Wojciech Zimoch

Could an analysis of mean corpuscular volume help to improve risk stratification in non-anemic patients with acute myocardial infarction?

BACKGROUND Nowadays, when the majority of patients with acute myocardial infarction (AMI) are treated with primary percutaneous coronary intervention and modern pharmacotherapy, risk stratification becomes a challenge. Simple and easily accessible parameters that would help in a better determination of prognosis are needed. The aim of the study was to estimate the prevalence of high mean corpuscular volume (MCV, defined as MCV > 92 fL) and to establish its prognostic value in non-anemic patients with AMI. METHODS We retrospectively analyzed the data of 248 consecutive non-anemic patients hospitalized due to AMI (median age: 65 [59-76] years, men: 63%, ST segment elevation myocardial infarction: 31%, and median left ventricular ejection fraction [LVEF]: 50%). RESULTS The prevalence of high MCV was 39 ± 6% (± 95% confidence interval) in the entire AMI population. High MCV was more prevalent in males, patients with low body mass index, non-diabetics and cigarette smokers (all p < 0.05). During the 180-day follow-up, there were 38 (15%) events, defined as another AMI or death. In a multivariable Cox proportional hazard model, female gender (p < 0.01), low LVEF (p < 0.001), previous AMI (p < 0.05), arterial hypertension (p < 0.05), and high MCV (p < 0.001) were prognosticators of pre-defined events. CONCLUSIONS In non-anemic patients with AMI, high MCV is an independent prognostic factor of poor outcome defined as another AMI or death.

Patients with acute myocardial infarction and severe target lesion calcifications undergoing percutaneous coronary intervention have poor long-term prognosis

BACKGROUND To assess the influence of severe target lesion calcification (TLC) on the outcomes of patients undergoing percutaneous coronary interventions (PCI) due to acute myocardial infarction (AMI). AIM Contemporary data concerning coronary artery calcifications (CAC) are based on pooled analyses from randomised trials with short follow-up. We still lack the knowledge on how CAC in target lesions affect long-term prognosis of patients with AMI in everyday practice. METHODS We evaluated clinical and laboratory data of 206 consecutive patients who underwent coronary angiography and PCI due to AMI. Primary endpoints were all-cause death and recurrent hospitalisations due to acute coronary syndrome (ACS). RESULTS Severe TLC lesions were present in 17% of patients. These patients were older (71 vs. 65 years, p = 0.02) and more often diagnosed with non-ST segment elevation myocardial infarction (77% vs. 58%, p = 0.03). Patients with severe TLC had lower rates of PCI success (80% vs. 97%, p < 0.0001) and less often achieved full revascularisation during index procedure (14% vs. 41%, p = 0.003). During 30 months follow-up patients with severe TLC more often suffered from another ACS (37% vs. 13%, p = 0.0005) and had higher all-cause mortality (31% vs. 16%, p = 0.04). Multivariate Cox regression model showed severe TLC to be an independent predictor of another ACS (HR 2.8; 95% CI 1.4-5.6; p = 0.004). CONCLUSIONS Severe TLC are not uncommon in patients with ACS. The presence of severe TLC is a prognostic factor of another ACS in AMI patients undergoing PCI.

Safety and efficacy assessment of carotid artery stenting in a high-risk population in a single-centre registry.

Introduction Ischaemic stroke is the primary cause of long-term disability and the third most common cause of death. Internal carotid artery stenosis is an important risk factor for stroke and transient ischaemic attack (TIA). European Society of Cardiology (ESC) and American Heart Association (AHA) guidelines allow carotid artery stenting (CAS) as an alternative to endarterectomy in centres with low rates of death or stroke. Aim To assess the safety and efficacy of CAS in a single-centre observation. Material and methods We performed a retrospective analysis of all patients treated with CAS between March 2008 and July 2012. Clinical data and outcomes in both asymptomatic and symptomatic patients were analysed. Results A total of 214 consecutive patients were included in the registry. Symptomatic patients accounted for 57% of the study group and were more likely to have a history of stroke and/or TIA that occurred more than 6 months before the procedure (50% vs. 8%, p < 0.001). Asymptomatic patients were more likely to have a history of coronary artery disease (88% vs. 61%, p < 0.001), and the rates of previous acute coronary syndrome and revascularisation were also higher in this group (58% vs. 41% and 71% vs. 52%, respectively, both p < 0.05). The symptomatic group had higher incidence of stroke in periprocedural and 30-day observation (4% vs. 0%, p < 0.05). There was no difference in incidence of adverse events in long-term observation. Conclusions Carotid artery stenting is a safe and efficacious procedure. Every centre performing CAS should monitor the rate of periprocedural complications.

The use of rotational atherectomy in high risk patients: high volume centre results

BACKGROUND Rotational atherectomy (RA) is indicated for fibrocalcified lesions when traditional percutaneous coronary intervention (PCI) could not be successfully performed. In some of the high-risk patients the RA procedure is the last resort for successful revascularisation. Such patients are, among others, those in whom coronary artery bypass grafting (CABG) is not feasible. AIM The aim of the study was to assess in-hospital and one-year outcomes of PCI with RA in high-risk patients without other revascularisation options (RA-only group), in comparison to lower-risk patients undergoing RA. METHODS We evaluated data of 207 consecutive patients who underwent PCI with RA. Primary endpoints were one-year all-cause mortality and one-year major adverse cardiac events (MACEs). Secondary endpoints were in-hospital outcomes. RESULTS During the study 35% of patients fulfilled the inclusion criteria to the high-risk group. Those patients had significantly lower left ventricular ejection fraction, more often prior CABG, higher admission glucose level, and higher EuroSCORE II and Syntax Score. Procedural success was similar in both groups (85% in RA-only group vs. 91% in remaining patients, p = 0.18). In-hospital outcomes were similar, except more frequent no/slow-flow phenomenon in the RA-only group. The MACE and mortality rates in one-year follow-up were not statistically different in both groups (19% vs. 18%, p = 0.82 and 11% vs. 9%, p = 0.64, respectively). CONCLUSIONS Despite the high-risk characteristics of the study subgroup, no significant differences between in-hospital and one-year outcomes were found in comparison to lower-risk RA patients. Complex PCI with RA in patients without other revascularisation options should be taken into consideration.

In patients undergoing percutaneous coronary intervention with rotational atherectomy radial access is safer and as efficient as femoral access

INTRODUCTION Transfemoral approach (TFA) may be preferred access site in order to facilitate complex percutaneous procedures such as rotational atherectomy (RA). Notwithstanding, there is a growing evidence that transradial approach (TRA) is associated with lower access site complication rates and even lower mortality. The aim was to assess in-hospital and 1-year outcomes in patients undergoing RA using TRA, in comparison to TFA. METHODS A single center observational study included all consecutive patients, who underwent RA from 2010 to 2015. Primary endpoints were procedural success, in-hospital mortality and major adverse cardiovascular events (MACE). Secondary endpoints were 1-year all-cause mortality and MACE. RESULTS The study included 177 patients, 69% in TRA group and 31% in TFA group. Except for male sex and logistic Euroscore II there were no differences in common risk factors. There was no difference in procedural success (95% vs 87%, P = 0.07) with even a trend in favor of TRA. Performing RA via TRA lower amount of contrast volume (P = 0.009) was used and hospital stay after the procedure was shorter (P = 0.004). Periprocedural complication rates were similar, however patients with TFA had significantly higher rate of major access site bleedings (13% vs 1%, P = 0.001), with no differences in mortality and other adverse events both in-hospital and during 1-year observation. CONCLUSIONS Even though RA is a demanding technique, when performed via TRA allows to maintain the same procedural success and long-term results in comparison to TFA, reduces in-hospital major access site bleedings, lowers the amount of contrast media and shortens hospital stay.

Novel predictors of outcome after coronary angioplasty with rotational atherectomy. Not only low ejection fraction and clinical parameters matter

Introduction Most established risk factors after rotational atherectomy (RA) of heavily fibro-calcified lesions are associated with patients’ general risk and clinical related factors and are not specific for either coronary and culprit lesion anatomy or the RA procedure. Aim To assess novel predictors of poor outcome after percutaneous coronary intervention using RA in an all-comers population. Material and methods A total of 207 consecutive patients after RA were included in a single-center observational study. Primary endpoints were 1-year mortality and 1-year major adverse cardiac events (MACE). Secondary endpoints were angiographic and procedural success and in-hospital complications. Results Procedural complications occurred in 19 (8%) patients. In-hospital mortality was 1%, peri-procedural myocardial infarction (MI) was 9%, and acute stroke occurred in one patient. The 1-year MACE rate was 20% with all-cause mortality 10%, MI 10% and stroke 1%. Multivariable analysis revealed heart failure with left ventricle ejection fraction (LVEF) ≤ 35% (p = 0.02) and uncrossable lesion, as compared to undilatable lesion (p = 0.01), as independent predictors of 1-year mortality and residual SYNTAX score ≤ 8 as an independent predictor of favorable outcome (p = 0.04). Heart failure with LVEF ≤ 35% (p < 0.01) and uncrossable lesion (p = 0.04) were independent predictors of 1-year MACE. Conclusions The presence of a novel factor, uncrossable lesion, as compared to undilatable lesion, is associated with poor outcome, and low residual SYNTAX score ≤ 8 is associated with favorable outcome in 1-year follow-up after the RA procedure and can help in risk stratification of patients undergoing complex coronary intervention with RA.

Acute heart failure in patients admitted to the emergency department with acute myocardial infarction

BACKGROUND Acute heart failure (AHF), occurring as a complication of ongoing acute myocardial infarction (AMI), is a common predictor of worse clinical outcome. Much less is known about the unique subpopulation of patients who present these two life-threatening conditions in the emergency department (ED). AIM The aim of the study was to establish the prevalence of coexistence of AHF with AMI in the ED, to identify clinical factors associated with the higher prevalence of AHF at very early onset of AMI, and to assess the prognostic impact of the presence of AHF with AMI. METHODS A prospective study of 289 consecutive patients (mean age: 68 ± 11 years, 61% men) admitted to our institution (via the ED) with the diagnosis of AMI between May and October 2012 and followed-up for 2.5 years. RESULTS Acute heart failure was diagnosed in 13% of patients in the ED. In multivariable analysis, female sex, chronic obstruc-tive pulmonary disease, and chronic kidney disease significantly increased the risk of developing AHF together with AMI (all p < 0.05). Patients with AHF were hospitalised for longer (9.2 ± 6.1 vs. 6.3 ± 4.5 days, p < 0.001), had higher in-hospital cardiovascular mortality (8% vs. 0%, p < 0.001), and all-cause (34% vs. 15%, p = 0.004) and cardiovascular mortality (26% vs. 9%, p = 0.002) during long-term follow-up. CONCLUSIONS Despite good logistic- and evidence-based treatment, AHF is present in one in eight patients with AMI at the time of admission to the ED. Particularly poor outcomes characterise critically ill patients; therefore, great effort should be undertaken to improve their care.

Left ventricle assist device supported rotational atherectomy of the highly calcified last remaining vessel in a patient with acute myocardial infarction and reduced left ventricular function

An 84-year-old man with history of myocardial infarction (MI) and poorly controlled hypertension was admitted to the orthopaedics department due to femoral neck fracture. Just after right hip hemiarthroplasty the patient reported acute chest pain. Electrocardiogram showed ST segment depression in leads I, II, V4–V6. Highly sensitive troponin I was raised to 3.489 (N < 0.059) ng/mL. Echocardiography revealed decreased left ventricular ejection fraction (LVEF) 40% and diffused wall motion abnormalities. The patient was diagnosed with non-ST segment elevation MI and referred to urgent coronary angiography, which showed severe calcifications in all coronary arteries and proximal occlusion in both the circumflex and right coronary artery (RCA). Left anterior descending artery (LAD), the last remaining vessel giving collaterals to RCA, revealed highly calcified 80% stenosis in the proximal segment (Fig. 1). The heart team decided that high-risk percutaneous coronary intervention (PCI) with rotational atherectomy optimally with left ventricle assist device (LVAD) is the best therapeutic option. The procedure began by placing an Impella CP (Abiomed, USA) into the left ventricle via the left femoral artery. The left coronary artery was intubated with an EBU 3.75/7 F guiding catheter via right femoral access. Due to ectasia in LAD wiring was extremely difficult, time consuming, and possible only after use of a microcatheter. The highly calcified lesion in the proximal part of the vessel was resistant to rotational atherectomy and subsided only after 18 runs with 1.5 mm burr at 145,000 rpm (Fig. 2). Just after the last burr passage, slow flow in the LAD occurred. The patient became bradycardic and his blood pressure dropped to 50/20 mm Hg. Simultaneously maximal Impella flow (4 L/min) was established. External cardiac massage was about to be started but finally was not induced because the patient improved quickly after increasing Impella flow. Within minutes his blood pressure gradually increased to a stable level. No catecholamines were required. The procedure was continued with 1.75 mm burr for following seven runs with no other complications. After successful predilatation two Synergy (Boston Scientific, USA) stents 3.5/38 mm and 4.0/24 mm were implanted. Postdilatation with noncompliant balloons provided an optimal final result (Fig. 3). After the procedure the patient was completely angina free. Standard pharmacotherapy was recommended. Rotational atherectomy of the last remaining vessel in patients with decreased LVEF and with MI is considered contraindicated due to increased risk of slow/no-flow phenomenon, which could easily lead to rapid deterioration of the patient’s haemodynamics. However, in this patient no other therapeutic option was possible. This case shows that careful planning and appropriate preparation with LVAD implantation prior to the procedure allows the prevention of potentially fatal complications of high-risk PCI. Continuous haemodynamic support ensured by LVAD allows elaborated and often lifesaving procedures to be performed in very high-risk patients. To our knowledge this is the first such case published in Polish literature.

TCT-238 Outcomes and clinical predictors of mortality of patients treated with rotational atherectomy: a single center registry

100, 34, and 1476 of these patients, respectively. TVF at 2 years occurred in 22.1% of the patients treated with RA, 25.0% treated with cutting balloon, and 17.1% treated with balloon angioplasty only; these rates were predominantly driven by target vessel revascularization (15.2%, 14.4%, and 9.5%, respectively). The propensity score-adjusted hazard ratio for TVF associated with RA vs angioplasty alone or cutting balloon was 1.08 (95% CI 0.69-1.68, p1⁄40.73).

Multilevel embolic protection in a patient with acute myocardial infarction and a huge thrombus in the right coronary artery

A 51-year-old man, a smoker with poorly controlled hypertension and obesity, was admitted to our centre with recurrent resting chest pain for the preceding 24 h. Electrocardiography showed sinus rhythm 80/min with 1-mm ST-segment elevation with negative T waves in V1, II, III, and aVF, and troponin level was positive. After administration of unfractioned heparin, clopidogrel, acetylsalicylic acid, nitroglycerin, and morphine the patient was transported to a catheterisation laboratory for urgent coronary angiography. The procedure was performed via right radial artery and revealed 80% stenosis of medial left anterior descending artery and proximal occlusion of dominant right coronary artery with massive thrombus (Fig. 1). After right coronary artery intubation with a 6 F guiding catheter a Fielder wire (Asahi) was placed distally in the artery. Abciximab was administered intravenously and several aspirations of Eliminate thrombectomy catheter (Terumo, 6 F compatible) were performed, but with little success. Taking into consideration the persistent huge thrombus and the risk of “no-flow” phenomenon we decided to insert a Filter-Wire (Boston Scientific) for distal protection and to use a self-expanding stent Stentys-DES (Stentys) 3.5–4.5/27 mm (Fig. 2), which was successfully placed and postdilated by a 4.5/15 mm balloon to 15 atm. The result was TIMI-3 flow with clinical stabilisation (Fig. 3). Thrombus debris was evacuated from the thrombectomy catheter and from the filter (Fig. 4). Echocardiography performed 2 days later revealed akinesis of the basal segment of the inferior wall with preserved ejection fraction. The patient was discharged home 4 days after the procedure; dual antiplatelet therapy (for 12 months) and remaining standard therapy was recommended. Treatment should always be individualised according to the patient’s conditions. We decided to open the artery and prevent “no-flow” phenomenon in quite an aggressive manner. Abciximab was used routinely in patients with acute myocardial infarction and huge thrombus burden. In our opinion manual thrombectomy, in spite of currently only IIb class recommendation, is very helpful in such cases as well. We also used a self-expandable stent instead of a balloon-expandable stent. These kinds of stent proved their efficacy in APPOSITION trials. They adhere closely to the vessel wall in patients with acute myocardial infarction and prevent distal embolisation of thrombi. We inserted additionally a Filter-Wire as distal protection. Although distal filters are recommended only for interventions in venous grafts, we decided to use it in this particular case, with optimal final result. We conclude that for more complex procedures heterogeneous devices should be available in high-volume catheterisation laboratories.