Tomislav Jakljević

Drug-Coated Balloon Versus Drug-Eluting Stent in Primary Percutaneous Coronary Intervention: A Feasibility Study

Background: Drug‐eluting stents (DES) represent a significant evolution in the treatment of patients with acute myocardial infarction with ST elevation. However, stent‐related adverse events have led to an introduction of drug‐coated balloons (DCB) applied particularly to bifurcation lesions, in‐stent restenosis and small vessel disease. The aim of this study was to determine whether a DCB‐only strategy has a similar safety profile and equal angiographic and clinical outcomes to DES implantation in primary percutaneous coronary intervention (pPCI). Materials and Methods: Seventy‐five patients with acute myocardial infarction with ST elevation were randomized into DES and DCB groups of 37 and 38 patients, respectively. The study end‐points were major adverse cardiac events and late lumen loss during the 6 months following the pPCI. Results: Reinfarction occurred in 5.4% of patients in the DES and 5.3% of patients in the DCB group after 1 month (risk ratio = 1.03, 95% CI [0.15‐6.91], P = 0.98). After 6 months, major adverse cardiac events were reported in 5.4% of patients in the DES group and none in the DCB group (risk ratio = 5.13, 95% CI [0.25‐103.42], P = 0.29). Late lumen loss in the DES group was 0.10 ± 0.19 mm and −0.09 ± 0.09 mm in the DCB group (P < 0.05). Conclusions: A DCB‐only strategy is safe and feasible in the pPCI setting and showed good clinical and angiographic outcomes in a 6‐month follow‐up period.

Mechanical thrombectomy in ST-segment elevation myocardial infarction.

Current evidence does not support the routine use of rheolytic thrombectomy in primary PCI. In specific cases that are involving large occlusive thrombus it may be a therapy of choice.

Life-saving percutaneous coronary intervention in acute occlusion of two saphenous vein grafts

Cardiologia CROATICA Introduction: ST elevation myocardial infarction (STEMI in patients after coronary bypass artery graft (CABG) surgery is evenly caused by acute saphenous vein graft (SVG) occlusion (~50%) or native vessel occlusion (~50%). Acute SVG occlusion is infrequent event accounting for 2-3% of primary percutaneous coronary interventions (PCI). Most SVG occlusion related STEMI occurred in degenerative grafts, usually — 10 years after the index CABG surgery. Case: We present a case of successful urgent PCI of acutely occluded venous grafts. Our patient is a 72 years old male. He suffered from inferoapical STEMI with primary PCI on OM1. A TIMI 3 flow in infarcted artery was achieved. Due to extensive coronary disease elective surgical revascularization was planned. The patient was operated 6 months after STEMI. LIMA was deemed unsuitable for revascularization and three saphena magna vein grafts were implanted (towards LAD, OM1 and PDA/RCA) using “off pump” technique. Three hours after the operation ECG changes suggested development of STEMI in anterolateral region with rapid haemodynamic deterioration. He was immediately transferred to a catheterization laboratory. Control angiogram showed acutely occluded venous grafts to LAD and PDA (RCA). We continued with urgent PCI on the grafts. Thrombotic occlusion of LAD graft was successfully passed with a coronary wire and after thromboaspiration several balloon dilatations were performed. After cannulation of the PDA graft ostium coronary wire was positioned distally. Anastomosis and distal PDA were dilated. TIMI 3 flow was achieved in both arteries and we ended the procedure without stent implantation. Further hospital course was uneventful with preserved ejection fraction. Patient is in CCS 1 class in a 9 month clinical follow-up. Conclusion: The outcome of patients who experienced STEMI due to acute SVG occlusion is significantly worse compared to native vessel related myocardial infarctions. The outcome of patients who experienced STEMI due to acute SVG occlusion is significantly worse compared to native vessel related myocardial infarctions. We achieved good immediate angiographic result but the patient remains at high risk for recurrent event.

Solitary pulmonary hematoma-unusual complication of thrombolytic treatment

A 76 year-old man with COPD was addmited to our coronary care unit because of ST elevation myocrdial infarction. It was diagnosed by a combination of typical history, clinical features and electrocardiographic changes (ishemic lesion of the inferoposterior wall of the left ventricul) [1]. On addmision cardiac biochemical markers were within normal limits. There were no relative or absolute contraindications for thromolytic therapy [2]. Intravenous therapy with streptokinase, 1.5 million IU over 60 minutes was administered, followed by low molecular weight heparin and aspirin. Chest pain resolved and ECG showed regression of ST segment elevation, with frequent ventricular premature beats ; cardiac markers peaked 8 hours after streptokinase administration. Forty-eight hours after streptokinase administration hemoptysis occured, next day followed by profuse hemoptoa with significant decrease in blood pressure (85/40 mmHg), tachycardia (120/min) and rise of body temperature to 38.2 o ; C. Control blood count showed decrease of hemoglobin level from initial 122 to 87 g/L, hematocrit from initial 0.36 to 0.20. A control chest radiogram showed a large localized region of opacification (9x7 cm) in the upper right lung lobe, suggesting pulmonary hematoma. Anticoagulant and antiplatel therapy was discontinued and correction of consequent anemia with transfusion of erythrocyts was carried out. Further diagnostic studies such as control chest radiogram, bronchoscopy, bronchoalveolar lavage (BAL), Ziehl-Nielsen stainig, Lowenstein sputum cultures and chest CT, excluded bronchopneumonia, malignancy, bronchiectatic disease, active pulmonary tuberculosis and confirmed pulmonary hematoma. On the second day hemoptoa stopped. The patient was discharged and in stable condition on follow-up. A control chest radiogram six months later showed coplete resolution of hematoma.