Infarct-related Lesion Research Articles

Вплив перкутанної тактики повної і неповної реваскуляризації міокарда при гострому коронарному синдромі з елевацією сегмента ST на динаміку лабораторних та інструментальних показників протягом госпітального періоду лікування

The aim – to identify and study the effect of percutaneous tactics of complete and incomplete myocardial revascularization on the dynamics of laboratory and instrumental indicators in patients with acute coronary syndrome (ACS) with ST-segment elevation at the hospital stage of treatment.Materials and methods. 120 patients with ACS with ST segment elevation were examined. The criteria for inclusion in the study were the presence of acute coronary syndrome with ST segment elevation and the presence of at least one lesion of the non infarct-related (non-IRA) coronary artery with stenosis of 70 % or more according to coronary angiography. Exclusion criteria were severe clinical condition of the patient (ischemic time of more than 24 hours, cardiogenic shock, clinical death at the pre-hospital stage, presence of mechanical complications of myocardial infarction), coronary artery bypass grafting, unsuitable for PCI coronary anatomy, etc. All patients were divided into a group of complete (n=60) and a group of incomplete (n=60) revascularization. The complete revascularization group included patients who received stenting of all hemodynamically significant stenoses of the coronary arteries either during primary PCI (subgroup of immediate non-IRA stenting, n=7) or during a separate planned PCI procedure (subgroup of staged stenting non-IRA, n=53).Results and discussion. According to the echocardiography before discharge from the hospital, patients who underwent a complete procedure (both one-time and staged) had a significantly higher left ventricular ejection fraction compared to patients in the incomplete revascularization group (46.3±6.41 % vs. 43.2±8.32 %, p=0.03). The anatomical complexity of the infarct-related lesion according to the SYNTAX score had a positive correlation with the duration of the primary PCI (correlation coefficient r=0.2; p<0.05) and a decrease in the left ventricular ejection fraction before discharge from the hospital (r=–0.26, p<0.05). An increase in the duration of PCI was associated with an increase in leukocyte count and creatinine levels in the first 48-72 hours after the intervention. However, there was no significant difference in the incidence of contrast-induced nephropathy. A positive correlation was found between the level of LDL and the deterioration of kidney function after pPCI (r=0.27, p<0.05), as well as the degree of non-IRA stenosis (3.39±0.99 mmol/l in patients with with non-IRA stenoses > 90 % versus 2.77±0.68 mmol/l in patients with non-IRA stenoses 70-89 %, p<0.05). While the complexity of non-IRA lesions according to the SYNTAX score had a negative correlation with the level of LDL (r=–0.26, p<0.05).Conclusions. Complete revascularization in ACS with ST-elevation patients was associated with higher LVEF before hospital discharge. Immediate stenting of all non-IRA during pPCI is associated with increased procedure time but has a lower total radiation burden compared with a staged PCI strategy. The complexity of the infarct-related lesion according to the SYNTAX score is an unmodified predictor of the duration of the pPCI and the reduction of LVEF in the short observation period. Increasing the duration of pPCI leads to a more pronounced inflammatory response with an increase in the level of leukocyte count and an increase of creatinine in the first 48-72 hours after pPCI. LDL is a risk factor for the deterioration of renal function after PCI and the presence of > 90 % non-IRA lesions. However, these lesions have less anatomical complexity.

Intracoronary Near-Infrared Spectroscopy to Predict No-Reflow Phenomenon During Percutaneous Coronary Intervention in Acute Coronary Syndrome

Near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) can identify the lipid-rich lesions, described as high lipid-core burden index (LCBI). The aim of this study was to investigate the relationship between lipid core plaque (LCP) in the infarct-related lesion detected using NIRS-IVUS and no-reflow phenomenon during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). We investigated 371 ACS patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. The extent of LCP in the infarct-related lesion was calculated as the maximum LCBI for each of the 4-mm longitudinal segments (maxLCBI4mm) measured by NIRS-IVUS. The patients were divided into 2 groups using a maxLCBI4mm cut-off value of 400. The overall incidence of no-reflow phenomenon was 53/371 (14.3%). No-reflow phenomenon was more frequently occurred in patients with maxLCBI4mm ≥400 compared to those with maxLCBI4mm <400 (17.5% vs. 2.5%, p<0.001). After propensity score matching, multivariable logistic regression analysis demonstrated that maxLCBI4mm (odds ratio: 1.008; 95% confidence interval: 1.005 - 1.012, p<0.001) was independently associated with no-reflow phenomenon. The maxLCBI4mm of 719 in the infarct-related lesion had the highest combined sensitivity (69.8%) and specificity (72.1%) for the identification of no-reflow phenomenon. In conclusion, in patients with ACS, maxLCBI4mm in the infarct-related lesion assessed by NIRS-IVUS was independently associated with no-reflow phenomenon during PCI.

Clinical outcomes of acute myocardial infarction arising from non-lipid-rich plaque determined by NIRS-IVUS

Acute myocardial infarction (AMI) can rarely arise from non-lipid-rich coronary plaques. This study sought to compare the clinical outcomes after percutaneous coronary intervention (PCI) between AMI showing maximum lipid-core burden index in 4 mm (maxLCBI4mm) < 400 and ≥ 400 in the infarct-related lesions assessed by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS). We investigated 426 AMI patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. Major adverse cardiovascular events (MACE) were defined as the composite of cardiac death, non-fatal MI, clinically driven target lesion revascularization (TLR), clinically driven non-TLR, and congestive heart failure requiring hospitalization. 107 (25%) patients had infarct-related lesions of maxLCBI4mm < 400, and 319 (75%) patients had those of maxLCBI4mm ≥ 400. The maxLCBI4mm < 400 group had a younger median age at onset (68 years [IQR: 57–78 years] vs. 73 years [IQR: 64–80 years], P = 0.007), less frequent multivessel disease (39% vs. 51%, P = 0.029), less frequent TIMI flow grade 0 or 1 before PCI (62% vs. 75%, P = 0.007), and less frequent no-reflow immediately after PCI (5% vs. 11%, P = 0.039). During a median follow-up period of 31 months [IQR: 19–48 months], the frequency of MACE was significantly lower in the maxLCBI4mm < 400 group compared with the maxLCBI4mm ≥ 400 group (4.7% vs. 17.2%, P = 0.001). MaxLCBI4mm < 400 was an independent predictor of MACE-free survival at multivariable analysis (hazard ratio: 0.36 [confidence interval: 0.13–0.98], P = 0.046). MaxLCBI4mm < 400 measured by NIRS in the infract-related lesions before PCI was associated with better long-term clinical outcomes in AMI patients.

Near-infrared spectroscopy to predict microvascular obstruction after primary percutaneous coronary intervention.

Successful restoration of epicardial coronary artery patency by primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) does not always lead to adequate reperfusion at the microvascular level. This study sought to investigate the association between lipid-rich coronary plaque identified by near-infrared spectroscopy combined with intravascular ultrasound (NIRS-IVUS) and microvascular obstruction (MVO) detected by cardiac magnetic resonance imaging (MRI) after PPCI for STEMI. We investigated 120 patients with STEMI undergoing PPCI. NIRS-IVUS was used to measure the maximum lipid core burden index in 4 mm (maxLCBI4 mm) in the infarct-related lesions before PPCI. Delayed contrast-enhanced cardiac MRI was performed to evaluate MVO one week after PPCI. MVO was identified in 40 (33%) patients. MaxLCBI4 mm in the infarct-related lesion was significantly larger in the MVO group compared with the no-MVO group (median [interquartile range]: 745 [522-853] vs 515 [349-698], p<0.001). A multivariable logistic regression model showed that maxLCBI4 mm was an independent predictor of MVO (odds ratio: 24.7 [95% confidence interval: 2.5-248.0], p=0.006). Receiver operating characteristic curve analysis demonstrated that maxLCBI4 mm >600 was the optimal cut-off value to predict MVO (Youden index=0.44 and area under the curve=0.71) with a sensitivity of 75% and a specificity of 69%. Lipid content measured by NIRS in the infarct-related lesions was associated with the occurrence of MVO after PPCI in STEMI.

Abstract 13267: The Shifted Balance of Arginine Metabolites in Patients With Acute Myocardial Infarction and Its Association With the Composition of the Infarct-Related Culprit Lesion

Introduction: We hypothesize that acute phase of myocardial infarction (MI) is associated with suppression of nitric oxide synthase (NOS) and enhanced arginase activity. Moreover, this altered metabolic balance might correlate with the composition of vulnerable culprit lesion in the infarct-related coronary artery (IRA). Methods: Arginine metabolites (μM) including ornithine, citrulline, proline, spermine, spermidine, agmatine, homoarginine, creatine, asymmetric dimethylarginine (ADMA) and monomethyl-L-arginine acetate were measured using liquid chromatography and tandem mass spectrometry in 85 consecutive MI patients upon admission and at 6-month follow-up and were compared with the composition of the IRA culprit lesion assessed with optical coherence tomography (OCT). Results: The concentration of ornithine in acute phase of MI was higher by 44% and homoarginine by 62% whereas level of arginine was lower by 39% and citrulline by 64% (P&lt;0.001 for all), when compared to 6-month stable conditions. Following ischemia, the ratios of citrulline/arginine (0.10 [0.08; 0.14] vs 0.22 [0.18; 0.28]) and citrulline/ornithine (0.09 [0.07; 0.12] vs 0.47 [0.36; 0.55]) were decreased while the indices of ornithine/arginine (1.48 [1.08, 2.39] vs 0.50 [0.41, 0.60]) and homoarginine/arginine (0.17 [0.12; 0.22] vs 0.04 [0.03; 0.05]) were higher as compared with 6-month results (P&lt;0.001 for all). Both, concentrations of arginine metabolites and their ratios were not associated with the mechanism of IRA occlusion, the amount of calcium or lipids and the presence of intramural hematoma. However, in patients with (n=67) versus without (n=18) thin-cap fibroatheroma (TCFA) in OCT the higher median concentrations of ornithine (10.24 [7.86; 12.52] vs 7.82 [4.38; 9.57]), ADMA (0.40 [0.29; 0.49] vs 0.29 [0.23; 0.42]), homoarginine (1.02 [0.81; 1.27] vs 0.74 [0.62; 1.00]) and a higher ornithine/arginine ratio (1.73 [1.29; 2.54] vs 1.18 [1.01; 2.07]) with a lower citrulline/ornithine ratio (0.07 [0.09; 0.11] vs 0.13 [0.09; 0.15]) were found (P&lt;0.05 for all). Conclusions: During acute phase of MI the altered balance of arginine metabolites indicates NOS suppression and enhanced arginase activation and is associated with the presence of TCFA in IRA culprit lesion.

Vitamin D deficiency predicts the no-reflow phenomenon in STEMI patients undergoing primary percutaneous coronary intervention

Abstract Background Vitamin D displays a broad spectrum of cardioprotective effects, preventing oxidative stress, inflammation and thrombosis and improving endothelial function. Previous studies have associated vitamin D deficiency with more extended and severe coronary artery disease (CAD) and worse outcome, and especially among patients with ST-segment elevation myocardial infarction (STEMI). Few data have been reported on the association of vitamin D levels with the features of infarct-related lesions and PCI outcomes. Aim We aimed at assessing the relationship between vitamin D and angiographic findings and the procedural results of primary percutaneous coronary intervention (pPCI) in STEMI. Methods A consecutive cohort of patients admitted for STEMI treated with pPCI were included. The levels of 25(OH)D were assessed at admission by chemiluminescence immunoassay kit LIAISON® Vitamin D assay. Hypovitaminosis D was defined for 25(OH)D &amp;lt;10 ng/ml. Results We included in our study 450 patients, divided according to tertiles values of 25(OH)D. Lower vitamin D was associated to higher use of diuretics (p=0.02), higher levels of white blood cells and glycemia (p&amp;lt;0.001), lower prevalence of lesions on bifurcations (p=0.03) and smaller diameter of the target coronary vessel (p=0.03). Procedural characteristics and pre-procedural TIMI flow were not different according to vitamin D levels, but for a higher rate of slow-flow/no-reflow phenomenon (12.8% vs 8.1% vs 5.3%, p=0.03, adjusted OR [95% CI]=2.6 [1.05–6.6], p=0.04 for I vs III tertile), requiring higher use of adenosine (p=0.006) and glycoprotein IIbIIIa inhibitors (p=0.01). Conclusion The present study shows that among patients with STEMI undergoing pPCI, lower levels of vitamin D indepently predict the occurrence of slowflow/no-reflow phenomenon. Future dedicated studies will shed light on the prognostic implications of hypovitaminosis D in these patients and the potential therapeutic perspectives. Funding Acknowledgement Type of funding sources: None.

Effects of Intracoronary Pro-urokinase or Tirofiban on Coronary Flow During Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction: A Multi-Center, Placebo-Controlled, Single-Blind, Randomized Clinical Trial.

Background: To determine whether intracoronary pro-urokinase or tirofiban improves myocardial reperfusion during primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI).Methods: The study included patients with acute STEMI presenting within 12 h of symptoms at 11 hospitals in China between November 2015 and July 2017. Patients were randomized to receive selective intracoronary infusion of recombinant pro-urokinase (20 mg), tirofiban (10 μg/kg), or saline (20 mL) proximal to the infarct-related lesion over a 3-min period before stent implantation during primary PCI. The primary outcome was final corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) after PCI.Results: This study included 345 patients. Initial angiography identified a high-grade thrombus (TIMI 4–5) in 80% of patients. Final CTFC after PCI was significantly lower in the pro-urokinase (P < 0.001) and tirofiban (P < 0.001) groups than in the saline group and similar between the pro-urokinase and tirofiban groups (P > 0.05). The pro-urokinase (P = 0.008) and tirofiban groups (P = 0.022) had more complete ST-segment resolution at 2 h and lower peak creatine kinase-MB levels after PCI than the saline group (P = 0.006 and P = 0.023). The 30-day incidence of major adverse cardiac events was 4.5% in the pro-urokinase group, 3.4% in the tirofiban group, and 2.6% in the saline group. The incidence of in-hospital TIMI major bleeding events was low and comparable between groups.Conclusions: Adjunctive intracoronary pro-urokinase or tirofiban given before stent implantation during primary PCI improves myocardial reperfusion without increasing the incidence of major bleeding events.

Complete interventional revascularization versus infarct-related artery revascularization only in stemi patients – part I

Multivessel coronary artery disease is a frequent fi nding during primary PCI procedures in patients with ST-elevation myocardial infarction (STEMI). Optimal therapy of the infarct-related lesion has been largely elucidated and is stipulated in current guideline documents. Therapeutic options for the additional lesions are a subject of active debate and clinical trial worldwide – both the target degree of revascularization and its timing in relation to the index procedure remain unclear.

Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent in Acute Myocardial Infarction: The REVELATION Randomized Trial

ObjectivesThis study sought to assess the efficacy and safety of a drug-coated balloon (DCB) strategy versus drug-eluting stent (DES) in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). BackgroundIn primary percutaneous coronary intervention for STEMI, stenting has proved to be beneficial with regard to repeat revascularization, but not recurrent myocardial infarction or death, compared with balloon angioplasty alone. A strategy of DCB angioplasty without stenting might abolish the potential disadvantages of stent implantation while reducing the probability of restenosis observed in plain old balloon angioplasty. MethodsIn the prospective, randomized, single-center REVELATION trial, we compared DCB with DES in patients presenting with STEMI. Patients with a new, nonseverely calcified culprit lesion in a native coronary artery and a residual stenosis of <50% after pre-dilatation were randomized to treatment with a DCB or DES. The primary endpoint was fractional flow reserve at 9 months, allowing for a functional measurement of the infarct-related lesion. ResultsA total of 120 patients were included. At 9 months after enrolment, the mean fractional flow reserve value was 0.92 ± 0.05 in the DCB group (n = 35) and 0.91 ± 0.06 in the DES group (n = 38) (p = 0.27). One abrupt vessel closure requiring treatment occurred after treatment with DCB. Up to 9-months follow-up, 2 patients required nonurgent target lesion revascularization (1 in each group). ConclusionsIn the setting of STEMI, the DCB strategy was noninferior to DES in terms of fractional flow reserve assessed at 9 months. Furthermore, it seemed to be a safe and feasible strategy. (Revascularization With Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stenting in Acute Myocardial Infarction [REVELATION]; NCT02219802)

Сравнение атеросклеротических поражений коронарных артерий у больных острым инфарктом миокарда и стабильной стенокардией по данным внутрисосудистого ультразвукового исследования

to compare noninfarct-related lesions in patients with acute myocardial infarction (MI) with culprit and non-culprit lesions in patients with stable angina pectoris (SAP) using intravascular ultrasound virtual histology (VH-IVUS).Overall 70 patients were enrolled: 38 with ST elevation (STE) MI and 32 with stable angina pectoris (SAP). All patients underwent three-vessel coronary angiography and gray-scale and VH-IVUS after percutaneous coronary intervention (PCI) of infarct-related lesion in STEMI or culprit lesion in SAP.A total of 130 plaques were examined: 70 in patients with STEMI and 60 in patients with SAP. Noninfarct-related lesions in acute MI compared with non-culprit lesions in SAP had significantly larger plaque burden and plaque volume, smaller minimum lumen area, and more positive remodeling. STEMI, hyperlipidemia, plaque burden, and hypertension were independent predictors of unstable plaques.

Editors' Picks for 2014 and a Look into the Future.

The year 2014 brought a large number of important advances to cardiovascular medicine that are likely to impact the field for many years, if not decades [1]. Herein are our thoughts on the top stories in 2014 and what is likely to remain hot in 2015. In the field of lipids, several studies with proprotein convertase subtilisin kexin 9 (PCSK9) inhibitors demonstrated their potent effects to lower low-density-lipoprotein cholesterol (LDL-C) in a wide variety of patients. In addition to reducing LDL-C by 50% or more, PCSK9 inhibitors have favorable effects on apolipoprotein-B, lipoprotein (a), and triglycerides. Although much less potent than the PCSK9 inhibitors, the cholesterol absorption inhibitor ezetimibe became the first non-statin to demonstrate a reduction in cardiovascular events on top of background statin therapy. In the IMPROVE IT trial (ClinicalTrials.gov NCT 00202878), the addition of ezetimibe to statin therapy decreased average LDL from 69.5 to 53.7 mg/dl and reduced cardiovascular events, without any safety concerns. Although the benefits were relatively modest (10% reduction in cardiovascular death, myocardial infarction (MI), or stroke), this proof of principle bodes well for PCSK9 inhibitors and other drugs in development that lower LDL-C by other mechanisms. In the field of heart failure, a novel approach that combined an angiotensin receptor blocker and a neprilysin inhibitor (LCZ696, valsartan/sacubitril) demonstrated a 20% reduction in hospitalization for heart failure or cardiovascular mortality as compared to enalapril alone. This landmark study demonstrated that dual-acting neurohormonal inhibition further reduced clinical events beyond that obtained with a single inhibitor of the renin-angiotensin system, which had been the gold standard for over 2 decades. In the world of interventional cardiology three developments stand out in 2014. An implantable loop recorder was six times more likely than conventional monitoring to pick up atrial fibrillation (the majority of episodes were asymptomatic) among patients who recently had an ischemic stroke of unknown etiology, while a second study confirmed the benefit of continued long-term monitoring for arrhythmia after a cryptogenic cerebrovascular event. Defying what had been long-standing conventional wisdom, percutaneous coronary intervention (PCI) of “non-culprit” stable lesions in addition to immediate PCI of the infarct-related lesion was shown in two small studies to improve long-term outcomes. These findings resulted in a 180° turn in PCI guidelines and was rapidly incorporated into clinical practice, however the results of a larger trial are eagerly awaited to support this turn. Lastly, the DAPT (ClinicalTrials.gov NCT01106534) trial showed that extended therapy with two oral antiplatelet drugs beyond the usual 12 months post stenting was associated with reduction in very late stent thrombosis and recurrent myocardial infarction, albeit with an increase in bleeding. Looking ahead to 2015, we anticipate a similar number of breakthroughs. Ongoing studies with 3 PCSK9 inhibitors will likely continue to bang a steady and increasingly louder drumbeat. We will learn more about extended duration of dual antiplatelet therapy with ticagrelor + aspirin when the PEGASUS-TIMI 54 (ClinicalTrails.gov NCT01225562) trial reports this spring. Several drugs targeting different mechanisms to treat diabetes are being studied and hold promise to be the first since metformin to reduce cardiovascular events. Ongoing research with percutaneous approaches for treating valvular disease and renovascular hypertension are also likely to make big news in 2015, whether the results are favorable or not. In patients with aortic stenosis the interventional approach (TAVI) is likely to become the standard of care, not only in patients with high surgical risk but in patients with intermediate risk as well. Given the enormous number of analyses that clinical studies and databases generate, a wide variety of opportunities to publish the results is required. We hope that many of you will not only look at Cardiology and Therapy to learn about these advances, but also encourage you to submit your best work to the journal for consideration.

The Third DANish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction: Ischemic postconditioning or deferred stent implantation versus conventional primary angioplasty and complete revascularization versus treatment of culprit lesion only: Rationale and design of the DANAMI 3 trial program

In patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, ischemic postconditioning has been shown to reduce infarct size, but the effect on clinical outcome has not been tested in a large randomized trial. In addition, deferring stent implantation in the infarct-related lesion 1 to 3 days after acute opening of the infarct-related artery could have protective effects, by reducing the risk of injury caused by distal embolization and microvascular obstruction. Finally, a considerable fraction of patients present with lesions in other coronary artery branches than the infarct-related artery. Whether a strategy of complete or partial revascularization of these patients should be preferred remains uncertain. The DANAMI 3 trial program was designed to investigate 3 different randomized treatment strategies in patients with ST-segment elevation myocardial infarction: (1) ischemic postconditioning versus conventional treatment with a primary end point of death and hospitalization for heart failure; (2) deferring stent implantation in the infarct-related lesion versus conventional treatment with a primary end point of death, hospitalization for heart failure, reinfarction, and repeat revascularization; and (3) treatment of the culprit lesion only versus fractional flow reserve-guided complete revascularization in patients with multivessel disease, with a primary end point of death, reinfarction, and repeat revascularization. The DANAMI 3 trial program will determine whether either of 2 approaches to reduce reperfusion injury and distal microvascular obstruction with postconditioning or deferred stent implantation will translate into improved clinical outcome and whether patients with multivessel disease undergoing primary percutaneous coronary intervention will benefit from a strategy of complete or partial revascularization.

ASSA14-01-05 Thrombus aspiration followed by direct stenting during primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

<h3>Background</h3> Previous studies have reported that low final thrombolysis in myocardial infarction (TIMI) flow and/or myocardial blush grade (MBG) are independent predictors of mortality in patients with ST-elevation myocardial infarction (STEMI). Several studies with thrombus aspiration (TA) showed different results, mainly due to use of TA as an additional device not instead of balloon predilatation (BP). The aim of the present study was to assess impact of TA followed by direct stenting during primary percutaneous coronary intervention (PPCI). <h3>Methods</h3> Between Dec 2008 and Jun 2011, a total of 429 patients (107 patients in TA group and 322 patients in BP group) who were eligible for the observation criteria, admitted with STEMI (within 12 h from symptoms onset) and candidates for PPCI were enrolled. Exclusion criteria were a previous PCI on infarct-related artery, infarct-related artery &lt;2.5 mm in diameter, previous coronary artery bypass graft, cardiogenic shock, 3-vessel disease, left main disease, infarct-related lesion treated with balloon predilatation and TA simultaneously, and calcium or tortuous infarct-related lesion. The main indexes of this study were the TIMI flow grade, MBG, and the rate of 60-min ST-segment resolution &gt;50% after PCI and in-hospital major adverse cardiac events (MACE). Secondary indexes included distal embolizations of infarct-related artery, peak CK-MB release, and MACE after two year. <h3>Results</h3> Baseline clinical and angiographic characteristics, initial TIMI flow and initial MBG did not differ between the two groups. Procedural success was obtained in all patients. Stent length, number of stents per patient, and stent/vessel ratio were similar between both groups. The rate of 60-min ST-segment resolution &gt;50% was significantly more frequent in TA group than in BP group (69.2% vs 48.5%, p &lt; 0.01). The TIMI flow grade after PCI was significantly higher among patients in TA group compared with BP group (2.65 ± 0.49 vs 2.44 ± 0.61, p &lt; 0.01). Also the MBG was significantly higher among patients in TA group compared with BP group (2.86 ± 0.34 vs 2.41 ± 0.56, p &lt; 0.01). There were 23 patients with evident distal embolizations in the group without TA and two patients in the group with TA (1.9% vs 7.1%, p &lt; 0.05). The peak CK-MB release was significantly lower in TA group compared with the BP group (660 ± 144 U/L vs 711 ± 165 U/L, p &lt; 0.01). There was no difference in between the groups in in-hospital MACE (1.9% vs 2.8%, p &gt; 0.05), in 24-month cardiac mortality (1.9% vs 2.8%, p &gt; 0.05), reinfarction rate (1.9% vs 3.4%, p &gt; 0.05) and target vessel revascularisation (3.7 vs 8.4%, p &gt; 0.05). But Total MACE was significantly higher in BP group compared with the TA group (9.3% vs 17.4%, p &lt; 0.05). <h3>Conclusions</h3> Compared with conventional PCI, TA and direct stenting before primary PCI improved final myocardial reperfusion and the two-year outcomes for STEMI patients.

Pattern and prognosis by localization of culprit lesions in coronary arteries of patients undergoing primary percutaneous coronary intervention with first ST-segment elevation myocardial infarction

Purpose: The aim of this study is to evaluate (1) the distribution of culprit lesions in the left (LCA) and right coronary arteries (RCA) and (2) prognosis related to the pattern of culprit lesions in patients undergoing primary percutaneous coronary intervention (PCI) after their first ST-segment elevation myocardial infarctions (STEMIs). Methods: Between November 2005 and November 2011, 857 patients (634 men; mean age = 62.8±12.0 year-old) without previous coronary heart disease were analyzed in this study. Coronary segments were identified according to the Coronary Artery Surgery Study vessel classification. An infarct-related culprit lesion was defined as the site of acute coronary occlusions or, for nonoccluded arteries, as the site of greatest narrowing within an angiographically significant stenosis corresponding to the electrocardiographic changes. Patients were divided into two groups according to the pattern of culprit lesions; bifurcation versus non-bifurcation. Propensity score (PS) indicating the likelihood of having bifurcation lesions was calculated using a multivariable logistic regression model, and was used to 1:1 match the patients with or without bifurcation lesions. The 6-months MACEs were defined as death, non-fatal MI, and revascularizations. Results: Overall, 49.5% of culprit lesions were located in left anterior descending artery (LAD), 9.4% in left circumflex artery (LCx), and 39.2% in RCA. Of LAD culprit lesions, 55.3% were located in proximal portion, 41.4% in mid-portion, and 2.6% in distal portion. Compared with those in the LAD, 35.9% were located in mid-portion, 29.7% in proximal portion, and 25.9% in distal portion of RCA. Overall, 42.7% of culprit lesions were located in bifurcation including 50.2% in LAD, 34.1% in LCx, and 32.9% in RCA. In LAD, bifurcation lesions are more prevalent in proximal portion (54.2%), whereas bifurcation lesions are more prevalent in distal portion of RCA (39.3%) and LCx (39.3%). Before PS match, the 6-month MACEs (14.3% versus 6.9%, p=0.023) and mortality (12.9% versus 5.9%, p=0.024) were significantly higher in patients with bifurcation lesions in the proximal portion of culprit artery. After PS match, bifurcation lesions in the proximal portion showed a trend of worse prognosis in terms of 6-month MACEs (14.2% versus 7.4%, p=0.070) and mortality (12.7% versus 6.1%, p=0.062). Conclusions: In patients with first STEMI, a bifurcation lesion which is located in proximal portion of culprit coronary artery showed a trend of worse 6-month clinical outcome.

GW24-e1823 Thrombus aspiration followed by direct stenting during primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

ObjectivesPrevious studies have reported that low final thrombolysis in myocardial infarction (TIMI) flow and/or myocardial blush grade (MBG) are independent predictors of mortality in patients with ST-elevation myocardial infarction (STEMI)....

Lipoprotein(a) is an important factor to determine coronary artery plaque morphology in patients with acute myocardial infarction

Lipoprotein(a) [Lp(a)] can influence the development and disruption of atherosclerotic plaques through its effect on lipid accumulation. The purpose of this study was to evaluate the relationship between serum Lp(a) levels and plaque morphology of an infarct-related lesion and non-infarct-related lesion of the coronary artery in acute myocardial infarction (AMI). Coronary plaque morphology was evaluated in 68 patients (age 62.1±12.1 years, mean±SD; men n=58, women n=10) with AMI by intravascular ultrasound with radiofrequency data analysis before coronary intervention and by 64-slice computed tomography angiography within 2 weeks. Patients were divided into a group with an Lp(a) level of 25 mg/dl or more (n=20) and a group with an Lp(a) level of less than 25 mg/dl (n=48). Intravascular ultrasound with radiofrequency data analysis identified four types of plaque components at the infarct-related lesion: fibrous, fibrofatty, dense calcium, and necrotic core. The necrotic core component was significantly larger in the group with an Lp(a) level of 25 mg/dl or more than in the group with an Lp(a) level of less than 25 mg/dl (27.6±8.0 vs. 15.7±10.0%, P=0.0001). Coronary plaques were classified as calcified plaques, noncalcified plaques, mixed plaques, and low-attenuation plaques on 64-slice computed tomography angiography. Computed tomography indicated that the group with an Lp(a) level of 25 mg/dl or more had a greater number of total plaques, noncalcified plaques, and low-attenuation plaques in whole coronary arteries than did the group with an Lp(a) level of less than 25 mg/dl (5.3±1.8 vs. 3.7±2.2, P=0.0061; 4.0±2.0 vs. 1.2±1.3, P=0.0001; 2.2±2.1 vs. 0.5±0.7, P=0.0001, respectively). Elevated serum Lp(a) levels are associated with the number of plaques and plaque morphology. Patients with a high Lp(a) level during AMI require more intensive treatment for plaque stabilization.

Impact of Attenuated Plaque as Detected by Intravascular Ultrasound on the Occurrence of Microvascular Obstruction After Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction

The aim of the study was to investigate whether intravascular ultrasound (IVUS) can predict microvascular obstruction (MVO) as detected by magnetic resonance imaging (MRI) after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). MVO occurs in a sizable proportion of patients with acute myocardial infarction despite successful PCI and results in poor clinical outcomes. We assessed infarct-related lesions in 68 patients with STEMI by using IVUS before primary PCI. All patients were examined by MRI 1 week after primary PCI. MRI-derived MVO was seen in 23 patients (34%). In the IVUS assessment, the frequency of plaque rupture, echolucent plaque, calcification and positive remodeling, and quantitative geometric data were not different between the MVO group and the no-MVO group. Although the frequency of plaque with ultrasound attenuation was similar between the 2 groups (87% vs. 89%, p= 0.999), the maximum attenuation angle (280° [range: 215° to 360°] vs. 150° [range: 95° to 300°], p= 0.008) and attenuation length (11.3 mm [range: 7.2 to 17.8 mm] vs. 6.8 mm [range: 3.0 to 10.4 mm], p= 0.009) were significantly greater in the MVO group than the no-MVO group. Multivariable logistic regression analysis showed that attenuated plaque with a maximum attenuation angle of >180° and attenuation length of >5 mm was an independent predictor of MVO (odds ratio: 6.07, 95% confidence interval: 1.89 to 19.53, p= 0.002). Attenuated plaque with maximum attenuation angle of >180° and attenuation length of >5 mm was associated with the occurrence of MVO after primary PCI. IVUS might to be a useful tool for risk stratification in STEMI patients undergoing primary PCI.

Diagnostic value of CTA in acute occlusion of coronary arterys

Objective To review the diagnostic value of CT angiography (CTA) (64-layer spiral CT) in coronary artery diseases in the recovery period of acute myocardial infarction (AMI) patients.Methods Coronary angiography (CAG) was taken as the gold standard,CTA and CAG were compared in 126 cases of recover-term AMI patients who underwent emergency PCI,to evaluate the value of CTA in the diagnosis of AMI lesions and distal vascular lesions.Results The sensitivity of CTA to recanalization in AMI lesions was 86.89％,specificity was 93.85％,positive predictive value was 92.98％ and negative predictive value was 88.41％.It was the most valuable diagnostic capabilities of the left anterior descending branch.In spite of the infarct-related artery reperfusion or nonreperfusion,the diagnostic value of CTA in distal vascular lesions were consistent with CAG(r=0.8123,P ＜ 0.01).Conclusion CTA can accurately diagnose coronary artery recanalization in AMI,and provide a primary diagnosis for the infarct-related lesion beyond related vessels. Key words: CTA; Coronary arterys; Diagnosis

The Relationship between Coronary Artery Movement Type andStenosis Severity with Acute Myocardial Infarction.

The severity of coronary artery stenosis which leads to myocardial infarction (MI) has been a matter of controversy. Historical data are in favor of mild luminal stenosis (<50% diameter stenosis) while recent studies suggest hemodynamically-significant coronary stenosis as the main substrate for subsequent MI. Also, mechanical stress resulted from coronary artery movement (CAM) may be responsible for plaques rupture. In this study, we evaluated the severity of plaques leading to MI and common CAM patterns in the involved coronary segments. In a cross-sectional descriptive-analytical study, on patients with acute ST-segment myocardial infarction (STEMI) undergoing coronary angiography, the relationship between coronary artery movement type and stenosis severity with acute MI was evaluated. Lesions with stenosis diameter greater than 50 percent were defined as moderate and those equal or higher than 70% were defined as severe stenosis. Three different patterns of coronary artery motion including compression, bending and displacement types were evaluated in segments with culprit lesion. One hundred and sixty two patients were enrolled. Ninety patients (55.6%) were male and 72 (44.4%) were female. Mean age of the patients was 60.56±13.43 years. In terms of Infarct related lesions (IRLs), 86% of the cases had at least moderate stenosis and in 67%, severe stenosis was present. More than 50% stenosis was found in all patients with anterior STEMI involving LAD. Among three types of coronary motion patterns, compression pattern was significantly higher in LAD (P<0.001), RCA (P<0.001), Diagonal artery (P<0.001) and OM branch (P=0.044), but not in proper LCX (P=0.307). Most of the lesions leading to myocardial infarction have a diameter stenosis of at least 50% and mainly are located in the coronary segments with compression movement pattern.

Long-Term Outcome After Drug-Eluting Versus Bare-Metal Stent Implantation in Patients With ST-Segment Elevation Myocardial Infarction: 5 Years Follow-Up From the Randomized DEDICATION Trial (Drug Elution and Distal Protection in Acute Myocardial Infarction)

This study sought to compare the long-term effects of drug-eluting stent (DES) compared with bare-metal stent (BMS) implantation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. The randomized DEDICATION (Drug Elution and Distal Protection in Acute Myocardial Infarction) trial evaluated the outcome after DES compared with BMS implantation in patients with STEMI undergoing primary percutaneous coronary intervention. Patients with a high-grade stenosis/occlusion of a native coronary artery presenting with symptoms <12 h and ST-segment elevation were enrolled after giving informed consent. Patients were randomly assigned to receive a DES or a BMS in the infarct-related lesion. Patients were followed for at least 5 years, and clinical endpoints were evaluated from population registries and hospital charts. The main endpoint was the occurrence of the first major adverse cardiac event (MACE), defined as cardiac death, nonfatal recurrent myocardial infarction, and target lesion revascularization. Complete clinical status was available in 623 patients (99.5%) at 5 years follow-up. The combined MACE rate was insignificantly lower in the DES group (16.9% vs. 23%), mainly driven by a lower need of repeat revascularization (p = 0.07). Whereas the number of deaths from all causes tended to be higher in the DES group (16.3% vs. 12.1%, p = 0.17), cardiac mortality was significantly higher (7.7% vs. 3.2%, p = 0.02). The 5-year stent thrombosis rates were generally low and similar between the DES and the BMS groups. No cardiac deaths occurring within 1 month could be clearly ascribed to stent thrombosis, whereas stent thrombosis was involved in 78% of later-occurring deaths. The 5-year MACE rate was insignificantly different, but the cardiac mortality was higher after DES versus BMS implantation in patients with STEMI. Stent thrombosis was the main cause of late cardiac deaths.