Zhen Kun Yang

Impact of successful staged revascularization of a chronic total occlusion in the non-infarct-related artery on long-term outcome in patients with acute ST-segment elevation myocardial infarction

BACKGROUND Recently, a chronic total occlusion (CTO) in the non-infarct-related artery (non-IRA) was reported as an independent predictor of clinical outcome in patients with acute ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the clinical significance of staged revascularization for a CTO in the non-IRA for patients with STEMI. METHODS A total of 136 patients with acute STEMI undergoing primary percutaneous coronary intervention (PCI) received staged revascularization (ranging 7-10 days) for a CTO in the non-IRA. Cardiac mortality and major adverse cardiac events (MACE) including death, recurrent myocardial infarction, repeat revascularization, and re-hospitalization because of heart failure during 2-year follow-up were recorded. RESULTS Recanalization of totally occluded lesions in the non-IRA was successful in 87 (64%) patients for 93 lesions but failed in 49 (36%) patients. During 2-year follow-up, cardiac mortality was lower (8.0% vs. 20.4%, p = 0.036) and MACE-free survival was higher (78.2% vs. 61.2%, p = 0.042) in patients with successful than in those with failed revascularization of a CTO in the non-IRA. Multivariable analysis showed that after adjustment for possible confounders, successful recanalization of a CTO in the non-IRA was an independent predictor for 2-year cardiac mortality (HR = 0.145, 95% CI 0.047-0.446, P = 0.001) and MACE-free survival (HR = 0.430, 95%CI 0.220-0.838, P = 0.013). CONCLUSION Successful revascularization of a CTO in the non-IRA is associated with improved clinical outcomes in patients with STEMI undergoing primary PCI.

Impact of moderate or severe renal insufficiency on long-term outcomes in patients undergoing drug-eluting stent based coronary intervention

AIMS We sought to examine the impact of moderate or severe renal insufficiency (RI) on long-term clinical outcomes after successful percutaneous coronary intervention (PCI) with drug-eluting stent implantation. METHODS All-cause mortality and major adverse cardiac events were prospectively determined for 1174 patients after successful PCI with drug-eluting stent implantation. Based on estimated creatinine clearance (CrCl) levels, long-term outcomes were compared between patients with CrCl<60 ml/min (RI group; n=460) and those with CrCl> or =60 ml/min (control group; n=714). Hazard ratio for mortality and myocardial infarction was further evaluated for patients with severe (CrCl<30 ml/min), moderate (CrCl 30-59 ml/min), mild RI (CrCl 60-89 ml/min) and normal renal function (CrCl> or =90 ml/min). RESULTS Patients in RI group were older, lower body weight and hemoglobin, more female gender, and less cigarette smokers than those in control group. During follow-up (averaged 19.2 months) after successful PCI, all-cause death (8.3% vs. 1.5%, P<0.001), cardiac death (5.7% vs. 1.1%, P<0.001) and occurrence of non-fatal myocardial infarction (2.2% vs. 0.4%, P=0.005) were significantly higher, but rate of target vessel revascularization (TVR) was lower (5.7% vs. 9.6%, P=0.017) in RI group than in control group. Multivariate analysis revealed that CrCl<60 ml/min, diabetes, left ventricular ejection fraction <0.50 and anemia were independent risk factors for mortality and non-fatal myocardial infarction. Compared with patients with normal renal function, hazard ratio for a composite of mortality and myocardial infarction was 1.079 (P=0.907), 5.067 (P=0.007) and 8.828 (P=0.002) in patents with mild, moderate and severe RI, respectively. CONCLUSIONS Irrespective of whether drug-eluting stent implantation reduces TVR, the presence of moderate or severe RI is still associated with unfavorable long-term outcomes.

Beneficial effects of intracoronary tirofiban bolus administration following upstream intravenous treatment in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: The ICT-AMI study

BACKGROUND We investigated whether an additional intracoronary tirofiban bolus administration following upstream intravenous treatment could further improve myocardial reperfusion and clinical outcome in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS A total of 453 eligible STEMI patients were randomly allocated to intracoronary bolus administration of tirofiban (10 μg/kg; n=229) or saline (10 mL; n=224) during primary PCI, followed by intravenous tirofiban infusion (0.15 μg/kg/min) for 24-36 h. Serum levels of P-selectin, vWF, CD40L and serum amyloid A (SAA) in the coronary sinus were measured before and after intracoronary bolus administration. The primary endpoint was ST-segment resolution (STR) at 90 min after the procedure. Second endpoints included corrected TIMI frame count (cTFC), left ventricular volumes and ejection fraction (EF), and major adverse cardiac events (MACE) at 30-day and 6-month follow-up. RESULTS Intracoronary tirofiban administration resulted in a higher rate of completed STR (59.0% vs. 44.6%, P=0.002), lower cTFC (21.6±5.4 vs. 23.7±7.8, P=0.048), and significantly reduced coronary sinus levels of P-selectin, vWF, CD40L and SAA. Patients treated with intracoronary tirofiban had a trend toward less MACE at 30 days (3.1% vs. 6.7%, P=0.072). At 6 months, left ventricular end-systolic volume was smaller, EF was higher and MACE-free survival was improved (96.1% vs. 90.6%, P=0.020) in the intracoronary tirofiban group. CONCLUSIONS An additional intracoronary tirofiban bolus administration following upstream intravenous treatment reduces coronary circulatory platelet activation and inflammatory process, and significantly improves myocardial reperfusion and left ventricular function as well as 6-month MACE-free survival for STEMI patients undergoing primary PCI.

The utility of a 5-in-6 double catheter technique in treating complex coronary lesions via transradial approach: the DOCA-TRI study

AIMS To evaluate the efficacy and safety of a 5-in-6 double catheter (DC) technique during transradial complex PCI compared to a conventional buddy-wire or balloon-anchoring approach. METHODS AND RESULTS One hundred and eighty-seven patients who failed in stent or balloon delivery after successful wiring of the target vessel were prospectively randomised to further treatment with a 5-in-6 DC technique (DC group, n=94) or by a conventional buddy-wire or balloon-anchoring approach (control group, n=93). Baseline clinical and lesion features were comparable between the two groups. The primary endpoint of technical success was significantly higher in the DC than in the control group (97.9% and 39.8%, p<0.001). Fifty-six patients (60.2%) in the control group with failure of the buddy-wire or balloon-anchoring approach achieved successful PCI with bailout use of a DC technique. Procedural x-ray time (58.2±23.1 min vs. 94.9±18.6 min, p<0.001), patient dose-area product (23,970±8,555 cGy.cm2 vs. 44,475±10,573 cGy.cm2, p<0.001) and contrast consumption (177±33 ml vs. 271±70 ml, p<0.001) were significantly reduced in the DC group. One-year major adverse cardiac event-free survival did not differ between the two groups (89.4% vs. 84.9%, p=0.36). CONCLUSIONS The use of a 5-in-6 DC technique, especially as a bailout strategy, is a more effective back-up support of the guiding system, subsequently facilitating the success of transradial PCI for complex coronary lesions, than a conventional buddy-wire or balloon-anchoring approach.

Impact of elevated serum glycated albumin levels on contrast-induced acute kidney injury in diabetic patients with moderate to severe renal insufficiency undergoing coronary angiography.

BACKGROUND Glycated albumin (GA) has been shown to be a better indicator than glycosylated hemoglobin A1c (HbA1c) in terms of severity of renal impairment in patients with type 2 diabetes mellitus (T2DM). This study aimed to determine whether elevated serum GA levels are associated with an increased risk for contrast-induced acute kidney injury (CI-AKI) and worse clinical outcome in patients with T2DM and at least moderate renal insufficiency (RI) undergoing coronary angiography. METHODS Serum levels of fasting blood glucose (FBG), HbA1c and GA were measured in 1030 patients with T2DM and moderate to severe RI (eGFR 15-59 mL/min/1.73 m(2)). CI-AKI was defined as ≥ 25% increase in serum creatinine within 72 h after the procedure. Receiver-operating characteristic curve was constructed to assess the predictive value of GA, HbA1c and FBG for CI-AKI. Multivariable logistic regression model was developed to identify risk factors for CI-AKI, and Kaplan-Meier curve analysis was used to compare the rates of dialysis and major adverse cardiac events (MACE) during one-year follow-up. RESULTS The overall rate of CI-AKI was 11.1%. GA was significantly higher in patients with CI-AKI than in those without, and correlated positively with changes of renal function after the procedure. After adjusting for age, sex, left ventricular ejection fraction, multi-vessel disease, type and volume of contrast media, FBG, and HbA1c, GA remained an independent risk factor for CI-AKI. GA ≥ 21% was associated with increased rates of dialysis and MACE during one-year follow-up in patients with or without CI-AKI. CONCLUSIONS Increased GA level serves as a valuable risk factor for CI-AKI and indicates poor one-year clinical outcome in patients with T2DM and moderate to severe RI.

Elevated glycated albumin and reduced endogenous secretory receptor for advanced glycation endproducts levels in serum predict major adverse cardio-cerebral events in patients with type 2 diabetes and stable coronary artery disease

BACKGROUND AND AIM Glycated albumin (GA) and the endogenous secretory receptor for advanced glycation endproducts (esRAGE) may modulate risk related to atherosclerosis. We tested the hypothesis that elevated GA and reduced esRAGE in serum are associated with adverse clinical outcomes in patients with type 2 diabetes and stable coronary artery disease (CAD). METHODS We determined GA and esRAGE serum levels in 576 consecutive patients with type 2 diabetes and stable CAD undergoing sirolimus-eluting stent (SES)-PCI. The primary endpoint was the incidence of major adverse cardio-cerebral events (MACCE) including cardiac death, non-fatal myocardial infarction, and non-fatal stroke during a 2-year follow-up. The secondary endpoint was the occurrence of clinically driven repeat revascularization during a 2-year follow-up. The prognostic value of GA and esRAGE was determined with the Cox-proportional hazard model after adjustment for covariates. RESULTS A total 40 patients (6.9%) experienced MACCE, and 108 (18.8%) patients underwent repeat coronary revascularization during the follow-up. Serum GA (HR=1.22, 95% CI 1.16-1.28; HR=1.15, 95% CI 1.11-1.19, respectively; for both p<0.001) and esRAGE (HR=0.60, 95% CI 0.40-0.87; HR=0.75, 95% CI 0.61-0.92, respectively; for both p<0.01) levels remained independent predictors of the primary and secondary endpoints after adjustment for possible confounders. CONCLUSIONS Serum GA and esRAGE are novel predictors of long-term clinical outcomes in patients with type 2 diabetes and stable CAD. Increased serum GA and decreased esRAGE are associated with a poor prognosis in such patients.

Insertion/insertion genotype of α2B-adrenergic receptor gene polymorphism is associated with silent myocardial ischemia in patients with type 2 diabetes mellitus

OBJECTIVES We investigated whether α(2)-adrenergic receptor (AR) polymorphisms (α(2A)-AR, α(2B)-AR and α(2C)-AR gene) affected silent myocardial ischemia (SMI) in patients with type 2 diabetes mellitus (T2DM). DESIGN AND METHODS Genetic polymorphisms were determined in 321 patients with T2DM and coronary artery disease (CAD). Among them, 129 patients experienced transient asymptomatic ST-depression during 24-hour ambulatory electrocardiogram (SMI group), and the remaining 192 patients who had ambulatory electrocardiogram-symptom matching angina were categorized as angina group. RESULTS The genotype distribution and allele frequencies of α(2B)-AR gene polymorphism (insertion [I]/deletion[D]) exhibited significant difference between SMI group and angina group (both P < 0.05), with genotype II (34.9%) being higher in SMI group than in angina group (19.8%) (P < 0.01). Multivariable logistic regression analysis revealed that duration of diabetes and genotype II of α(2B)-AR gene polymorphism were independently associated with SMI. CONCLUSIONS Homozygote for I allele of α(2B)-AR gene polymorphism is associated with SMI in T2DM patients with CAD.

Impact of coronary collateral circulation on angiographic in-stent restenosis in patients with stable coronary artery disease and chronic total occlusion

OBJECTIVE This study aimed to evaluate the relationship between coronary collateralization and in-stent restenosis (ISR) in stable coronary artery disease patients with chronic total occlusion (CTO) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. METHODS The degree of coronary collaterals supplying the distal aspect of a total occlusion from the contra-lateral vessel was graded according to Rentrop classification in 216 patients with stable angina undergoing successful DES based PCI for CTO. Univariable and multivariable logistic regression analyses were performed to assess the potential factors related to angiographic ISR during follow-up. RESULTS Despite similar number of diseased coronary arteries, good collateralization (Rentrop score 2 or 3) was more frequently associated with right coronary artery occlusion (60%), whereas poor collaterals (Rentrop score 0 or 1) occurred more often in left anterior descending artery occlusion (40%). Despite similar number of CTO intervened, stent length was longer in patients with good collateralization (59±27mm vs 47±23mm, p=0.001). At mean 18months, the rate of ISR did not significantly differ between patients with good collateralization and those with poor collateralization (12.7% vs 20.2%, p=0.148). At multivariable analysis, age (OR 1.058, 95%CI 1.015-1.104, p=0.008), history of diabetes mellitus (OR 2.382, 95%CI 1.109-5.116, p=0.026) and reference CTO vessel diameter (OR 0.219, 95% CI 0.051-0.951, p=0.043) were independent risk factors for ISR while Rentrop collateral grade (OR 0.795, 95% CI 0.365-1.732, p=0.414) was not associated with ISR. CONCLUSIONS The occurrence of ISR after successful DES based PCI for CTO may be not influenced by coronary collateralization.

Impact of angiographic and intravascular ultrasound features on clinical outcome after sirolimus-eluting stent implantation for de-novo lesions in nondiabetic and type 2 diabetic patients.

ObjectivesThis study aimed to evaluate the impact of angiographic and intravascular ultrasound (IVUS) features on clinical outcome in nondiabetic and type 2 diabetic patients after percutaneous coronary intervention (PCI) with sirolimus-eluting stent (SES) implantation. MethodsRepeat coronary angiography with IVUS imaging was performed after SES-based PCI for de-novo lesions in 128 diabetic and 327 nondiabetic patients (189 lesions and 504 lesions, respectively). The rate of major adverse cardiac events including cardiac death, non fatal myocardial infarction (MI), and target lesion revascularization during clinical follow-up was recorded. ResultsIn-stent and in-segment late loss, intimal hyperplasia volume, and percentage volumetric obstruction were similar, but stented external elastic membrane cross-sectional area and reference/stented segment ratio were lower in diabetic than in nondiabetic patients. Incomplete stent apposition (ISA) was less frequent, but occurrence of new coronary lesions was higher in diabetic than in nondiabetic patients. Despite similar target lesion revascularization, cumulative survival rates freedom from composite cardiac death and nonfatal MI or major adverse cardiac events were reduced in diabetic patients. Cox proportional hazards model identified diabetes, left ventricular ejection fraction, minimal stent CSA, maximal ISA area, atherosclerotic progression and lesion length as independent predictors of non fatal MI or mortality at follow-up. ConclusionIn diabetic patients, PCI with SES implantation neutralizes the excess risk of intimal hyperplasia and decreases occurrence of ISA, but could not modify the propensity of increased adverse clinical outcomes at follow-up.

Correlates and outcomes related to periprocedural myocardial injury during percutaneous coronary intervention for chronic total occlusion: Results from a prospective, single center PCI registry.

There is increasing interest in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Periprocedural myocardial injury (PMI) post CTO PCI is not uncommon, but true incidence and implications of PMI are not well understood.