Failed Thrombolysis Research Articles

THROMBOLYSIS IN ST- ELEVATION MYOCARDIALINFRACTION PATIENTS: CLINICAL PREDICTORS OF REPERFUSIONAND ANGIOGRAPHIC OUTCOMES

Background: Thrombolysis is an alternative strategy for reperfusion in the management of ST- Elevation Myocardial Infraction (STEMI) patients, when percutaneous coronary intervention (PCI) cannot be performed. However, using clinical markers of reperfusion, thrombolysis is not always successful for all patients and immediate angiographicrescue PCI is indicated. Aim of the Work: Thegoal of this clinical study was to determinethe angiographic efficacy of thrombolysis in STEMI patients. Besides its correlation in successful or failed thrombolysis (FT) based on clinicalcriteria of reperfusion. Material/Methods: The study population included patients with acute STEMI within 12 hours of onset chest pain, who were admitted to The Cardiac Intensive Care Unit of cardiology department, atUniversityHospital Center Mohammed VI of Marrakech Morocco, receiving thrombolysis with Tenecteplase, during the period from January2021 to January2023. Repeated Electrocardiogram (EKG) at baseline, 90 minutes after Thrombolysis to define FT and PCIwereperformedfor all patients. Results:121 patients with a mean age of 56 years were recruited in the study. Successful thrombolysis was present in 60% of patients (n = 73) in Group I, while 40% of patients (n = 48) had FT in Group II. There was no significant difference between patients in both groups regarding gender, risk factors for coronary artery disease like dyslipidemia, diabetes mellitus, obesity, smoking, and myocardial infraction territory on the EKG. However, hypertension, delayed presentation after six hours of onset chest pain, and severe alteration of the systolic ejection fraction were mostly present in Group II. The TIMI III flow rates represent 76%(n = 93) of the patients in the study, with higher rates in both groups, at 80% versus 70% for groups I and II, respectively. Conclusion: The study confirmed that unsuccessful thrombolysisdoes not mean always-unsuccessful restoring of epicardial coronary flow.As a result, our current results clearly demonstrate the benefits of fibrinolysisfor STEMI patients when resources are limited for primary PCI. However, Additional clinical studies are also needed to investigate the recovery of microvascular and tissular perfusion to improve myocardial function and long-term clinical outcomes.

Mortality outcomes and predictors of failed thrombolysis following STEMI thrombolysis in a non-PCI capable tertiary hospital: a 5-year analysis.

Pharmacological reperfusion remains the primary strategy for ST-elevation myocardial infarction (STEMI) in low- and medium-income countries. Literature has reported inconsistent incidences and outcomes of failed thrombolysis (FT). This study aimed to identify the incidence, mortality outcomes and predictors of FT in STEMIpharmacological reperfusion. This single-centre retrospective cohort study analyzed data on consecutive STEMI patients who received thrombolytic therapy from 2016 to 2020 in a public tertiary hospital. Total population sampling was used in this study. Logistic regression analyses were used to assess independent predictors of the mortality outcomes and FT. We analyzed 941 patients with a mean age of 53.0 ± 12.2years who were predominantly male (n = 846, 89.9%). The in-hospital mortality was 10.3% (n = 97). FT occurred in 86 (9.1%) patients and was one of the predictors of mortality (aOR 3.847, p < 0.001). Overall, tenecteplase use (aOR 1.749, p = 0.021), pre-existing hypertension (aOR 1.730, p = 0.024), history of stroke (aOR 4.176, p = 0.004), and heart rate ≥ 100bpm at presentation (aOR 2.333, p < 0.001) were the general predictors of FT. The predictors of FT with streptokinase were Killip class ≥ II (aOR 3.197, p = 0.004) and heart rate ≥ 100bpm at presentation (aOR 3.536, p = 0.001). History of stroke (aOR 6.144, p = 0.004) and heart rate ≥ 100bpm at presentation (aOR 2.216, p = 0.015) were the predictors of FT in STEMI patients who received tenecteplase. Mortality following STEMI thrombolysis remained high in our population and was attributed to FT. Identified predictors of FT enable early risk stratification to evaluate the patients' prognosis to manage them better.

Discussion on the causes of thrombolysis failure in a patient with STEMI: a case report

BackgroundSpontaneous coronary artery dissection (SCAD) has emerged as an increasingly diagnosed cause of ST-segment elevation myocardial infarction (STEMI), which is easily missed or delayed. The effective use of coronary angiography (CAG) and advanced intracoronary imaging examinations in STEMI patients has led to increased detection of SCAD.Case presentationA 59-year-old woman with acute angina pectoris was diagnosed with STEMI detected by electrocardiography combined with measurement of myocardial enzymes. Due to the ongoing pandemic of coronavirus disease 2019 (COVID-19) in Wuhan, she was first given thrombolytic therapy after excluding contraindications according to the requirements of the current consensus statement; however, subsequently, both the symptoms of ongoing chest pain and the electrocardiographic results indicated the failure of thrombolytic therapy, so the intervention team administered rescue percutaneous coronary intervention treatment under third-grade protection. CAG confirmed total occlusion in the distal left anterior descending (LAD) artery, with thrombolysis in myocardial infarction (TIMI) 0 flow, whereas the left circumflex and right coronary arteries appeared normal, with TIMI 3 flow. Intravenous ultrasound (IVUS) was further performed to investigate the causes of occlusion, which verified the absence of atherosclerosis but detected SCAD with intramural haematoma. During the operation, the guidewire reached the distal end of the LAD artery smoothly, the balloon was dilated slightly, and the reflow of TIMI blood could be seen by repeated CAG. During the follow-up period of one and a half years, the patient complained of occasional, slight chest tightness. The repeated CAG showed that the spontaneous dissection in the LAD artery had healed well, with TIMI 3 flow. The repeated IVUS confirmed that the SCAD and intramural haematoma had been mostly resorbed and repaired.ConclusionThis was a case of failed STEMI thrombolysis in our hospital during the outbreak of COVID-19. This case indicates that doctors need to consider the cause of the disease when treating STEMI patients, especially patients without traditional cardiovascular risk factors. Moreover, CAG and intracoronary imaging examinations should be actively performed to identify the aetiology and improve the treatment success rate.

Anticoagulant management for transition from failed thrombolysis to extra-corporeal membrane oxygenation in patients with high-risk pulmonary embolism: A thoughtful approach

Acute venous thromboembolism represents a spectrum of clinical syndromes of which high-risk pulmonary embolism (PE) with consecutive right ventricular failure and cardiogenic shock (CS) is the most severe presentation. First-line treatment options are surgical pulmonary embolectomy, systemic thrombolysis or catheter-based therapies. The role of mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is multifarious in this setting and can be considered as either a bridge to pulmonary artery reperfusion by any of the aforementioned options or as salvage bridge intervention for patients in refractory CS after failure of another treatment. In the subpopulation of patients that are placed on V-A-ECMO after failed thrombolysis, the mortality rates are among the highest, partially due to the high rates of bleeding events. The challenges in the interpretation of anticoagulant monitoring and, consequently, the titration of anticoagulation at least contribute to this high mortality. Here, we discuss the strengths and limitations of different anticoagulant parameters in this setting and propose an approach based on monitoring of Heparin anti-factor Xa (anti-Xa) assay and activated partial thromboplastin time (APTT) in parallel to drive unfractionated heparin (UFH) titration in patients with high-risk PE after fibrinolysis during the first 24 h on V-A-ECMO.

SARS-CoV-2 Positivity, Stent Thrombosis, and 30-day Mortality in STEMI Patients Undergoing Mechanical Reperfusion.

SARS-Cov-2 has been suggested to promote thrombotic complications and higher mortality. The aim of the present study was to evaluate the impact of SARS-CoV-2 positivity on in-hospital outcome and 30-day mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) enrolled in the International Survey on Acute Coronary Syndromes ST-segment elevation Myocardial Infarction (ISACS-STEMI COVID-19 registry. The 109 SARS-CoV-2 positive patients were compared with 2005 SARS-CoV-2 negative patients. Positive patients were older (P = .002), less often active smokers (P = .002), and hypercholesterolemic (P = .006), they presented more often later than 12h (P = .037), more often to the hub and were more often in cardiogenic shock (P = .02), or requiring rescue percutaneous coronary intervention after failed thrombolysis (P < .0001). Lower postprocedural Thrombolysis in Myocardial Infarction 3 flow (P = .029) and more thrombectomy (P = .046) were observed. SARS-CoV-2 was associated with a significantly higher in-hospital mortality (25.7 vs 7%, adjusted Odds Ratio (OR) [95% Confidence Interval] = 3.2 [1.71-5.99], P < .001) in-hospital definite in-stent thrombosis (6.4 vs 1.1%, adjusted Odds Ratio [95% CI] = 6.26 [2.41-16.25], P < .001) and 30-day mortality (34.4 vs 8.5%, adjusted Hazard Ratio [95% CI] = 2.16 [1.45-3.23], P < .001), confirming that SARS-CoV-2 positivity is associated with impaired reperfusion, with negative prognostic consequences.

TIMI flow and myocardial blushing after rescue PCI and cardiac magnetic resonance: Results from the Myocardial Salvage After Rescue Angioplasty: Evaluation by Magnetic Resonance (SAVE-ME) study

IntroductionThrombolysis is currently reserved for ST-elevation myocardial infarction (STEMI) patients who cannot access timely percutaneous coronary intervention (PCI). In case of failed thrombolysis, rescue PCI is a viable option. Substantial data concerning the outcomes in terms of infarct size and myocardial function after rescue PCI are lacking. MethodsForty patients treated with rescue PCI underwent serial contrast-enhanced cardiac magnetic resonance imaging (CMR) at 1 week, 3 months and 6 months from the index STEMI. Angiographic images were reviewed to assess Thrombolysis in Myocardial Infarction (TIMI) blood flow and TIMI Myocardial Blush Grade (TMBG) in the infarct related artery after PCI. ResultsPatients with lower TMBG at the end of procedure, but not patients with worse TIMI flow, had lower left ventricular ejection fraction (LVEF) and higher volume of late gadolinium enhancement (LGE) on baseline CMR (44 ± 13% vs 52 ± 9%, p = 0.026, and 41 ± 21 ml vs 26 ± 12, p = 0.030, respectively). Patients with lower TMBG remained with significantly lower LVEF at 6 months follow up (48 ± 16% vs 59 ± 14, p = 0.049). ConclusionTMBG after rescue PCI is associated with reduced LVEF and increased LGE burden. As TMBG is a known marker of microvascular damage after STEMI, novel strategies aimed at improving microvascular function in the setting of rescue PCI are needed to improve the outcomes in this patient population.

Post Thrombolytic Angiographic Profile and TIMI Flow in Patients with ST-Elevation Myocardial Infarction

Background: Myocardial infarction (MI) is the leading cause of morbidity and mortality worldwide. Primary Percutaneous coronary intervention (PPCI) is recommended as a treatment of choice in patients with STEMI but fibrinolysis also remains prevalent as a reperfusion strategy in most of the patients with STEMI presenting to non-PCI capable hospitals where timely PPCI cannot be performed. Objectives: To assess the angiographic characteristics and angiographic success of thrombolysis in terms of TIMI 3 flow in patients who underwent angiography after thrombolysis for STEMI and the factors most commonly associated with unsuccessful thrombolysis. Methods: All 130 hospitalized patients in the department of Cardiology, at Bolan Medical Complex Hospital, Quetta from 31st July 2021 to 30th November 2021 with an acute ST-segment elevation MI (STEMI) diagnosis who received thrombolytics were included in this observational study. We didn't include patients who couldn't benefit from thrombolysis e.g. NSTEMI, contraindication to thrombolytics, and refused fibrinolysis. A 12-lead electrocardiogram (ECG) was performed when the patient arrived in ER and a repeat ECG was done 90 minutes after the administration of a thrombolytic agent (streptokinase). To assess the angiographic success of thrombolysis, coronary anatomy, and TIMI flow, we performed coronary angiography in all patients included in this study. Results: The study included 130 patients, 72 of whom had successful thrombolysis and 58 who had unsuccessful thrombolysis. Angiography reported TIMI 3 flow rates of 48(36.9%). Subjects in the unsuccessful thrombolysis group had the single-vessel disease in 29 (50%) and a multi-vessel disease was found in 19 (32.75%) of the patients. Patients with successful thrombolysis had Single vessel disease 6 (19.3%), Multivessel disease 1 (3.2) It was observed that patients with diabetes mellitus had a significant rise in the number of failed thrombolysis compared to those without diabetes mellitus (p&lt;0.005). It was also observed that anterior wall MI was significantly at risk for a failure in thrombolysis (82.1%) compared to inferior wall MI (17.8%). Conclusions: Effective thrombolysis was more prevalent than failed thrombolysis in our study. This data reiterates the utility of thrombolysis in resource-limited settings. Patients with diabetes, anterior wall MI, and delay in the presentations of the patients have a higher risk of thrombolysis failure. Type B lesions and multivessel disease were also prevalent in subjects with unsuccessful thrombolysis. According to the findings of this study, screening for risk factors before starting thrombolysis can aid in the development of alternative treatment methods that reduce failure rates and redirect resources to more successful treatment options. Keywords: Post thrombolytic; Angiographic Profile, TIMI flow; St-elevation; Myocardial Infarction

Worrisome trends of ST-elevation myocardial infarction during the Covid-19 pandemic: Data from Portuguese centers

IntroductionDuring the Covid-19 pandemic there has been a general belief that hospital admissions for non-infectious causes, especially cardiovascular diseases, have fallen. ObjectivesTo assess the impact of the pandemic on admissions for ST-elevation myocardial infarction (STEMI) during the first pandemic wave. MethodsWe performed a multicenter retrospective analysis of consecutive patients presenting with STEMI in two Portuguese hospital centers in two sequential periods – P1 (March 1 to April 30) and P2 (May 1 to June 30). Patient's clinical data and hospital outcomes were compared between the years 2017 to 2019 and 2020 for both periods. ResultsDuring P1 in 2020, a reduction in the number of STEMI patients was observed in comparison with previous years (26.0±4.2 vs. 16.5±4.9 cases per month; p=0.033), as well as an increase in the number of mechanical complications (0.0% vs. 3.0%; p=0.029). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs. 9.1%; p=0.033). An overall trend for longer delays in key timings of STEMI care bundles was noted. Mortality was higher during P1 compared to previous years (1.9% vs. 12.1%; p=0.005). ConclusionsDuring the first Covid-19 wave fewer patients presented with STEMI at the catheterization laboratory for percutaneous coronary intervention. These patients presented more mechanical complications and higher mortality.

Not All STEMI Patients Receive Timely Reperfusion: Considerations for Rural Emergency Departments.

Early reperfusion for ST-elevation myocardial infarction (STEMI) is well known to improve patient outcomes. A review of patient records in one rural health service in New South Wales, Australia, suggested that not all STEMI patients were receiving timely reperfusion. Consequently, the aim of this study was to further investigate factors influencing clinical decision making by primary care providers in relation to rural STEMI patients. This cross-sectional observational study was in two phases, a retrospective audit of patient records and a survey of rural general practitioners (GPs). In the first phase, patients with STEMI who were referred from small rural hospitals to a regional hospital emergency department (ED) were identified through the local health district database. In phase two, information from the database informed questions for a survey distributed to the GP visiting medical officers (VMOs) at small rural hospitals in the region. The survey was designed to ascertain factors that may contribute to delays in the care of STEMI patients. Of the STEMI patients identified (n = 139), 15% (21) who were eligible for medical reperfusion were not administered thrombolysis within 4 hours of triage. Auditing of this group's records found that ECGs were inaccurately interpreted for 76% of the missed STEMI patients. In the survey, about 55% of the GP respondents said they “very much agree” with the statement that they felt competent in STEMI management. Only 64% of the GP VMOs agreed they felt competent in diagnosis and management of a failed thrombolysis and not all respondents were aware of the relevant clinical guideline. Patients with missed STEMI are at higher risk of morbidity and mortality and increased length of stay, adding burden to the patient, carer and health service. Without addressing gaps in service provision and better adherence to clinical guidelines, unacceptable delays in STEMI management in rural health services are likely to continue.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Abstract Introduction Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases. Objectives To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave. Methods Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods. Results A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed. Conclusions During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates. Funding Acknowledgement Type of funding sources: None.

THROMBOLYTIC EFFICACY OF STREPTOKINASE IN ELDERLY TYPE 2 DIABETES MELLITUS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION USING ELECTROCARDIOGRAPHIC ST-SEGMENT RESOLUTION

Background: Age and diabetes are important prognostic factors in patients with acute ST-elevation myocardial infarction (STEMI) undergoing thrombolysis. In our study we compared the post-thrombolytic effect of streptokinase in elderly diabetic and non-diabetic patients. Methods: A prospective observational study was conducted in tertiary care center of India in which 140 elderly patients diagnosed with STEMI and undergoing thrombolytic therapy with streptokinase were enrolled after making necessary exclusions and were divided into diabetic (n=70) and non-diabetic (n=70) as study and control groups respectively. ECG was done immediately before and at 60 minutes after thrombolytic therapy. ST-segment resolution was measured and patients were classied as failed (&lt;30%), partial (30-70%) and successful (&gt;70%) resolution of STsegment. Results: Failed thrombolysis was evident in 34.3% non-diabetic and 57.1% diabetic patients (p=0.010). The incidence of successful thrombolysis was present in 41.4% non-diabetic and 28.6% diabetic patients, whereas partial thrombolysis was seen in 24.3% non-diabetic and 14.3% diabetics. Anterior wall was the most common location of infarction in elderly population but the proportion was higher in diabetics than non-diabetics (p=0.025). Conclusion: Failed thrombolysis with streptokinase was higher in diabetics than in non-diabetics after 60 minutes of streptokinase infusion in elderly patients warranting the need of using another cost effective and easily available agent for elderly diabetic population.

The Role of VWF, FVIII, ADAMTS13 and Inflammatory Response in the Outcome of Acute Ischemic Stroke Mechanical Thrombectomy Procedure

Background and Purpose: Mechanical thrombectomy is the method of choice for the intracranial arteries large vessel occlusions therapy in acute ischemic stroke after failed intravenous thrombolysis. Stent retrievers, aspiration catheters or combination are the most often techniques used for the intracranial thrombus extraction. Procedure length, TICI grade of recanalisation and the risk factors like diabetes, hypertension and arhytmia are the critical parameters influencing 3month-mRS clinical outcome after ischemic stroke treatment. Procedure time of the sticky emboli extraction and the endothelial cells damage are influenced with blood coagulation parameters, especially platelet adhesion molecules, D-dimers, fibrinogen, FVIII, von Willebrand factor multimers and by the inflammatory response of the body. Large vWF-multimers are cleaved into smaller, less coagulant forms by the metalloprotease ADAMTS13. In case of ADAMTS13 deficiency, large vWF-multimers are not cleaved from the circulation with the higher risk of thrombosis. Methods: 120 consecutive patients with acute ischemic stroke underwent mechanical thrombectomy. Clinical and interventional procedure parameters, as well as blood coagulation factors and cell counts, extracted emboli light microscopy and peripheral blood inflammatory respond were analysed. Results: Significantly higher vWF/ADAMTS13 ratio was found in patients with higher NIHSS in the time of the admission with a worse outcome in 3month-mRS. Extractedvthromboemboli contained significantly higher amount of the inflammatory cells granulocytes, monocytes, vWF/FVIII with fibrin and platelets. Also significantly higher inflammatory respond was observed in patients with NIHSS >15 which correlates with the thromboemboli histology and procedure length prolongation. Conclusion: Platelets, coagulation factors vWF/FVIII and metalloprotease ADAMTS13, in conjunction with inflammatory responsive cells are important factors influencing patient's NIHSS outcome at Day 7 and 3 month after mechanical extraction procedure. High level of the vWF/FVIII and low ADAMTS13 protease activity are responsible for the resistance of the large vessel occlusions to the rt-PA thrombolytic efficacy. The sticky emboli contains red blood cells, fibrin, vWF/FVIII complexes, platelets and inflammation accompanying cells - granulocytes, monocytes and eosinophils. DisclosuresHajek:Novartis: Consultancy, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Consultancy, Honoraria, Research Funding; Pharma MAR: Consultancy, Honoraria; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

English

BACKGROUND Acute Myocardial Infarction (AMI) can lead to death, and thrombolytic therapy (TLT) is a common treatment protocol. However, thrombolysis is not always successful, and there are numerous contributing factors. We wanted to compare and contrast the coronary angiographic profile of patients with successful and failed thrombolysis with tenecteplase. METHODS Cases of AMI receiving tenecteplase were categorized as successful and failed thrombolysis groups. Fifty patients in each group were compared for various characteristics such as age, sex, risk factors, time to thrombolysis, LV function, number of coronary vessels involved, angiographic lesion characteristics, thrombolysis in myocardial infarction (TIMI) flow, and to look for features that may predispose to thrombolysis failure. To determine the association between variables, chi-square test and logistic regression were used. RESULTS The mean age in the successful &amp; failed thrombolysis group was 50.72 years and 53.48 years. Gender, diabetes, hypertension, smoking, alcohol, type of MI were not statistically significant for failed thrombolysis. All patients with window period &lt; 3 hrs had successful thrombolysis and most patients with window period &gt; 6 hrs had failed thrombolysis (87.2 %). (P &lt; 0.001). Most patients (75.9 %) with Type A lesions had successful thrombolysis and patients with Type B &amp; C lesions (88.1 %) had failed thrombolysis. (P &lt; 0.001). CONCLUSIONS In patients with longer window periods, failed thrombolysis was more common and was associated with complex coronary lesion morphology. This study reemphasizes the value of early thrombolysis for effective reperfusion and clinical outcome improvement. KEYWORDS Failed Thrombolysis, Tenecteplase, Angiographic Profile

Management and prognostic of right ventricular extended myocardial infarction: About a Moroccan experience

Myocardial infarction can affect any myocardial territory, however, the isolated right ventricle infarction is exceptional. It is often biventricular with a high mortality of about 30% compared to that of isolated LV (6%). Assess the prevalence of acute myocardial infarction extended to RV, and study the epidemiological, clinical, diagnostic, therapeutic and prognostic. Retrospective and descriptive study conducted in the Cardiology department in CHU Ibn-Rochd in Casablanca. It was conducted on patients admitted in ICU for acute MI extended to the RV, in the period January 2016 to June 2018. Of the 360 patients, who suffered a myocardial infarction in acute phase, 22 patients (6% of all AMI, 23% inferior MI) had an acute MI extended to RV. The average age of our patients was 61 years ranging from 53 to 70 years, with a male predominance. The majority of our patients (81%) have more than 03 cardiovascular risk factors. Chest pain with in physical examination: the jugular turgor, hypotension and bradycardia were the most common clinical signs in our patients. The ECG showed an ST-elevation in right leads (V3R, V4R) and in the inferior territory (DII, DIII and AvF) in all our patients. Dilatation of right cavities and wall motion disorders were the most frequent echocardiographic abnormalities (63% of patients). The most frequent complications were hemodynamic instability (46%) and rhythmic complications (36%). From the therapeutic point, thrombolysis was performed in 18 patients, which 6 patients received an additional angioplasty after failed thrombolysis. Ten patients required vascular filling, and inotropic drugs were used in 4 of our patients. Mortality in our series was 10%. Our series underscores the value of nearly management of patients admitted to the acute phase of MI extended to RV, and the considerable contribution of thrombolysis as a means of revascularization and its positive impact on prognosis.

TCTAP C-061 Drug-coated Balloon Usage in Left Main Bifurcation Lesion

### Patient Initials or Identifier Number Mr. JK ### Relevant Clinical History and Physical Exam A 55-year-old gentleman, an army officer was admitted electively for stage PCI to LAD and LCX. The patient was admitted 4 weeks ago for rescue PCI to RCA for inferior wall MI after failed thrombolysis

Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.

Reperfusion Treatment for Acute Pulmonary Embolism.

Due to the manifold treatment options for the management of acute pulmonary embolism, state-of-the-art management requires risk stratification for choosing the adapted treatment for each patient. Reperfusion therapy is an integral part of therapy for patients with pulmonary embolism at high risk for mortality, but its role in patients with intermediate risk pulmonary embolism is more debated. The largest amount of evidence exists for systemic thrombolysis, which is an efficient therapy, but at the prize of an increased bleeding risk. In recent years, various types of catheter-based reperfusion therapies have been introduced, and evidence is growing that this therapy is as efficient as systemic thrombolysis, but with a more favourable safety profile. Surgical embolectomy remains a good alternative for unstable patients, especially for those with absolute contraindications for thrombolysis or after failed systemic thrombolysis. While the early benefits of reperfusion therapy are well documented, evidence for long-term benefit is still scarce. The scope of this review is to summarize the evidence for the currently available reperfusion therapies in the management of acute pulmonary embolism.

A Randomized Double-Blind Placebo-Controlled Study Comparing Intracoronary Versus Intravenous Abciximab in Patients With ST-Elevation Myocardial Infarction Undergoing Transradial Rescue Percutaneous Coronary Intervention After Failed Thrombolysis

The risk and benefit ratio of glycoprotein IIb/IIIa inhibitors with dual oral antiplatelet therapy after failed thrombolysis and rescue percutaneous coronary intervention (PCI) is unclear. Using a randomized placebo-controlled, double-blind design, we compared intravenous (IV) and intracoronary (IC) abciximab delivery in 74 patients referred for rescue transradial PCI. The primary angiographic end points were the final thrombolysis in myocardial infarction flow and myocardial blush grades. Secondary end points included acute and 6-month outcomes using angiographic parameters, platelet aggregation parameters, cardiac biomarkers, cardiac magnetic resonance measurements (CMR) and clinical end points. After rescue PCI, normal thrombolysis in myocardial infarction 3 flows were obtained in 70% in the IC group, 48% in the IV group, and 71% in the placebo group, respectively (p = 0.056). Final myocardial blush grades 2 and 3 were obtained in 43% and 39% in the IC group, 48% and 26% in the IV group, and 46% and 42% in the placebo group (p = 0.67), respectively. Acutely, peak release of cardiac biomarkers, necrosis size, myocardial perfusion and no-reflow as assessed by CMR, and clinical end points were similar between the groups and did not suggest a benefit for IC or IV abciximab compared with placebo. There was no increase in bleeding or access site-related complications with abciximab compared with placebo. Clinical, angiographic, and CMR outcomes at 6 months remained comparable between the groups. In patients with ST-elevation myocardial infarction presenting with failed thrombolysis undergoing transradial rescue PCI, IC or IV abciximab had no significant clinical impact.

Utility of a Power Aspiration–Based Extraction Technique as an Initial and Secondary Approach in the Treatment of Peripheral Arterial Thromboembolism: Results of the Multicenter PRISM Trial

PurposeTo investigate the safety and initial efficacy of XTRACT, a power aspiration–based extraction technique for treatment of peripheral arterial thromboembolism with the use of the Penumbra/Indigo system. Materials and MethodsA total of 79 patients were enrolled: 39 (49.4%) underwent XTRACT as the initial therapy and 40 (50.6%) underwent XTRACT after failed catheter-directed thrombolysis or other mechanical intervention or for removal of distal emboli that occurred during an intervention. Occlusion locations were as follows: 36.7% (n = 29) in the profunda, common, or superficial femoral artery; 35.4% (n = 28) in the popliteal artery; 15.2% (n = 12) in the tibial artery; 7.6% (n = 6) in the peroneal artery; and the remainder in the common iliac (n = 1), external iliac (n = 1), sciatic (n = 1), and brachial (n = 1) arteries. ResultsComplete or near-complete revascularization (Thrombolysis In Myocardial Infarction [TIMI] grade 2/3 flow) was achieved in 87.2% of patients (68 of 78) immediately after the XTRACT procedure and before any other intervention. Successful revascularization was achieved in 79.5% of patients (31 of 39) as an initial treatment and in 92.5% (37 of 40) as salvage or secondary therapy. After additional adjunctive endovascular interventions, TIMI grade 2/3 flow was achieved in 96.2% of patients (76 of 79). Complete thrombus removal and restoration of normal flow (TIMI grade 3) was achieved in 77.2% of patients (61 of 79) after all endovascular treatment was completed. No patients required surgical revascularization. No device-related adverse events occurred. ConclusionsXTRACT was safe and effective for revascularization of acute or subacute peripheral arterial occlusions as a primary therapy or as a secondary therapy after other endovascular techniques had failed.

Antithrombotic treatment during coronary angioplasty after failed thrombolysis: strategies and prognostic implications. Results of the RESPIRE registry

BackgroundThrombolysis is still used when primary angioplasty is delayed for a long time, but 25%–30% of patients require rescue angioplasty (RA). There are no established recommendations for antithrombotic management in RA. This registry analyzes regimens for antithrombotic management.MethodsA retrospective, multicenter, observational registry of consecutive patients treated with RA at 8 hospitals. All variables were collected and follow-up took place at 6 months.ResultsThe study included 417 patients. Antithrombotic therapy in RA was: no additional drugs 22.3%, unfractionated heparin (UFH) 36.6%, abciximab 15.5%, abciximab plus UFH 10.5%, bivalirudin 5.7%, enoxaparin 4.3%, and others 4.7%. Outcomes at 6 months were: mortality 9.1%, infarction 3.3%, definite or probable stent thrombosis 4.3%, revascularization 1.9%, and stroke 0.5%. Mortality was related to cardiogenic shock, age > 75 years, and anterior location. The stent thrombosis rate was highest with bivalirudin (12.5% at 6 months). The incidence of bleeding at admission was high (14.8%), but most cases were not severe (82% BARC ≤2). Variables independently associated with bleeding were: femoral access (OR 3.30; 95% CI 1.3–8.3: p = 0.004) and post-RA abciximab infusion (OR 2.26; 95% CI 1.02–5: p = 0.04).ConclusionsAntithrombotic treatment regimens in RA vary greatly, predominant strategies consisting of no additional drugs or UFH 70 U/kg. No regimen proved predictive of mortality, but bivalirudin was related to more stent thrombosis. There was a high incidence of bleeding, associated with post-RA abciximab infusion and femoral access.