) in many centers. Previous studies reported higher intimal thickness of the radial artery (RA) wall in patients with a previous history of TRC. In this investigation

Short sheath benefit in radial artery injury after PCI -optical coherence tomography serial study

BACKGROUND AND AIMS Transradial catheterization is the predominant access site for coronary catheterization and percutaneous coronary interventions (PCI). Previous studies have reported a high incidence of radial artery (RA) injury. The aim of this investigation was to evaluate the incidence of RA injury using last generation optical coherence tomography (OCT) intravascular imaging in a serial manner. METHODS 100 patients with a diagnosis of non-ST-elevation myocardial infarction (nSTEMI) treated by PCI were enrolled. OCT of RA was performed immediately after the index PCI. OCT was repeated 9 months later. RESULTS There were 11 patients with RA injuries (11.0%) at baseline, including 3 patients with RA medial dissection and 8 patients with intimal tears. In the follow-up OCT data, the number of RA injuries was 10 (10.0%), including 7 patients with RA medial dissection and 3 patients with intimal tear. All injuries were clinically asymptomatic and there was no finding of vessel perforation. There was no significant difference between the baseline and follow-up procedure in terms of number of injuries. CONCLUSION The study showed no significant difference between baseline and follow-up RA injury incidence. There was a higher risk of radial injury for repeated catheterization in women. The conclusion is that radial catheterization is a very safe procedure in terms of radial artery damage. This is evidenced by considerably fewer injuries compared to published studies. The use of the short radial sheath (7 cm in this study) is protective and reduces the incidence of radial injury.