Wojciech Zasada

Impact of Multivessel Coronary Artery Disease and Noninfarct-Related Artery Revascularization on Outcome of Patients With ST-Elevation Myocardial Infarction Transferred for Primary Percutaneous Coronary Intervention (from the EUROTRANSFER Registry)

The aim of the study was to assess the impact of multivessel coronary artery disease (MVD) and noninfarct-related artery (non-IRA) revascularization during index percutaneous coronary intervention (PCI) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI). Data on 1,598 of 1,650 patients with complete angiographic data, with >or=1 significantly stenosed epicardial coronary artery, and without previous coronary artery bypass grafting were retrieved from the EUROTRANSFER Registry database. Patients with 1-, 2-, and 3-vessel disease made up 48.5%, 32.0%, and 19.5% of the registry population, respectively. Patients with MVD were less likely to achieve final Thrombolysis In Myocardial Infarction grade 3 flow (1- vs 2- vs 3-vessel disease, 93.6% vs 89.3% vs 87.9%, respectively, p = 0.003) and ST-segment resolution >50% within 60 minutes after PCI (1- vs 2- vs 3-vessel disease, 80.9% vs 77.5% vs 69.3%, respectively, p <0.001). They were also at higher risk of death during 1-year follow-up (1- vs 2- vs 3-vessel disease, 4.9% vs 7.4% vs 13.5%, respectively, p <0.001), and MVD was identified as an independent predictor of 1-year death. In 70 patients (9%) non-IRA PCI was performed during index PCI. These patients were at higher risk of 30-day and 1-year death compared to patients without non-IRA PCI, but this difference in mortality was no longer significant after adjustment for covariates. In conclusion, patients with MVD have decreased epicardial and myocardial reperfusion success and had worse prognosis after primary PCI for STEMI compared to patients with 1-vessel disease. In this large multicenter registry, non-IRA PCI during the index procedure was performed in 9% of patients with MVD and it was associated with increased 1-year mortality.

Transradial approach in patients with ST-elevation myocardial infarction treated with abciximab results in fewer bleeding complications: data from EUROTRANSFER registry.

ObjectivesOur aim was to investigate the safety and efficacy of transradial approach, predictors of bleeding complications, and choice of radial access site in a real-life setting using a contemporary European registry of percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). BackgroundThere is an increasing amount of data suggesting that transradial approach is associated with less bleeding at access site and other vascular complications when compared with procedures carried out through the femoral artery. MethodsConsecutive data on STEMI patients transferred for primary PCI in hospital STEMI networks between November 2005 and January 2007 from seven countries in Europe were gathered. Patients were divided into the following two groups: radial approach – with radial access site for primary PCI, and transfemoral approach (FEM) – with femoral access site. ResultsData from a total of 1650 patients were collected in the EUROTRANSFER Registry. Abciximab was administered in 1086 patients (66%), 169 patients were assigned to radial approach group, whereas 917 to FEM group. Puncture site hematomas were more frequent in the FEM group (1.2 vs. 9.4%, P<0.001). Major bleedings requiring blood transfusion occurred similarly in both the studied groups. Independent predictors of bleeding (puncture site hematoma and major bleeding requiring transfusion) included female sex, lower weight, chronic renal failure, past stroke, and femoral access site (odds ratio=3.54). ConclusionThe choice of radial access site in patients with STEMI treated with primary PCI is associated with lower local bleeding complications like puncture site hematomas and is an independent predictor of fewer bleedings.

The basics of intravascular optical coherence tomography.

Optical coherence tomography (OCT) has opened new horizons for intravascular coronary imaging. It utilizes near-infrared light to provide a microscopic insight into the pathology of coronary arteries in vivo. Optical coherence tomography is also capable of identifying the chemical composition of atherosclerotic plaques and detecting traits of their vulnerability. At present it is the only tool to measure the thickness of the fibrous cap covering the lipid core of the atheroma, and thus it is an exceptional modality to detect plaques that are prone to rupture (thin fibrous cap atheromas). Moreover, it facilitates distinguishing between plaque rupture and plaque erosion as a cause of acute intracoronary thrombosis. Optical coherence tomography is applied to guide angioplasties of coronary lesions and to assess outcomes of percutaneous coronary interventions broadly. It identifies stent malapposition, dissections, and thrombosis with unprecedented precision. Furthermore, OCT helps to monitor vessel healing after stenting. It evaluates the coverage of stent struts by the neointima and detects in-stent neoatherosclerosis. With so much potential, new studies are warranted to determine OCTs clinical impact. The following review presents the technical background, basics of OCT image interpretation, and practical tips for adequate OCT imaging, and outlines its established and potential clinical application.

Impact of direct stenting on outcome of patients with ST‐elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER registry)

We sought to evaluate the impact of direct stenting technique on angiographic and clinical outcomes of patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary angioplasty (PCI).

Effects of Trans-Endocardial Delivery of Bone Marrow-Derived CD133+ Cells on Left Ventricle Perfusion and Function in Patients With Refractory Angina: Final Results of Randomized, Double-Blinded, Placebo-Controlled REGENT-VSEL Trial.

Rationale: New therapies for refractory angina are needed. Objective: Assessment of transendocardial delivery of bone marrow CD133+ cells in patients with refractory angina. Methods and Results: Randomized, double-blinded, placebo-controlled trial enrolled 31 patients with recurrent Canadian Cardiovascular Society II–IV angina, despite optimal medical therapy, ≥1 myocardial segment with inducible ischemia in Tc-99m SPECT who underwent bone marrow biopsy and were allocated to cells (n=16) or placebo (n=15). Primary end point was absolute change in myocardial ischemia by SPECT. Secondary end points were left ventricular function and volumes by magnetic resonance imaging and angina severity. After 4 months, there were no significant differences in extent of inducible ischemia between groups (summed difference score mean [±SD]: 2.60 [2.6] versus 3.63 [3.6], P=0.52; total perfusion deficit: 3.60 [3.6] versus 5.01 [4.3], P=0.32; absolute changes of summed difference score: −1.38 [5.2] versus −0.73 [1.9], P=0.65; and total perfusion deficit: −1.33 [3.3] versus −2.19 [6.6], P=0.65). There was a significant reduction of left ventricular volumes (end-systolic volume: −4.3 [11.3] versus 7.4 [11.8], P=0.02; end-diastolic volume: −9.1 [14.9] versus 7.4 [15.8], P=0.02) and no significant change of left ventricular ejection fraction in the cell group. There was no difference in number of patients showing improvement of ≥1 Canadian Cardiovascular Society class after 1 (41.7% versus 58.3%; P=0.68), 4 (50% versus 33.3%; P=0.63), 6 (70% versus 50.0%; P=0.42), and 12 months (55.6% versus 81.8%; P=0.33) and use of nitrates after 12 months. Conclusion: Transendocardial CD133+ cell therapy was safe. Study was underpowered to conclusively validate the efficacy, but it did not show a significant reduction of myocardial ischemia and angina versus placebo. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01660581.

Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement.

Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini‐thoracotomy, mini‐sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high‐risk patients.

Impact of intra-aortic balloon pump on long-term mortality of unselected patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock

Introduction A large, randomised trial (IABP-SHOCK II) confirmed no benefit of intra-aortic balloon pump (IABP) on clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. However, the ‘sickest’ patients are often excluded from randomised clinical trials, so it is difficult to generalise expected outcomes from randomized clinical trials to the real life setting. Aim We sought to evaluate the impact of IABP on 1-year mortality of unselected patients with STEMI presenting in cardiogenic shock. Material and methods Data were gathered for 1,650 consecutive patients with STEMI transferred for primary angioplasty from hospital networks in 7 countries in Europe from November 2005 to January 2007 (the EUROTRANSFER registry population). Of them, 51 patients with cardiogenic shock on admission were identified and stratified based on the use of IABP. Outcome results were adjusted for age and sex, to control possible selection bias. Results At the discretion of the operators, IABP was applied in 30 patients (58.8%, IABP group). The remaining 21 patients were treated without IABP (no-IABP group). The use of IABP was more frequent among males, younger patients, and patients with STEMI of the anterior wall. There was no difference in 30-day mortality in patients with and without IABP (no-IABP vs. IABP: 38.1% vs. 33.3%; adjusted OR 1.79 (95% CI 0.43–7.52); p = 0.43). Similarly, IABP had no impact on 1-year mortality (42.9% vs. 33.3%; adjusted OR 1.27 (95% CI 0.32–5.09); p = 0.74). One-year mortality was comparable among patients who survived hospitalisation (14.3% vs. 13%; p = 0.64). Conclusions We observed no benefit of IABP on short – and long-term mortality of unselected patients with STEMI complicated by cardiogenic shock.

Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in diabetic patients with ST-segment elevation myocardial infarction (EUROTRANSFER Registry)

BACKGROUND Diabetes is an important determinant of prognosis in patients with ST-segment elevation myocardial infarction (STEMI). Limited data are available concerning benefits and risks of upstream abciximab administration in diabetic patients. Thus, the objective of the study was to assess the impact of early abciximab administration before primary angioplasty (PCI) for STEMI in diabetic patients. METHODS Data were gathered for 1650 consecutive STEMI patients transferred for primary PCI from hospital networks in seven countries in Europe from November 2005 to January 2007 (the EUROTRANSFER Registry population). Patients were stratified by diabetes mellitus presence and then by abciximab administration strategy (early - more than 30 min before PCI vs. late). RESULTS Diabetes mellitus was diagnosed in 262 (15.9%) patients. Patients with diabetes mellitus were high-risk individuals, with advanced age, higher prevalence of comorbidities and increased risk of ischemic events during follow-up in comparison to non-diabetic patients. A total of 1086 patients who received abciximab were identified. Strategy of early abciximab administration was associated with enhanced infarct-related artery patency before PCI, and improved epicardial flow after PCI in both diabetic and non-diabetic patients. Importantly, early abciximab in diabetic patients led to the decrease in ischemic events, including 30-day (OR 0.260, 95% CI 0.089-0.759, p = 0.012) and 1-year (OR 0.273, 95% CI 0.099-0.749, p = 0.012) mortality reduction. However, only a trend toward improved survival was confirmed after adjustment for potential confounders. On the contrary, the reduction of 30-day (OR 0.620, 95% CI 0.334-1.189, p = 0.16) and 1-year (OR 0.643, 95% CI 0.379-1.089, p = 0.10) mortality rates was not significant among non-diabetic patients. CONCLUSIONS Early administration of abciximab improves infarct-related artery patency before and after primary PCI, and leads to improved survival in diabetic STEMI patients.

Borderline trend towards long-term mortality benefit from drug eluting stents implantation in ST-elevation myocardial infarction patients in Poland-data from NRDES registry.

To analyze long‐term outcome of ST‐Elevation Myocardial Infarction (STEMI) and non‐STEMI (NSTEMI) patients treated with Drug Eluting Stents (DES) stents with regard to mortality and stent thrombosis rates based on the national Polish PCI registry database.

Predictors of Coronary and Carotid Atherosclerosis in Patients with Severe Degenerative Aortic Stenosis

Background. Patients with degenerative aortic stenosis (AS) exhibit elevated prevalence of coronary artery disease (CAD) and internal carotid artery stenosis (ICAS). Our aim was to investigate prevalence of significant CAD and ICAS in relation to demographic and cardiovascular risk profile among patients with severe degenerative AS. Methods. We studied 145 consecutive patients (77 men and 68 women) aged 49-91 years (median, 76) with severe degenerative AS who underwent coronary angiography and carotid ultrasonography in our tertiary care center. The patients were divided into two groups according to the presence of either significant CAD (n=86) or ICAS (n=22). Results. The prevalence of significant CAD or ICAS was higher with increasing number of traditional risk factors (hypertension, hypercholesterolemia, diabetes, smoking habit) and decreasing renal function. We found interactions between age and gender in terms of CAD (p=0.01) and ICAS (p=0.06), which was confirmed by multivariate approach. With the reference to men with a below-median age, the prevalence of CAD or ICAS increased in men aged >76 years (89% vs. 55% and 28% vs. 14%, respectively), whereas the respective percentages were lower in older vs. younger women (48% vs. 54% and 7% vs. 17%). Conclusions. In severe degenerative AS gender modulates the association of age with coronary and carotid atherosclerosis with its lower prevalence in women aged >76 years compared to their younger counterparts. This may result from a hypothetical “survival bias”, i.e., an excessive risk of death in very elderly women with severe AS and coexisting relevant coronary or carotid atherosclerosis.