Vincent van Ommen

Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction

OBJECTIVESnThe study assessed the value of the electrocardiogram (ECG) as predictor of the left anterior descending coronary artery (LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1) in patients with acute anterior myocardial infarction (AMI).nnnBACKGROUNDnIn anterior AMI, determination of the exact site of LAD occlusion is important because the more proximal the occlusion the less favorable the prognosis.nnnMETHODSnOne hundred patients with a first anterior AMI were included. The ECG showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site as determined by coronary angiography.nnnRESULTSnST-elevation in lead aVR (ST elevation(aVR)), complete right bundle branch block, ST-depression in lead V5 (ST depression(V5)) and ST elevation(V1) > 2.5 mm strongly predicted LAD occlusion proximal to S1, whereas abnormal Q-waves in V4-6 were associated with occlusion distal to S1 (p = 0.000, p = 0.004, p = 0.009, p = 0.011 and p = 0.031 to 0.005, respectively). Abnormal Q-wave in lead aVL was associated with occlusion proximal to D1, whereas ST depression(aVL) was suggestive of occlusion distal to D1 (p = 0.002 and p = 0.022, respectively). For both the S1 and D1, inferior ST depression > or = 1.0 mm strongly predicted proximal LAD occlusion, whereas absence of inferior ST depression predicted distal occlusion (p < or = 0.002 and p < or = 0.020, respectively).nnnCONCLUSIONSnIn anterior AMI, the ECG is useful to predict the LAD occlusion site in relation to its major side branches.

Left Bundle-Branch Block Induced by Transcatheter Aortic Valve Implantation Increases Risk of Death

Background— Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear. Methods and Results— Data were collected in a multicenter registry encompassing TAVI patients from 2005 until 2010. The all-cause mortality rate at follow-up was compared between patients who did and did not develop new LBBB. Of 679 patients analyzed, 387 (57.0%) underwent TAVI with the Medtronic CoreValve System and 292 (43.0%) with the Edwards SAPIEN valve. A total of 233 patients (34.3%) developed new LBBB. Median follow-up was 449.5 (interquartile range, 174–834) days in patients with and 450 (interquartile range, 253–725) days in patients without LBBB (P=0.90). All-cause mortality was 37.8% (n=88) in patients with LBBB and 24.0% (n=107) in patients without LBBB (P=0.002). By multivariate regression analysis, independent predictors of all-cause mortality were TAVI-induced LBBB (hazard ratio [HR], 1.54; confidence interval [CI], 1.12–2.10), chronic obstructive lung disease (HR, 1.56; CI, 1.15–2.10), female sex (HR, 1.39; CI, 1.04–1.85), left ventricular ejection fraction ⩽50% (HR, 1.38; CI, 1.02–1.86), and baseline creatinine (HR, 1.32; CI, 1.19–1.43). LBBB was more frequent after implantation of the Medtronic CoreValve System than after Edwards SAPIEN implantation (51.1% and 12.0%, respectively; P<0.001), but device type did not influence the mortality risk of TAVI-induced LBBB. Conclusions— All-cause mortality after TAVI is higher in patients who develop LBBB than in patients who do not. TAVI-induced LBBB is an independent predictor of mortality.

Value of lead V4R for recognition of the infarct coronary artery in acute inferior myocardial infarction.

In 84 patients with an acute inferior wall myocardial infarction (MI) admitted within 10 hours after the onset of chest pain, a right precordial lead V4R electrocardiogram was recorded in addition to the standard 12-lead electrocardiogram. The presence or absence of ST-segment elevation in lead V4R was correlated with results of coronary angiography performed 2 to 26 weeks (mean 10) after MI. Patients were classified into 3 groups: (1) those with a critical stenosis or occlusion proximal to the first right ventricular (RV) branch (27 patients); (2) those with stenosis distal to the right ventricular branch of the right coronary artery (36 patients); and (3) those with stenosis in the left circumflex coronary artery (21 patients). The presence of ST-segment elevation greater than or equal to 1 mm in lead V4R has a sensitivity of 100% and a specificity of 87% for occlusion of the right coronary artery above the first RV branch; the predictive accuracy is 92%. Seven of 36 patients with a distal occlusion of the right coronary artery showed ST-segment elevation of 1 mm or more in lead V4R . The absence of ST-segment elevation greater than or equal to 1 mm in lead V4R excluded proximal occlusion of the right coronary artery. ST-segment elevation in lead V4R was not seen either in 29 of 36 patients with a distal occlusion of the right coronary artery or in all patients with an occlusion of the left circumflex artery. Recording of lead V4R within 10 hours after onset of acute inferior wall MI can give information rapidly about the vessel responsible for MI.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial

BACKGROUNDnIntravenous saline is recommended in clinical practice guidelines as the cornerstone for preventing contrast-induced nephropathy in patients with compromised renal function. However, clinical-effectiveness and cost-effectiveness of this prophylactic hydration treatment in protecting renal function has not been adequately studied in the population targeted by the guidelines, against a group receiving no prophylaxis. This was the aim of the AMACING trial.nnnMETHODSnAMACING is a prospective, randomised, phase 3, parallel-group, open-label, non-inferiority trial of patients at risk of contrast-induced nephropathy according to current guidelines. High-risk patients (with an estimated glomerular filtration rate [eGFR] of 30-59 mL per min/1·73 m2) aged 18 years and older, undergoing an elective procedure requiring iodinated contrast material administration at Maastricht University Medical Centre, the Netherlands, were randomly assigned (1:1) to receive intravenous 0·9% NaCl or no prophylaxis. We excluded patients with eGFR lower than 30 mL per min/1·73 m2, previous dialysis, or no referral for intravenous hydration. Randomisation was stratified by predefined risk factors. The primary outcome was incidence of contrast-induced nephropathy, defined as an increase in serum creatinine from baseline of more than 25% or 44 μmol/L within 2-6 days of contrast exposure, and cost-effectiveness of no prophylaxis compared with intravenous hydration in the prevention of contrast-induced nephropathy. We measured serum creatinine immediately before, 2-6 days, and 26-35 days after contrast-material exposure. Laboratory personnel were masked to treatment allocation. Adverse events and use of resources were systematically recorded. The non-inferiority margin was set at 2·1%. Both intention-to-treat and per-protocol analyses were done. This trial is registered with ClinicalTrials.gov, number NCT02106234.nnnFINDINGSnBetween June 17, 2014, and July 17, 2016, 660 consecutive patients were randomly assigned to receive no prophylaxis (n=332) or intravenous hydration (n=328). 2-6 day serum creatinine was available for 307 (92%) of 332 patients in the no prophylaxis group and 296 (90%) of 328 patients in the intravenous hydration group. Contrast-induced nephropathy was recorded in eight (2·6%) of 307 non-hydrated patients and in eight (2·7%) of 296 hydrated patients. The absolute difference (no hydration vs hydration) was -0·10% (one-sided 95% CI -2·25 to 2·06; one-tailed p=0·4710). No hydration was cost-saving relative to hydration. No haemodialysis or related deaths occurred within 35 days. 18 (5·5%) of 328 patients had complications associated with intravenous hydration.nnnINTERPRETATIONnWe found no prophylaxis to be non-inferior and cost-saving in preventing contrast-induced nephropathy compared with intravenous hydration according to current clinical practice guidelines.nnnFUNDINGnStichting de Weijerhorst.

A new hemostatic puncture closure device for the immediate sealing of arterial puncture sites

After angiography, 6 to 24 hours of bedrest is indicated to assure that adequate hemostasis of the femoral artery has been achieved. Recently, a new hemostatic puncture closure device (HPCD) has been developed, which consists of a resorbable polymer anchor, a resorbable suture, a small collagen plug and an 8Fr delivery device. The device is delivered into the femoral artery through the introducer sheath, the anchor is secured against the intraluminal artery wall, and the collagen plug is deployed on the arterial wall. The prototype of the HPCD was used in 20 patients administered heparin. After insertion of the HPCD, hemostasis was achieved in 1.2 +/- 2.1 minutes; in 2 patients a light pressure dressing was applied for 4 hours to stop oozing. No late bleeding occurred. In 1 patient the positioning suture broke, requiring the application of a pressure bandage. Patients were uneventfully mobilized after 6.7 +/- 3.5 hours. In all patients serial duplex scanning of the femoral artery was performed before and after 1, 7, 30 and 90 days after HPCD placement. In 5 patients a small subcutaneous hematoma close to the site of introduction could be detected by ultrasound 1 day after catheterization. All but 1 patient had normalization of the flow patterns in the femoral artery. It is concluded that: (1) the HPCD is an effective device to achieve immediate hemostasis after arterial catheterization despite antithrombotic therapy, (2) early mobilization was uneventful, (3) duplex ultrasound studies demonstrated only transient changes in the punctured femoral artery, and (4) further investigations are needed to establish the efficacy and safety of the device.

Percutaneous Transcatheter Valve-in-Valve Implantation in Stenosed Tricuspid Valve Bioprosthesis

Transcatheter valve-in-valve implantation is a promising treatment option for degenerated bioprosthetic heart valves in high-risk patients.1 Successful percutaneous techniques have been described for pulmonary and aortic valves.2,3 We present the first successful percutaneous tricuspid valve-in-valve implantation.nnThe patient was a fragile 74-year-old woman with chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 53%), impaired renal function (modified diet in renal disease 35 mL/min/1.73 m2), and cardiac hepatic cirrhosis with ascites and cachexia (body mass index 19 kg/m2), admitted with chronic right-sided heart failure and severe stenosis of a degenerated tricuspid bioprosthesis. Previously, a partial atrioventricular canal defect had been treated in 3 consecutive surgical interventions. During the last procedure, 23 years ago, a mechanical mitral valve replacement (St. Jude 25 mm, SJM, Inc., St. Paul, MN) had been performed, combined with a bioprosthetic tricuspid valve replacement (pericardial Carpentier Edwards …

In vivo evaluation of the Hydrolyser hydrodynamic thrombectomy catheter.

PURPOSEnThe authors evaluated a 7-F double-lumen thrombectomy catheter (Hydrolyser) in vivo.nnnMATERIALS AND METHODSnTo evaluate efficacy, thrombectomy was performed 1, 4, or 8 days after local denudation in peripheral arteries (n = 18) and veins (n = 29) of nine goats. To evaluate safety, the reaction of the vessel wall to a functioning and nonfunctioning Hydrolyser catheter was evaluated in the peripheral arteries and veins of three goats 10 days after the procedure.nnnRESULTSnReopening was achieved in all vessels with residual thrombus in 11% of arteries (two of 18) and 55% of veins (16 of 29). Slight intimal thickening was observed, but no difference was seen between the passage of a functioning versus nonfunctioning catheter.nnnCONCLUSIONSnThe Hydrolyser device can remove intravascular thrombus up to 8 days after induction. There was no difference in vessel wall reaction after the passage of a functioning and nonfunctioning catheter.

Removal of thrombus from aortocoronary bypass grafts and coronary arteries using the 6Fr Hydrolyser.

This study evaluates the feasibility and safety of a 6Fr hydrodynamic thrombectomy catheter, the Hydrolyser, in native coronary arteries and aortocoronary bypass grafts. With use of a conventional contrast injector, saline solution is injected into the narrow lumen of the catheter which makes a 180 degrees bend at the tip. The resultant high-velocity jet (150 km/hour) is directed over a sidehole near the tip into a wide exhaust lumen. As a consequence of the Venturi effect, thrombus is sucked into that sidehole, fragmented, and removed through the wide exhaust lumen into a collection bag. Thirty-one thrombotic lesions were treated in 31 patients. The culprit vessel was a venous graft in 21 patients (15 with Thrombolysis in Myocardial Infarction Trial [TIMI] grade 0 or 1 flow) and a coronary artery in 11 patients (9 with grade 0 or 1 flow). Twenty-six patients had angina New York Heart Association functional class III or IV heart failure and 5 an acute myocardial infarction. In 26 patients, Hydrolyser therapy was the primary treatment, whereas in 5 patients coronary angioplasty preceded Hydrolyser therapy. In 1 patient the Hydrolyser could not reach the lesion. Thrombus was removed in 29 of the 31 patients. Successful reperfusion (TIMI grade 2 or 3 flow) by Hydrolyser therapy alone was achieved in 14 of the 24 patients with TIMI grade 0 or 1 flow before the procedure. Adjunctive therapy (coronary angioplasty, stent, or thrombolysis) was performed in 28 of the 31 patients. At the end of the total procedure 24 patients had TIMI grade 3 flow. Distal embolization during thrombectomy occurred in 2 patients, which led to a non-Q-wave infarction in 1. No patient died or needed emergency coronary bypass due to the Hydrolyser procedure. Thus, thrombectomy using the 6Fr Hydrolyser is feasible and was performed safely in 31 patients.

Early referral for intentional rescue PTCA after initiation of thrombolytic therapy in patients admitted to a community hospital because of a large acute myocardial infarction

BACKGROUNDnIf no in-house facilities for percutaneous transluminal coronary angioplasty (PTCA) are present, thrombolytic therapy is the treatment of choice for acute myocardial infarction (AMI). A few studies have shown benefit from rescue PTCA in patients directly admitted to centers with PTCA facilities. The obvious question arises whether patients with AMI initially admitted to a community hospital can benefit from early transfer for intentional rescue PTCA.nnnMETHODS AND RESULTSnOne hundred sixty-five patients were transferred early for intentional rescue PTCA from a community hospital at a distance of 20 miles. On arrival at the angioplasty center, bedside markers were used to determine reperfusion. In case of obvious reperfusion, no invasive procedure was done; otherwise, coronary angiography and rescue PTCA, if necessary, was performed. During transfer, 1 (1%) patient died and 15 (9%) patients had arrhythmic or hemodynamic problems. Median time delay between onset of chest pain and arrival at the community hospital and the PTCA center was 61 minutes (range 0 to 413) and 150 minutes (range 28 to 472), respectively. In 66 (40%) patients, reperfusion was diagnosed by noninvasive reperfusion criteria on arrival at the PTCA center (group 1). Ninety-eight (59%) patients without evident noninvasive criteria of reperfusion underwent angiography 187 median minutes after the onset of chest pain. Forty-one (25%) patients had Thrombolysis In Myocardial Infarction grade 3 flow, and no further intervention was performed (group 2). In the remaining 57 (35%) patients, rescue PTCA was performed, which was successful in 96% (group 3). In-hospital mortality rate was lowest in group 1 compared with the other 2 groups (0% vs 7% vs 11%; P <.05). Reinfarction was highest in group 1 compared with the other groups (17% vs 5% vs 2%; P <.01). No significant differences were found in coronary artery bypass grafting, stroke, or bleeding complications. The 1-year follow-up data showed low revascularization rates; 2 (1%) patients died after discharge from the hospital.nnnCONCLUSIONSnEarly transfer of patients with large AMI for intentional rescue PTCA can be done with acceptable safety and is feasible within therapeutically acceptable time limits and results in additional early reperfusion in 33% of patients. A large, randomized, multicenter trial is needed to compare efficacy of intravenous thrombolytic treatment in a community hospital versus early referral for either rescue or primary PTCA.

Comparison of arterial wall reaction after passage of the Hydrolyser device versus a thrombectomy balloon in an animal model

PURPOSEnThis study was designed to compare the reaction of the vessel wall after application of the Hydrolyser hydrodynamic thrombectomy device to the reaction after use of a balloon thrombectomy catheter. The influence of the vessel inner diameter on vessel wall reaction was evaluated after passage of the Hydrolyser.nnnMATERIALS AND METHODSnAfter measurement of the vessel inner diameter with intravascular ultrasound (US), 102 segments of femoral and carotid arteries of goats were treated with one of the following four procedures: passage of the intravascular US catheter alone; passage of the Hydrolyser without or with an activated jet; or passage of an inflated thrombectomy balloon. Histologic evaluation was performed after 3 weeks.nnnRESULTSnIntimal thickening (more than five cell layers of neointima) 3 weeks after treatment occurred more frequently after passage of the balloon than after any of the other procedures (P < .001). For vessels with a diameter of 3-4 mm, 4-5mm, or more than 5 mm, no significant difference in vessel wall reaction was observed following Hydrolyser passage.nnnCONCLUSIONnIn this model, passage of the Hydrolyser device resulted in less intimal reaction compared with the thrombectomy balloon.