Emergency Coronary Bypass Surgery Research Articles

Systemic inflammatory response syndrome after on-pump cardiac surgery in emergency coronary artery bypass grafting: a retrospective trial

INTRODUCTION: The frequency, spectrum and pathophysiological relationships of systemic inflammatory response syndrome in acute coronary artery bypass grafting is not fully understood. OBJECTIVE: To determine the clinical significance of systemic inflammatory response syndrome (SIRS) in emergency coronary artery bypass grafting (CABG) performed with cardiopulmonary bypass. MATERIALS AND METHODS: We examined 60 patients (38 men and 22 women, aged 65 ± 9 years) who underwent emergency CABG (3 ± 1 bypass), with cardiopulmonary bypass (CPB) (97 ± 47 min). We retrospectively studied clinical and laboratory data of the perioperative and early postoperative period from emergency and elective coronary bypass surgery. RESULTS: In urgently operated patients (n = 30) in the early postoperative period, a higher frequency (53.3 and 13.3 %; p = 0.0022) of the development of systemic manifestations of the inflammatory response (neutrophilic leukocytosis, fever, postperfusion vasoplegia), as well as respiratory complications (70 and 10 %; p < 0.001) was noted. A pathophysiological relationship was established between the manifestations of SIRS and respiratory dysfunction during emergency interventions. CONCLUSIONS: SIRS pathophysiologically associated with respiratory dysfunction is characteristic of emergency CABG. It is during emergency myocardial revascularization that the duration of cardiopulmonary bypass and myocardial ischemia (MI) are predictors of SIRS.

Premature coronary artery disease in all-comers undergoing first PCI

Abstract Background The prevalence of coronary artery disease (CAD) increases with age, yet some individuals develop obstructive CAD at younger age. Purpose The present analysis aimed to assess differences in baseline risk profile and 3-year adverse event risk between patients undergoing percutaneous coronary intervention (PCI) for premature or non-premature CAD. Methods We pooled patient-level data of four randomized PCI trials in all-comers (TWENTE (clinicaltrials.gov: NCT01066650); DUTCH PEERS (NCT01331707); BIO-RESORT (NCT01674803); and BIONYX (NCT02508714)), who had no previous coronary revascularization (by PCI or coronary artery bypass surgery) or myocardial infarction (MI). Premature CAD was defined as CAD in men <50 years and in women <55 years, while non-premature CAD was classified as CAD in older patients. Main clinical endpoint was major adverse cardiac events (MACE), a composite of all-cause mortality, any MI, emergent coronary bypass surgery, or clinically indicated target lesion revascularization. Results Of all 6,171 PCI patients with first revascularizations, one out of seven (n=887, 14.4%) had premature CAD. These patients had lower rates of diabetes (10.6% vs. 16.6%, p<0.001), hypertension (32.7% vs. 50.7%, p<0.001), hypercholesterolemia (35.9% vs. 40.3%, p=0.012), and peripheral arterial disease (2.0% vs. 6.6%, p<0.001). Yet, they were more often overweight (76.2% vs. 69.8%, p<0.001), smoker (60.7% vs. 26.4%, p<0.001), and had more often a family history of CAD (59.8% vs. 44.5%, p<0.001). Patients with premature CAD suffered more often from acute ST-segment elevation MI and underwent less often treatment of calcified or bifurcated lesions (Table 1). At 3-year follow-up, the main endpoint MACE did not differ significantly between patients with premature and non-premature CAD (6.6% vs. 9.4%; adj.HR:0.86, 95%-CI:0.65-1.16, p=0.33; Figure 1). All-cause mortality was lower in patients with premature CAD (0.8% vs. 4.4%; adj.HR:0.23, 95%-CI:0.10-0.52, p<0.001). Yet, in patients with premature CAD the rate of repeated target vessel revascularization was higher than in patients with non-premature CAD (6.1% vs. 4.3%; adj.HR: 1.63, 95%-CI:1.18-2.26, p=0.003). In addition, their definite stent thrombosis risk was higher (1.0% vs. 0.5%; adj.HR:3.20, 95%-CI:1.39-7.38; p=0.006) than in patients with non-premature CAD. Conclusions One out of seven patients who were treated with PCI had premature CAD, and these patients had less complex risk profiles. Patients with premature CAD had higher risks for repeated revascularization and stent thrombosis, but the 3-year all-cause mortality risk was lower. In patients with premature CAD, long-term outcome after PCI might be improved by addressing modifiable risk factors such as smoking and overweight.Figure 1:Kaplan-Meier cumulative event

Rare Complication in The Coronary Angiography Laboratory: Stent Stripping

Although foreign body embolization is a rare complication of percutaneous coronary intervention, the increase in the number of procedures results in this problem being more frequently encountered by interventional cardiologists. Contemporary case studies have reported the rate of stent stripping to be below 1%. Interventional cardiologists attend to a considerable number of cases in everyday practice and witness a diverse spectrum of complications. Stent stripping can result in severe complications such as emergency coronary bypass surgery, coronary thrombosis, myocardial infarction, cerebrovascular event and death. Thus, the proper management of stent stripping is important for reducing the risk of mortality and morbidity. In this article, we present a case of left main coronary artery stent stripping; we discuss the removal procedure and the complications that arose.

Iatrogenic type A aortic dissection during percutaneous coronary intervention: A single-center experience

Iatrogenic aortic dissection (IAD) during coronary interventions is a rare but fatal complication. There is not enough experience and trial on this subject. In this study, we report our IAD cases and their acute, short-term, and long-term results.In this study, we screened 6,096 coronary angiographies performed in our center between February 2016 and February 2019. Ascending aortic dissection developed in 8 patients. A total of 7 patients had computed tomographic angiography images after the event and during the follow-up. We performed 1-month and 1-year follow-up examinations.The incidence of IAD was 0.13%. The female sex ratio was as 63%. A total of 37% of the patients had presented with acute coronary syndrome. In 37% of the patients, dissection occured while support catheter use, but in the remaining patients, dissections developed owing to hydraulic pressure. Regardless of the Dunning staging, 7 patients were followed-up with medical treatment, and 1 patient with decreased coronary flow was referred to emergency coronary bypass surgery. Regression was in the first tomography in 4 patients and observed in the control tomography in the remaining patients with medical treatment. The in-hospital 1-month and 1-year mortality rates were 0%.IAD is a fatal disease, and conservative follow-up is suggested due to lack of clear management recommendations. The findings in our study showed that medical treatment is the first choice for the hemodynamically stable patients when dissection is sealed by stenting; however, surgical treatment is required in patients with the decreased coronary flow.

Outcomes of coronary artery bypass grafting in patients with high-risk non-ST-segment elevation acute coronary syndrome within the first 24 hours of admission

Aim. The current myocardial re-vascularisation guidelines recommend that the coronary re-vascularisation of patients with high-risk non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) should be performed within 24 hours of admission. In real clinical practice; however, it is not always possible to keep coronary bypass surgery on schedule owing to various reasons. The aim of the current study, which presents cases of successful adherence to the surgical schedule, was to explore the need for 24/7 cardiac surgery services and to evaluate the outcomes of early (i.e. during the first 24 hours) coronary artery bypass grafting in 21 patients with high-risk NSTE-ACSs.Methods. The medical records of patients undergone coronary bypass surgery for high-risk NSTE-ACSs within the first 24 hours of admission between 2017 and 2019 were retrospectively analysed.Results. The mean age of the patients was 64.3 ± 5.6 years. Myocardial infarction was confirmed in 52.4 % (n = 11) of the subjects and progressive angina pectoris in 47.6 % (n = 10). The average waiting time to surgery was 17.8 ± 4.7 hours. Besides, 9.5 % (n = 2) of the cases, who had received dual antiplatelet therapy, exhibited a shorter waiting time to surgery. Patients were characterised by extremely severe clinical and angiographic status as follows: one in three had post-infarction cardiosclerosis and a first-degree family history of obesity; one in four had a history of percutaneous coronary intervention; and 61.9 % (n = 13) were found to have a left main coronary artery lesion, in 79.6 % (n = 10) of whom the left main coronary artery stenosis appeared to be greater than 80 %, necessitating the intra-aortic balloon counter-pulsation therapy in 33.3 % (n = 7) overall. Also, the mean cardiopulmonary bypass time turned out to be 88.6 ± 27.1 minutes, with an aortic clamping time of 47.6 ± 14.7 minutes. The in-hospital mortality rate was 14.3 % (n = 3), with cardiac and respiratory failure as well as mediastinitis (in one patient) being among the causes of adverse outcomes. So far, none of the studied cases has required re-sternotomy due to bleeding or perioperative acute cerebrovascular accident.Conclusion. In high-risk NSTE-ACS patients with severe clinical and angiographic status, emergency coronary bypass surgery performed within 24 hours of admission may prove an effective treatment option that can help save patients’ lives through complete re-vascularisation.Received 31 March 2020. Revised 2 May2020. Accepted 16 May 2020. Funding: The study is supported as a part of the research program "Complete myocardial revascularization in patients with non-ST segment elevation acute coronary syndrome with coronary artery bypass grafting". Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and design: A.B. NishonovData collection and analysis: A.B. NishonovDrafting the article: A.B. Nishonov, R.S. TarasovCritical revision of the article: S.V. Ivanov, T.S. Golovina, L.S. BarbarashFinal approval of the version to be published: A.B. Nishonov, R.S. Tarasov, S.V. Ivanov, T.S. Golovina, L.S. Barbarash

Emergency coronary bypass surgery in patients under the influence of dualantiplatelet therapy: effects of tranexamic acid and desmopressin acetate

Background/aim: Bleeding in patients undergoing coronary artery bypass grafting (CABG) while using dual antiplatelet therapy (DAPT) is a cause of significant morbidity and mortality. The aim of this study is to examine the perioperative hemostatic effects of tranexamic acid (TnX-A) and desmopressin acetate (Des) in these patients. Materials and methods: This clinical study was planned in a prospective and randomized manner. Fifty-four patients were enrolled and classified into 4 different groups. They were compared in terms of various bleeding and transfusion parameters.Results: No significant differences were observed between the groups in pre/intraoperative data apart from closure times. Plasmin/α-2 antiplasmin complex values in the TnX-A and control groups were significantly higher than those in the Des and TnX-A+Des groups at the end of postoperative drug infusion. Mean duration of closure times, first 3-h and total postoperative amounts of drainage, administered volumes of erythrocyte suspension/fresh frozen plasma, cost of blood products, length of intubation, length of stay in the intensive care unit, and time to discharge were also significantly higher in the Des and control groups.Conclusion: Des had no significant effect on bleeding control and even delayed the hemostatic efficacy of TnX-A. Use of TnX-A infusion alone in these patient groups had a positive effect on hemostasis-related data.

Massive coagulopathy caused by the bite of a Crotalus basiliscus snake

SummaryCrotalus basiliscus (Mexican West Coast Rattlesnake) is a crotalid snake native to Mexico. Whilst there is abundant information on bites by other pit vipers, there is none on the bite of this particular snake. We present the first case report of a bite by Crotalus basiliscus in a 57‐year‐old snake breeder, who after being bitten by one of his largest rattlesnakes, developed shock, a ventricular arrhythmia, profound coagulopathy and signs of compartment syndrome in his left lower extremity. Following repeated administration of antivenom, his clinical condition stabilised, but he required emergency coronary bypass surgery for newly diagnosed severe triple vessel disease.

Heavily calcified plaques in acutely angulated coronary segment: high risk features of rotablation resulting in Rotawire transection and coronary perforation

Percutaneous treatment of complex coronary disease not only is challenging but also paves the road for constantly evolving treatment modalities. Percutaneous transluminal rotational atherectomy (PTRA) has been shown to be particularly beneficial when treating highly calcified lesions and as a useful adjunct to balloon angioplasty and stent placement [ [1] Tomey M.I. Kini A.S. Sharma S.K. Current status of rotational atherectomy. JACC Cardiovasc. Interv. 2014; 7: 345-353 Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar ]. With the improvement of devices and the accumulation of operator's experiences, PTRA has a high successful rate with low risk of complications. We present a case of Rotawire fracture during rotational ablation through a long and severely calcified segment with acute angulation of the left anterior descending artery (LAD), resulting in coronary perforation and cardiac tamponade. The patient was treated with emergent pericardiocentesis and coronary bypass surgery. Despite the high successful rates, to our knowledge, there were few published cases of guide-wire fracture during PTRA [ 2 Woodfield S.L. Lopez A. Heuser R.R. Fracture of coronary guidewire during rotational atherectomy with coronary perforation and tamponade. Catheter. Cardiovasc. Diagn. 1998; 44: 220-223 Crossref PubMed Scopus (32) Google Scholar , 3 Sakakura K. et al. Comparison of frequency of complications with on-label versus off-label use of rotational atherectomy. Am. J. Cardiol. 2012; 110: 498-501 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar ]. Selection of appropriate lesions and recognition of possible high-risk feature of long, highly calcified and highly angulated segment of coronary artery can potentially reduce the complication risks.

The effects of clopidogrel loading doses on postoperative bleeding in patients with acute coronary syndrome requiring emergent coronary bypass surgery

Background: This study aims to evaluate the effect of high dose clopidogrel administered before coronary angiography in patients with the diagnosis of acute coronary syndromes (ACS) requiring emergent coronary angiography and emergent coronary artery bypass graft (CABG) surgery on postoperative bleeding and other complications. Methods: A total of 1800 consecutive patients who underwent CABG between October 2007 and October 2010 in our clinic were retrospectively analyzed. A total of 61 patients (44 males, 17 females; mean age 63±10 years; range 42 to 79 years) were enrolled including 21 of them without clopidogrel, 20 with clopidogrel 300 mg and 20 with clopidogrel 600 mg due to ACS. All of the patients underwent emergent angiography due to ACS. All of them underwent CABG surgery within minimum two hours and maximum 18 hours. Postoperative bleeding, reoperation due to bleeding, length of stay in the intensive care unit (ICU) and hospital and early-term mortality of the patients were compared. Results: No significant difference in the amount of bleeding was observed between the postoperative chest tube drainages of patients who received clopidogrel 300 mg compared to the patients who received no clopidogrel therapy (450cc, 400cc, respectively, p>0.05). The amount of bleeding was significantly higher in patients who received clopidogrel 600 mg compared to patients who received no clopidogrel therapy (625cc, 400cc, respectively p0.05). The length of stay in the ICU and hospital were similar in all three groups. Conclusion: Patients who received loading dose of clopidogrel 300 mg due to ACS may undergo CABG surgery after emergent angiography. Postoperative bleeding may not be a critical challenge in these patients. However patients who receive loading dose of clopidogrel 600 mg are at high risk for postoperative bleeding and complications compared to patients not receiving clopidogrel.

Use of Registries to Complement Clinical Trials in Renal Artery Stenting

The role of renal artery stenting in the treatment of atherosclerotic lesions of renal artery remains intensely debated. There were similar debates several times in interventional cardiology arena, and interestingly the data in renal artery stenting have followed the same footsteps. Use of registry data helped in the debate on many issues in cardiology, and we make a case for use of registries to complement clinical trials in renal artery stenting. Rapid developments followed after Dr Gruntzig pioneered treatment of atherosclerotic blockages in coronary and renal arteries with angioplasty. Results in the first 50 patients who underwent percutaneous transluminal coronary angioplasty (PTCA), the primary success rate was only 64%, and emergency coronary bypass surgery (CABG) was required in 14%, with a periprocedural myocardial infarction (MI) rate of 6%. Subsequently, as a result of greater operator experience and refinements in catheter and imaging technology, acute complication rates of balloon angioplasty steadily decreased. However, restenosis and the need for repeat intervention remained a severe limitation, occurring in up to 40% of cases. An alternative strategy evolved and in 1986, Sigwart performed first stent implantation in a human coronary artery. Restenosis was soon recognized to be a major problem that found viable solution in the form of drug-eluting stents, first of which was approved by the Food and Drug Administration (FDA) in 2003. Initial treatment of ostial renal atherosclerotic lesions was limited by a low acute technical success rate of 50% to 62% and a high restenosis rate of up to 47% in the long term due to dissections, elastic recoil, and rigidity of the lesion in calcified stenoses. Single-center reports of stenting started trickling in 1990s. Two randomized studies proved the superiority of stenting over conventional balloon angioplasty in terms of acute treatment success and technical durability of the endovascular treatment of atherosclerotic ostial renal artery stenosis (RAS). Larger clinical trials were required to define the indications for interventional treatment of RAS. Unfortunately, 3 prospective randomized controlled clinical trials (RCTs) that have been published on the subject thus far have failed to provide clear answers. With the exception of Stenting for Renal Artery Lesions (ASTRAL) trial, the studies were underpowered to provide meaningful answers. All the trials enrolled patients with limited disease burden (stenosis <70%) and who had little plausible survival benefit from intervention versus medical therapy. Large number of patients did not receive the intended treatment and the statistical analysis was performed on intention-to-treat basis that could never account for high crossover rates. A large national institute of health funded Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial that will randomize over 900 participants with greater than 60% stenosis to stenting and optimal medical therapy or medical therapy alone is underway. Recruitment for this trial has also been slow and research protocol has undergone multiple revisions to ease the recruitment process. The primary end point is survival free of cardiovascular and renal adverse events. The results of this trial are awaited. Sketching parallels, Taggart elaborated that trials evaluating the use of drug-eluting stents in multivessel coronary disease faced similar problems. The trials systematically enrolled patients with limited disease burden and who had little plausible survival benefit from surgery versus medical therapy. In the mentioned trials, more than 90% of screened patients were excluded from randomization as they did not meet the inclusion criteria. The investigations only represented a small portion of the spectrum of multivessel disease, but their results were used to justify percutaneous coronary intervention (PCI) in much more anatomically complex patients without corroborating evidence. Evidence from total population-based studies such as the New York State registry indicates that when all patients are considered, CABG provides superior survival in the setting of all patients with left anterior descending coronary artery disease and at least 1 other diseased vessel.

The Comparison between Self-Expanding and Balloon Expandable Stent Results in Left Anterior Descending Artery.

The first Wallstent results had high thrombosis and death. It was reported that the left anterior descending (LAD) artery was the vessel implicated in major complications that occurred in patients who received a Wallstent. Subsequently, Wallstent applications were refrained from with LAD lesions. However, the promising results of second-generation self-expanding Magic Wallstent implantation have been reported recently. The purpose of this study is to assess the immediate and intermediate clinical outcomes of patients undergoing self-expanding Magic Wallstent implantation at the LAD site and to compare those outcomes with those of a similar group of patients undergoing balloon expandable stenting at the same site. Between 1995 and 1999, 255 consecutive patients underwent LAD stenting at our center. The study population was divided into two groups based on the mode of delivery (self-expanding versus balloon-expandable) of stent design. Group I included 97 patients in whom self-expanding Magic Wallstents were implanted. Group II included 158 patients in whom various types of balloon-expandable stents were implanted. Procedural success was defined as successful deployment of the stent in the absence of adverse cardiac events (death, acute myocardial infarction, emergency coronary bypass surgery). Clinical success was defined as the absence of adverse cardiac events (death, acute myocardial infarction, emergency coronary bypass surgery, repeat balloon angioplasty) within the first two weeks. The mean follow-up period was 8 +/- 5.3 months for Group I and 9.8 +/- 7.5 months for Group II. There was no difference in baseline characteristics between the two groups. Fourteen patients in Group I and 22 patients in Group II had bailout procedures. The number of patients with reference vessel diameter less than 3 mm was 37 in Group I and 60 in Group II. The stent length was greater in Group I than in Group II (p = 0.0003). In Group I, stenting improved minimal lumen diameter (MLD) from 0.65 +/- 0.4 mm to 2.35 +/- 0.4 and percent diameter stenosis (PDS) from 76.24 +/- 17.3 to 22.78 +/- 13.6. In Group II, stenting improved MLD from 0.73 +/- 0.4 mm to 2.49 +/- 0.5 and PDS from 76.71 +/- 15.5 to 18.99 +/- 9.6. Final MLD and final PDS improved more in Group II than Group I. Stent could not be delivered in three patients in Group I and nine in Group II. In Group II, six stents were dislocated from its delivery system. Procedural and clinical success and subacute stent thrombosis rates were 93.8%, 85.6%, and 7.2% in Group I, and 93%, 86.7%, and 5.1% in Group II, respectively. Within the first two weeks, death occurred in one patient in each group, acute myocardial infarction in four (Group I) and two (Group II) patients; coronary bypass surgery in three (Group I) and five (Group II) patients, and balloon angioplasty in two (Group I) and four (Group II) patients, respectively. In Group I, following the first two weeks, no patients died, two patients had nonfatal myocardial infarction, and coronary bypass surgery and target vessel repeat balloon angioplasty was required in five and ten patients, respectively. In Group II, one patient died in the follow-up period, there was no nonfatal myocardial infarction, and bypass surgery and target vessel repeat balloon angioplasties were required in three and eleven patients, respectively. None of these differences in clinical events was statically significant. We found that self-expanding Magic Wallstent implantation can be performed in LAD lesions and was associated with a rate of early clinical results and intermediate term clinical results similar to that of balloon-expandable stents in LAD arteries. In conclusion, the Magic Wallstent may confidently be used for LAD lesions. </hea

Changing trends in emergency coronary bypass surgery

Patients undergoing emergency coronary artery bypass grafting represent a unique and high-risk population that remains challenging for cardiac surgeons. We examined the changing trends in patients undergoing emergency bypass grafting over the past 20 years. We conducted a retrospective review of our database between 1990 and 2009 and patients were divided into 2 groups based on year of operation: 1990-1999, n = 393; 2000-2009, n = 184. The primary outcomes of interest for this study are operative mortality and incidence of low cardiac output syndrome. The percentage of patients undergoing emergency coronary bypass grafting has decreased from 2.7% to 1.7% over time. The percentage of patients with dyslipidemia, hypertension, triple vessel disease, peripheral vascular disease, and left main disease increased over time (P < .05). Operative mortality remained at 8.1% in both year groups. Preoperative hypertension, congestive heart failure, left ventricular ejection fraction less than 20%, and previous cardiac surgery independently predicted operative mortality by logistic regression analysis. Low cardiac output syndrome developed in 25% of the patient population undergoing emergency bypass grafting. The independent predictors of low cardiac output syndrome were small body surface area, congestive heart failure, shock, myocardial infarction, earlier decade (1990-1999) and increased age. Despite a changing preoperative risk profile, the operative mortality of emergency coronary artery bypass grafting has remained stable over the years. However, mortality remains significantly above the observed mortality in elective bypass grafting. Continued improvements in the management of heart failure and the care of the elderly will likely result in reduced risks of emergency coronary artery bypass grafting.

Embolic Occlusion of the Left Main Coronary Artery Following an Isolated Aortic Valve Replacement

Coronary occlusion after aortic valve replacement due to embolization is a rare complication. We report the case of a patient who developed acute heart failure due to occlusion of the left main coronary artery following an aortic valve replacement. Successful treatment was achieved with emergent coronary bypass surgery.

Usefulness of Mean Platelet Volume as a Biomarker for Long-Term Outcomes After Percutaneous Coronary Intervention

Larger size platelets have enhanced reactivity. The mean platelet volume (MPV) is a marker of platelet activation and is usually measured as part of blood testing. The aim of the present study was to investigate the utility of the MPV as a biomarker in prognosticating the long-term outcomes after percutaneous coronary intervention (PCI). The baseline MPV values from consecutive patients undergoing PCI were screened. Of the 1,432 patients, the composite primary end point of mortality or myocardial infarction at 1 year occurred in 80 (5.6%). The patients in the highest tertile (MPV >9.1 fL) had an increased frequency of the primary end point compared to those in the mid (8.1 to 9.1 fL) and lowest (<8.1 fL) tertiles (9.0%, 4.5%, and 3.5%, respectively; p <0.01). Logistic regression analysis demonstrated diabetes (odds ratio 2.44, 95% confidence interval 1.48 to 4.00) and highest tertile of MPV (odds ratio 2.42, 95% confidence interval 1.47 to 3.99) as the best predictors of adverse outcomes. In patients with acute coronary syndrome, the preprocedural MPV and troponin levels demonstrated a comparable predictive relation to the primary end point (receiver operator characteristics curve analysis, area under the curve 0.64, p = 0.01; and 0.63, p = 0.01, respectively). In conclusion, an elevated MPV was a strong independent predictor of long-term outcomes after PCI. The preprocedural MPV had prognostic value similar to that of troponin in patients with acute coronary syndrome. These findings could be of importance in the clinical evaluation of patients before PCI and the design of future studies assessing antiplatelet therapies.

Repair of coronary artery perforation following angioplasty using TachoSil® patches

Coronary perforation is a rare complication of percutaneous interventional procedures, occurring in 0.2-3% of procedures, which may require emergency coronary bypass surgery. We describe here an alternative method to deal with such complication, which proved effective in a patient with active bleeding from the left anterior descending (LAD) coronary artery. By temporary pressing on beating heart patches of TachoSil, a sponge impregnated with human fibrinogen and thrombin, on the bleeding site, complete and stable hemostasis was achieved.

Three-Year Experience of Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction in a Hospital without On-site Cardiac Surgery

Introduction: Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in hospitals without on-site cardiac surgery capability, despite receiving only a class IIb recommendation in the ACC/AHA practice guidelines, can be per-formed effectively and safely. We reviewed the first 3 years of our experience. Materials and Methods: This is a retrospective single centre review of all patients receiving primary PCI for STEMI between 2003 and 2005. Demographic, procedural and outcome data were analysed. Results: There were 259 patients who underwent primary PCI. The mean age was 55.3 ± 12.3 years. Median door-to-balloon time was 97.5 minutes and 45.2% and 52.9% had anterior and inferior STEMI, respectively. The majority of patients presented with Killip class I (87.6%); however, 5.8% were in Killip class IV. Single vessel disease was found in 47.1%. Angiographic PCI success (defined as residual stenosis &lt;50% with TIMI 3 flow) was achieved in 89.1%. Usage of stents, distal protection and aspiration devices were 97.2%, 27.8% and 34.1 %, respectively; 9.3% required intra-aortic balloon pump insertion. No patients required transfer for emergency coronary bypass surgery as a result of PCI complications. Post-PCI ST resolution &gt;50% was achieved in 80.6%. The mean post-infarct left ventricular ejection fraction was 44.1%. In-hospital, 30-day, 6-month and 1-year mortality rates were 2%, 2.8%, 4.0% and 4.8%, respectively. Clini-cally driven target lesion revascularisation rate was 2.8% at 1 year. Conclusions: Our results are comparable to those from on-site surgical centres. This supports the feasibility and safety of primary PCI in cardiac centres without on-site cardiac surgery. Key words: Emergency, PCI, STEMI, Transfer

Emergent coronary bypass surgery following percutaneous coronary intervention: incidence, predictors, and outcomes

Emergent coronary bypass surgery following percutaneous coronary intervention: incidence, predictors, and outcomes

A Pivotal Medical-Device Case

This spring the Supreme Court of the United States will decide whether premarketing approval of a medical device by the Food and Drug Administration (FDA) immunizes the manufacturer against product-liability litigation in state courts. This decision, we believe, is a matter of particular importance to patients and the medical community.On December 4, 2007, the Supreme Court heard oral arguments in Riegel v. Medtronic.1 In May 1996, Charles Riegel underwent coronary angioplasty in Albany, New York. During the procedure, the balloon ruptured, and advanced cardiac life support and emergency coronary bypass surgery were needed. Mr. Riegel and his wife . . .

Who Should Protect the Public? The Supreme Court and Medical Device Regulation

A decade ago, Charles Riegel was undergoing a coronary angioplasty procedure when a balloon catheter ruptured. Complete heart block developed, and Riegel lost consciousness and had to undergo emergency coronary bypass surgery. A U.S. Court of Appeals ruled that Riegel could not sue Medtronic, the manufacturer of the catheter, for his injuries and resulting disability. The Supreme Court recently agreed to review that holding and will hear oral arguments later this fall. Its decision is expected by June 2008.The technical issue in the case is the proper interpretation of the 1976 Medical Device Amendments (MDA) to the federal Food, . . .

Treatment of Coronary Artery Perforations Complicating Percutaneous Coronary Intervention With a Polytetrafluoroethylene-Covered Stent Graft

Coronary artery perforation is a rare, but dreaded, complication of percutaneous coronary intervention. Conventional treatment, including reversal of anticoagulation and prolonged balloon inflation, is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Although a number of case reports have demonstrated the feasibility of sealing coronary perforations with synthetic material-covered stent grafts, the efficacy of this treatment has not been reported in a large, multicenter series. We used a retrospective international registry to examine the outcomes of the polytetrafluoroethylene-coated JOSTENT coronary stent graft (CSG) in 41 cases of coronary perforations. Perforations were relatively severe: 16.7% Ellis grade 1, 54.2% grade 2, and 29.1% grade 3. Of the 41 patients, > 1/3 (n = 14) experienced life-threatening complications before stent graft implantation, including pericardial tamponade (12.2%), cardiogenic shock (9.8%), and cardiac arrest (2.4%). A total of 52 CSGs were used to treat the 41 perforations (mean 1.3 per lesion). All CSGs were placed successfully, with 92.9% of the perforations sealed completely and 7.1% partially. One patient developed abrupt vessel closure after CSG deployment, resulting in an overall procedure success rate of 96.4%. No in-hospital Q-wave myocardial infarctions, emergency coronary bypass surgeries, or deaths resulted. The CSG may be a reliable and highly effective treatment option for sealing coronary perforations complicating percutaneous coronary interventions.