Ulun Crimizade

Impaired inhibition of P2Y12 by clopidogrel is a major determinant of cardiac death in diabetes mellitus patients treated by percutaneous coronary intervention

OBJECTIVES We sought to determine whether low platelet response (LR) to the P2Y(12) receptor antagonist as assessed by vasodilator-stimulated phosphoprotein flow cytometry (VASP-FCT) differentially affects outcome in patients with or without diabetes mellitus undergoing percutaneous coronary intervention. BACKGROUND While both DM and LR to clopidogrel are known to predict an unfavorable outcome after PCI, the deleterious effect of their association is less well established. The VASP-FCT is specific for the P2Y(12) ADP receptor pathway. In this test, platelet activation is expressed as the platelet reactivity index (PRI). METHODS Patients were assigned to four different groups according to the presence or not of DM (DM, NDM) and LR to clopidogrel (LR, R). LR was defined as a PRI of >61%, a threshold previously identified as the optimal cut-off value to predict cardiac death following PCI. RESULTS A total of 436 consecutive patients (163 DM, 273 NDM) were enrolled. The proportion of LR patients was higher in DM (47.9% vs. 35.2% p=0.011). At 9±2 months follow-up, the rates of total and cardiac mortality and possible and overall stent thrombosis were higher in DM-LR patients. Conversely, the cardiovascular outcome of DM-R patients was comparable to that of NDM (-LR or -R) patients. In DM, a multivariate analysis identified LR to clopidogrel (HR 6.09 [1.27-29.08], p=0.023) as the sole independent predictor of cardiac mortality. CONCLUSIONS In DM patients undergoing PCI, LR to clopidogrel is an independent predictor of cardiac death.

The extent of P2Y12 inhibition by clopidogrel in diabetes mellitus patients with acute coronary syndrome is not related to glycaemic control: Roles of white blood cell count and body weight

It was the study objective to determine whether glycaemic control affects the extent of platelet inhibition by thienopyridines as assessed by vasodilator-stimulated phosphoprotein flow cytometry (VASP-FCT) in patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) during acute coronary syndrome (ACS). Although the proportion of high on-treatment residual platelet reactivity is higher in DM, the contributions of glycaemic control and other factors associated with DM, such as excess body weight and inflammation, to this impaired platelet inhibition by thienopyridines have not yet been fully characterised. In this study, the extent of P2Y12 ADP receptor pathway inhibition was evaluated by the VASP-FCT. Platelet activation was expressed as the platelet reactivity index (PRI). Low response to clopidogrel (LR) was defined as a PRI of >61%. Four hundred forty-five consecutive ACS patients (DM = 160, NDM = 285) were enrolled. The proportion of LR was higher in DM patients (50 vs. 37.5%). In DM, PRI was not correlated with glycosylated haemoglobin (HbA1c) or glycaemia. In a univariate analysis, LR was associated with age, male sex, overweight, and white blood cell count (WBC). In a multivariate analysis, WBC >10,000 and body weight >80 kg were the sole independent predictors of LR to clopidogrel (hazard ratio (HR) 3.02 [1.36-6.68], p=0.006 and HR 2.47 [1.14-5.35], p = 0.021, respectively). Conversely, in non-DM patients, ST-elevation myocardial infarction was the sole independent predictor of LR. In conclusion, in ACS DM patients undergoing PCI, the extent of P2Y12 inhibition by clopidogrel is not related to glycaemic control but is related to body weight and inflammatory status as assessed by the WBC.

Out-of-hospital cardiac arrest survivors sent for emergency angiography: a clinical score for predicting acute myocardial infarction

Background: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue. Emergency coronary angiography and percutaneous coronary intervention might improve survival, especially when cardiac arrest is caused by acute myocardial infarction (AMI). However, identifying patients with AMI after OHCA remains challenging. The aim of this study was to determine the clinical and ECG criteria in OHCA that may help to identify better the patients with AMI. Methods: Consecutive OHCA patients who underwent emergency coronary angiography in our centre between 2009 and 2013 were included in this retrospective single-centre observational study. Results: A total of 177 patients with complete datasets were included. Significant coronary artery disease was found in 71% of the patients, and 43% presented with AMI. The independent predictors of AMI were ST elevation in any lead including aVR (odds ratio (OR) 18.06; 95% confidence interval (CI) 6.6–49.38), chest pain before cardiac arrest (OR 4.05; 95% CI 1.55–10.54) and an initial shockable rhythm (OR 2.99; 95% CI 1.34–6.45). An additive score that included these three predictors yielded a sensitivity and a specificity for detecting AMI of 93% and 63%, respectively. Conclusions: These data suggest that fewer than half of patients with OHCA undergoing emergency coronary angiography present with AMI. The identification of OHCA patients with AMI might be improved by a simple score using post-resuscitation ECG and simple clinical criteria.

CT-ADP Point-of-Care Assay Predicts 30-Day Paravalvular Aortic Regurgitation and Bleeding Events following Transcatheter Aortic Valve Replacement

BACKGROUND Paravalvular aortic regurgitation (PVAR) remains a frequent postprocedural concern following transcatheter aortic valve replacement (TAVR). Persistence of flow turbulence results in the cleavage of high-molecular-weight von Willebrand multimers, primary haemostasis dysfunction and may favour bleedings. Recent data have emphasized the value of a point-of-care measure of von Willebrand factor-dependent platelet function (closure time [CT] adenosine diphosphate [ADP]) in the monitoring of immediate PVAR. This study examined whether CT-ADP could detect PVAR at 30 days and bleeding complications following TAVR. METHODS CT-ADP was assessed at baseline and the day after the procedure. At 30 days, significant PVAR was defined as a circumferential extent of regurgitation more than 10% by transthoracic echocardiography. Events at follow-up were assessed according to the Valve Academic Research Consortium-2 consensus classification. RESULTS Significant PVAR was diagnosed in 44 out of 219 patients (20.1%). Important reduction of CT-ADP could be found in patients without PVAR, contrasting with the lack of CT-ADP improvement in significant PVAR patients. By multivariate analysis, CT-ADP > 180 seconds (hazard ratio [HR]: 5.1, 95% confidence interval [CI]: 2.5-10.6; p < 0.001) and a self-expandable valve were the sole independent predictors of 30-day PVAR. At follow-up, postprocedural CT-ADP >180 seconds was identified as an independent predictor of major/life-threatening bleeding (HR: 1.7, 95% CI [1.0-3.1]; p = 0.049). Major/life-threatening bleedings were at their highest levels in patients with postprocedural CT-ADP > 180 seconds (35.2 vs. 18.8%; p = 0.013). CONCLUSION Postprocedural CT-ADP > 180 seconds is an independent predictor of significant PVAR 30 days after TAVR and may independently contribute to major/life-threatening bleedings.

Giant ventricular pseudoaneurysm following inferior myocardial infarction: insights from multimodal imaging approach

An 85-year-old woman was referred to our institution because of inferior ST-segment elevation myocardial infarction (STEMI) with a moderate troponin peak of 10.88 lg/L (N < 0.04 lg/L). Angiographic data showed a two-vessel coronary artery disease with a proximal occlusion of the right coronary artery (RCA) and a complex highly calcified bifurcation stenosis involving the left anterior descending artery (LAD segment 2) and the ostium of the second diagonal branch. The patient underwent angioplasty of the infarct-related RCA. Decision was made to refer the patient within a month to our cath lab for secondary treatment of the LAD bifurcation lesion. The discharge TTE disclosed inferior wall akinesia, small basal inferior aneurysm, and normal left ventricular ejection fraction (LVEF). The patient was readmitted 17 days after discharge due to recurrent acute anterior STEMI and cardiogenic shock (severe left ventricular (LV) dysfunction with LVEF of 25% at the time of admission in the cath lab). Urgent coronary angiography was performed 4 h after symptoms onset and showed a complete occlusion of the proximal LAD, well above the bifurcation lesion. Percutaneous coronary intervention with stenting of the culprit lesion was performed, but revascularization of the bifurcation lesion was considered too high risk. Transthoracic echocardiography disclosed a large defect (8.5 mm) of the basal inferior wall (Figure 1A), with extension in to a pseudoaneurysm. A colour Doppler analysis (Figure 1B) showed shunt flows passing from the LV to the aneurysmal pouch. 2D and 3D maximum intensity projection (MIP) multiphasic cardiac CT images provided a non-invasive modality for the evaluation of the pseudoaneurysm. It helped to define the anatomy, size, course, relationship of the pseudoaneurysm and determine further therapeutic strategies. Cardiac CT revealed a giant pseudoaneurysm (31 47 mm) running the length of the right ventricle (Figure 2). The final diagnosis was cardiogenic shock related to recurrent anterior STEMI and the fast growing development of an inferior pseudoaneurysm.

0258: Comparison of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement in very high risk patients, monocentric registry of an early experience

Introduction The PARTNER trial has shown that TAVI is not inferior to surgical aortic valve replacement (AVR) in high-risk aortic stenosis. However, real life registry comparing TAVI and surgery are lacking. Methods monocentric registry of high-risk patients (lEUROSCORE1 ≥15%) undergoing TAVI (114 patients) or AVR (81 patients) between 2009 and 2013 in our institution. Results Mean age was 84,4 and 83,6 yo (p=NS). TAVI patients had higher EUROSCORE1 (31 vs 24.5%, p Conclusion The present registry results confirm that TAVI is a real alternative to surgery in patients with at high surgical risk. Longer follow up is required to confirm these results. Abstract 0258 – Table. AVR TAVI p n 81 114 Age 83.6 84.4 0.21 Euroscore1 (%) 24.5 31 FEV (%) 57.1 48.5 DTVG (mm) 51 54 0.086 Mean Gradient (mmHg) 53 46 0.008 Creatinin pre (microM/L) 111 138 0.003 Hemoglobin pre (g/100) 12.6 11.6 Death (%) 17.3 9.6 0.12 Vascular complication (%) 0 11.4 0.001 Infection (%) 19 11 0.008 Dialysis (%) 13.6 11.4 0.65 AFIB post (%) 41 20 0.002 Pericardial effusion (% ) 2.5 8.8 0.13 Stroke (%) 4.9 1.8 0.23 Pace Maker (%) 4.9 24.6 Transfusions (%) 80 25

0228: Aortic annulus sizing strategy in TAVI, comparison of echocardiography and CT, impact on aortic regurgitation incidence and patients prognosis

Background Aortic regurgitation (AR) after TAVI is the main limitation of this procedure. The aim of this study was to evaluate i) aortic annulus sizing by CT and/or echocardiography (TTE or TEE) ii) the incidence of AR and its determinism iii) the prognostic impact of AR and other survival predictors. Methods 136 consecutive patients undergoing TAVI were included between 2010 and 2013. The aortic annulus sizing for prosthesis choice was done by TEE in 29 patients and by CT in 107 patients. Aortic valve calcium volume was measured by the volume technique in 67% of patients who have got CT. Follow-up was performed at 1, 6, 12 and 24 months. Results Aortic annulus sizing by TTE and TEE echocardiography (TEE) were well correlated (r=0,73, p=0,0001, n=51) but were significantly lower than CT sizing (p 25%, aortic regurgitation ≥ 2/4, renal failure with creatinin> 130μmol/l, anemia after TAVI Conclusion This study showed that aortic annulus sizing by echocardiography is significantly lower than sizing by CT. AR have an independent prognostic on survival. Prevention of aortic regurgitation is an important issue for the future of this technique.