Post Primary Percutaneous Coronary Intervention Research Articles

Mesh covered stent in ST-segment elevation myocardial infarction

The MGuard stent (bare metal stent wrapped externally with a polymer mesh sleeve) is designed to prevent distal embolisation by reducing thrombus and plaque fragments released during and post percutaneous coronary intervention (PCI). The aim of this study was to confirm the clinical feasibility, safety and performance of the MGuard stent during primary PCI for ST-segment elevation myocardial infarction (STEMI). The present study was a multicentre, prospective, single arm study in which 60 patients with STEMI <12 hours were enrolled. Predilatation was performed in 61.7% of the cases and thrombus aspiration in 18.3%. In one (1.7%) patient the stent could not cross the lesion. Final TIMI grade 3 flow was observed in 90.0% of patients, with myocardial blush grade 3 in 73.3% of patients and complete (>70%) ST-segment resolution 60 minutes after PCI in 61.4% of patients. In 5.0% of cases distal embolisation occurred. The total major adverse cardiac events rate during the 6-month follow-up was 1.7%. Based on this experience, the MGuard stent implantation in STEMI patients is safe and highly effective. A larger randomised trial is warranted to confirm the clinical endpoints.

Dynamic Changes in ST Segment Resolution After Myocardial Infarction and the Association with Microvascular Injury on Cardiac Magnetic Resonance Imaging

persistent ST elevation after reperfused ST elevation myocardial infarction (STEMI) is believed to be related to poor microvascular perfusion. Cardiac magnetic resonance imaging (CMR) can evaluate microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH) both of which represent severe microvascular damage, have independent prognostic value and are dynamic and evolving over the first 48hours after reperfusion. The aim of this study was to assess whether the development of MVO or IMH has an impact upon ST segment resolution. patients undergoing primary percutaneous coronary intervention (PCI) for STEMI had serial 12 lead electrocardiograms (ECG) from one hour after PCI until discharge. Persistent single lead maximal residual ST elevation (maxSTE) at each time point was calculated. ST segment deterioration (re-elevation) was calculated on each ECG until discharge compared with one hour post PCI ECG. CMR was performed within seven days post infarct utilising T2 weighted imaging to evaluate culprit artery area at risk (AAR) and IMH. Gadolinium delayed enhancement CMR quantified infarct size and MVO. in the 41 patients studied 58% had MVO and 41% had IMH. ST segment deterioration was more common in those with MVO or IMH (p=0.03 and p=0.008 respectively). MaxSTE was higher at each time point after PCI in those with MVO but only became statistically significant after 24hours. The measurement of maxSTE at 48 or 72hours after revascularisation provided the best correlation with the combination of infarct size, AAR, MVO and intramyocardial haemorrhage. microvascular injury as defined on CMR is associated with dynamic changes and persistence of ST segment elevation in the first 72hours after reperfusion.

E0482 The efficiency and safety of the Seek aspiration thrombectomy catheter and tirofiban in primary percutaneous coronary intervention of acute myocardial infarction

ObjectiveTo assess the effect of the Zeek aspiration thrombectomy catheter and tirofiban in the myocardial reperfusion and clinical prognosis in patients with acute ST-segment elevation myocardial infarction (AMI) who were...

128 Impact of diabetes on 30-day and 1-year mortality after primary percutaneous coronary intervention for acute myocardial infarction

<h3>Background</h3> The presence of diabetes mellitus (DM) is associated with increased mortality in patients with acute ST segment elevation myocardial infarction (STEMI) treated with fibrinolysis. Primary percutaneous coronary intervention (PPCI) confers improved outcomes compared to fibrinolysis in unselected patients and is now the reperfusion strategy of choice. However, the impact of DM on survival in the era of PPCI for STEMI remains unclear. <h3>Methods</h3> We carried out a retrospective analysis of a database of all patients undergoing PPCI for STEMI at the Yorkshire Heart Centre, Leeds General Infirmary (covering a regional population of ∼3.2 million). 30-day and 1-year mortality, demographic factors and procedural characteristics were compared between patients with and without a diagnosis of DM on presentation. <h3>Results</h3> Between September 2002 and September 2008, 1629 patients underwent PPCI for STEMI at our centre. 209 (12.8%) patients had a prior diagnosis of DM. Mortality at 30 days (8.4% vs 3.9%; p=0.0023) and 1 year (15.8% vs 6.8%; p&lt;0.0001) was significantly higher in patients with DM (Abstract 128 Figure 1). Patients with DM were older (mean age 63.78 vs 61.16; p=0.006) and more often required circulatory support (8.6% vs 4.5%; p=0.014) than patients without DM. Triple vessel disease was more common in patients with DM (32.5% vs 19.6%; p=0.001). Drug eluting stents were deployed more frequently in patients with DM (32% vs 25%; p=0.03). Administration of heparin+abciximab (62.1% vs 61.2%) and bivalirudin (38.8% vs 37.9%) was similar in both groups. TIMI flow grade was similar in the two groups at baseline. However, final TIMI flow achieved was lower in patients with DM compared to patients without diabetes (mean 2.74 vs 2.85; p=0.001). ‘Symptom to balloon time’ (Median time (minutes) (IQR): 244 (168–447) vs 211 (153–350); p=0.006) and ‘door to balloon time’ (107 (62–165) vs 85 (52–129); p=0.0003) were significantly longer in patients with DM. <h3>Conclusions</h3> Survival remains substantially impaired in patients with DM undergoing contemporary reperfusion with PPCI for STEMI. Increased age, more advanced coronary disease and greater requirement for circulatory support may contribute to poorer outcomes, but the influence of DM on timing of presentation and reperfusion requires further investigation. Abstract 128 Figure 1. Kaplan Meier curves showing 1-year mortality post PPCI.

Longitudinal peak strain detects a smaller risk area than visual assessment of wall motion in acute myocardial infarction

BackgroundOpening of an occluded infarct related artery reduces infarct size and improves survival in acute ST-elevation myocardial infarction (STEMI). In this study we performed tissue Doppler analysis (peak strain, displacement, mitral annular movement (MAM)) and compared with visual assessment for the study of the correlation of measurements of global, regional and segmental function with final infarct size and transmurality. In addition, myocardial risk area was determined and a prediction sought for the development of infarct transmurality ≥50%.MethodsTwenty six patients with STEMI submitted for primary percutaneous coronary intervention (PCI) were examined with echocardiography on the catheterization table. Four to eight weeks later repeat echocardiography was performed for reassessment of function and magnetic resonance imaging for the determination of final infarct size and transmurality.ResultsOn a global level, wall motion score index (WMSI), ejection fraction (EF), strain, and displacement all showed significant differences (p ≤ 0.001, p ≤ 0.001, p ≤ 0.001 and p = 0.03) between the two study visits, but MAM did not (p = 0.17). On all levels (global, regional and segmental) and both pre- and post PCI, WMSI showed a higher correlation with scar transmurality compared to strain. We found that both strain and WMSI predicted the development of scar transmurality ≥50%, but strain added no significant information to that obtained with WMSI in a logistic regression analysis.ConclusionsIn patients with acute STEMI, WMSI, EF, strain, and displacement showed significant changes between the pre- and post PCI exam. In a ROC-analysis, strain had 64% sensitivity at 80% specificity and WMSI around 90% sensitivity at 80% specificity for the detection of scar with transmurality ≥50% at follow-up.

061 Thrombectomy in Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial infarction. Observational data From the RICO Survey

The use of adjunctive thrombectomy (AT) as device to primary percutaneous coronary intervention (PCI) for an acute ST segment elevation myocardial infarction (STEMI) has shown clinical benefit in randomized trials. Whether this benefit could translate to all patients with partial or complete occlusion of a coronary artery in primary PCI remains to be determined. From the RICO Survey, all the patients admitted with TIMI grade 0 or 1 before primary PCI for a STEMI < 12 H after symptom onset were included in the study. Among the study population, 156 (29%) patients underwent AT (AT group) and were compared with patients with TIMI grade 0/1 who do not undergo AT (control group, n=384). Patients with AT were younger and less frequently hypertensive. Glycoprotein IIb/IIIa inhibitors were more frequently administrated in the AT group. However, a decrease in the rate of patients with TIMI 3 flow grade post PCI was observed in the AT group. Peak creatine kinase was significantly higher in patients with AT while ischemic time was similar for the 2 groups. Stenting the infarct-related lesion was less frequent than in the control group. CV mortality at 30 days and at 1-year were higher in the AT group (11.4 vs. 5.2%, p=0.016, and 14.6 vs. 7%, p=0.013) respectively. By multivariate analysis, AT remains an independent predictor of 1-Y mortality even when adjusted for potential confounders (HR(95%CI):4.95(2.08-11.77)). These results were unchanged when the propensity score for AT was introduced into the model. In the contemporary era of interventional therapy, this large observational study revealed that routine use of AT in primary PCI with a baseline TIMI 0 or 1 flow was not associated with an improved outcome. Prospective studies are warranted to precisely analyse the impact of AT in such patients and to further investigate its potential benefit.

Clinical Significance of Post-Procedural TIMI Flow in Patients With Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention

We sought to evaluate the impact of post-primary percutaneous coronary intervention (PCI) Thrombolysis In Myocardial Infarction (TIMI) flow grades in the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock. The clinical implications and correlates of post-procedural TIMI flow grades in patients with STEMI and cardiogenic shock treated with primary PCI have not been elucidated. We evaluated 4,731 STEMI patients with cardiogenic shock undergoing primary PCI at 567 hospitals participating in the American College of Cardiology-National Cardiovascular Database CathPCI Registry to determine the association of post-procedural TIMI flow grades 0 to 2 with in-hospital outcomes. Post-PCI TIMI flow grades 0 to 2 in the IRA were present in 14.7% of patients. Compared with patients with TIMI flow grade 3, those with TIMI flow grades 0 to 2 were more likely to undergo coronary artery bypass graft surgery after PCI (20% vs. 5.4%), and develop renal failure (10.1% vs. 5.1%), cardiac tamponade (1.0% vs. 0.5%), and bleeding requiring blood transfusion (35.2% vs. 21.6%). Unadjusted mortality was more than 2-fold higher with TIMI flow grades 0 to 2 versus TIMI flow grade 3 (63% vs. 27%). There was a graded inverse relationship with TIMI flow in the IRA and the adjusted mortality (odds ratio [OR] for TIMI flow grades 0/1: 5.47 [95% confidence interval (CI): 4.13 to 7.24] and for TIMI flow grade 2: 2.63 [95% CI: 2.02 to 3.42] compared with TIMI flow grade 3). Our study also identified factors associated with post-PCI TIMI flow grades 0 to 2. Lack of procedural success (post-PCI TIMI flow grades 0 to 2 in the IRA) after primary PCI for STEMI among patients with cardiogenic shock is associated with a much higher risk of mortality compared with the risk for patients with normal post-PCI TIMI flow grade 3.

Abstract 2018: Comparison of Risks and Clinical Predictors of Contrast Induced Nephropathy in Patients Undergoing Primary versus Elective Percutaneous Coronary Intervention

Background: Contrast nephropathy (CIN) post percutaneous coronary intervention (PCI) increases adverse clinical outcomes. We examine and compare the risks and clinical predictors of CIN among patients who undergo primary versus elective PCI and the effectiveness of prophylactic treatments. Methods: A cohort of 8798 patients who underwent PCI from May 1996 to April 2008 were enrolled. We divided patients into 3 groups(Grp). A: STEMI patient undergoing primary PCI. B: NSTEMI patients undergoing early elective PCI. C: stable patients without myocardial infarction(MI) undergoing elective PCI. Prophylactic saline hydration and oral N-acetylcysteine (NAC) treatment were given to Grp B and C if they have baseline renal impairment (glomerular filtration rate, GFR ≤60ml/min/1.73m 2 ). Grp A patients were unable to receive pre-PCI prophylaxis due to emergency situation. The occurrence of CIN and mortality were compared among 3 grps. Results: Mean age was 57.4±11.1 years. 3146(35.9%) were diabetics. CIN occurred in 12.0% vs. 9.2% vs. 4.5% p=&lt;0.0005, in Grp A, B, C respectively. CIN correlated with increased mortality (15.5% vs. 1.3% p&lt;0.0005) at 1 month. Significant risk predictors of CIN are shown in table Incidence of CIN categorized according baseline renal function based on GFR range are shown in table Clinical predictors of CIN Incidence of CIN categorized by different GFR subgroups Conclusion: Saline and NAC prophylaxis are effective in preventing CIN in milder renal impaired patients (GFR 40 – 60) but are less effective in the more severely renal impaired patients (GFR&lt;40). Patients presenting with STEMI undergoing primary PCI are at the highest risk for development of CIN. Accelerated prophylactic therapy need to be developed to reduce CIN in this cohort. Table 1 Table 2

Abstract 3705: Risk factors and Clinical Outcomes for Contrast Induced Nephropathy Post Percutaneous Coronary Intervention in Patients with Normal baseline Renal Function

Background: Contrast induced nephropathy (CIN) is an important complication post percutaneous coronary intervention (PCI). We examine the risk factors for developing CIN in patients with normal baseline renal function so that prophylactic measures may be undertaken to prevent its development. Methods: A cohort of 5086 patients with normal baseline renal function (defined as serum creatinine &lt;1.5mg/dl) who did not receive prophylactic treatment while undergoing PCI (primary or elective) between May 1996 to March 2007 in our centre was enrolled in the study. We examine the occurrence of CIN (defined as &gt;25% increase from baseline creatinine within 48 hours post PCI) in 3036 subjects of this cohort with available creatinine data and aim to identify the clinical predictors. Results: CIN occurred in 7.3% of the patients. The mean age of these patients was 57.5 yrs, 78.7% were men, and 34.6% had diabetes mellitus. Clinical predictors for CIN were age (OR 6.4, 95% CI 0.1–13.3, p=0.042), female gender (OR 2.0, 95% CI 1.5–2.7, p=0.001), lower left ventricular ejection fraction (OR 1.02, 95% CI 1.01–1.04, p=0.01), anemia with hemoglobin &lt;11mg/dl (OR 1.5 (95% CI 1.01–2.4, p=0.044) and systolic hypotension with blood pressure &lt;100mmHg on admission(OR 1.5, 95% CI 1.01–2.2, p=0.004). While there was no increase in the incidence of CIN among diabetics and nondiabetics (8.2% vs 6.8%, p=0.18), those who are on insulin therapy are at the highest risk compared with diabetics on diet control and oral hypoglycemic drugs (18.9% vs 3.6% vs 6.8%, p=0.001). There was no significant difference between patients who underwent primary vs elective PCI (7.0% vs. 6.6% p=0.75). Patients who developed CIN had higher mortality rate at 1 month (14.5% vs 1.1%, p&lt;0.001) and 6 month (17.8% vs 2.2%, p&lt;0.001) Conclusion: Patients with normal baseline renal function undergoing PCI are also at risk of developing CIN with resultant higher mortality. Age, female, insulin dependent diabetes mellitus, hypotension, anemia, low left ventricular ejection fraction are predictors of CIN. Such patients should also be considered CIN prophylactic therapy.

Abstract 3008: Intracoronary Compared with Intravenous Bolus Abciximab Application in Patients with ST-Elevation Myocardial Infarction Undergoing Primary Coronary Intervention The randomized Leipzig Immediate PercutaneouS Coronary Intervention Abciximab i.v. versus i.c. in ST-Elevation Myocardial Infarction Trial (LIPSIAbciximab-STEMI)

Background Abciximab reduces major adverse cardiac events in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). Intracoronary bolus application of abciximab results in high local drug concentrations and may be more effective than standard intravenous bolus application for reduction of infarct size, no-reflow and improvement in perfusion. Methods Patients undergoing primary PCI were randomized to either intracoronary (n=77) or intravenous (n=77) bolus administration of abciximab with subsequent 12 hour intravenous infusion. Primary endpoint was infarct size and extent of microvascular obstruction assessed by delayed enhancement magnetic resonance. Secondary endpoints were ST-resolution at 90 minutes, Thrombolysis in Myocardial Infarction (TIMI)-flow and perfusion grade post PCI, and the occurrence of major adverse cardiac events within 30 days. Results The primary endpoint infarct size could be reduced by absolute 7% (17.7% i.c. versus 24.7% i.v., p=0.005). Similarly, the extent of microvascular obstruction was significantly smaller in i.c. patients in comparison to i.v. patients (p=0.02). Myocardial perfusion measured as early ST-segment resolution was significantly improved in i.c. patients with an absolute ST-resolution of 76±23% versus 64±31% (p=0.009). The TIMI flow after PCI was not different between treatment groups (p=0.51), but there was a trend towards an improved perfusion grade (p=0.12). There was a trend towards a higher major adverse cardiac event rate after intravenous versus intracoronary abciximab application (15.6% versus 5.2%, p=0.06; relative risk 3.00; 95% confidence intervals 0.94 –10.80). Conclusions: Intracoronary bolus administration of abciximab is superior to standard intravenous treatment with respect to infarct size, extent of microvascular obstruction, and perfusion in primary PCI. An adequately powered trial for major adverse cardiac event reduction is warranted.

Heart fatty acid binding protein and myoglobin after reperfusion of acute myocardial infarction

Objective — The aim of this study was to disclose the release kinetics of heart fatty acid binding protein (HFABP) and myoglobin in acute myocardial infarction (AMI) reperfused by primary percutaneous coronary intervention (PPCI) and to determine the influence of the quality of coronary flow post PPCI on the release properties of these markers.Methods and results — Twenty-four patients with AMI who underwent successful PPCI and had no evidence of reocclusion within the first 120 minutes were studied. Serum myoglobin and HFABP levels at baseline and at 15, 30, 45, 60, 90 and 120 minutes after reperfusion were measured. Corrected TIMI frame count (CTFC) in the relevant vessel post PPCI was used to categorize patients in group 1 (CTFC > 21) and group 2 (CTFC < 21). Biomarker ratios at each sampling point were calculated by dividing the serum level of the biomarker at the specific sampling time by its baseline level.Baseline myoglobin and HFABP levels rose significantly at 15 minutes (153 ± 251.5 pg/L vs. 904.3 ± 542.6 pg/L, 10.9 ± 8 pg/L vs. 17.8 ± 9.1 pg/L, both P < 0.0001) after successful PPCI. Group 2 patients tended to have higher biomarker ratios at each time point as compared to group 1.Conclusions — Successful PPCI for AMI results in a significant increase of both HFABP and myoglobin levels within 15 minutes of vessel opening and the quality of flow in the infarction-related artery post PCI as evaluated by CTFC does not influence the release kinetics of these biomarkers.

1400: A study to investigate the role of anxiety and depression on re-presentation rates post Primary Percutaneous Coronary Intervention

1400: A study to investigate the role of anxiety and depression on re-presentation rates post Primary Percutaneous Coronary Intervention

Predictors of in-hospital mortality after percutaneous coronary intervention for cardiogenic shock

The mortality of patients with cardiogenic shock (CS) complicating ST elevation acute myocardial infarction (STEMI) remains high, despite early revascularization. Current knowledge of predictors of death is limited. The pathophysiologic understanding of CS after acute myocardial infarction has shifted from a mere hemodynamic disorder to a more complex approach including imbalance in metabolic functions. In 45 consecutive patients (71.4+/-13 years) with CS complicating STEMI treated with primary percutaneous coronary intervention (PCI) serum levels of lactate, glucose and uric acid on coronary care unit (CCU) admission were measured. The end-point was in-hospital death. The following parameters, on CCU admission, were univariate predictors of in-hospital mortality: serum glucose >200 mg/dl (OR=11.3, p=0.002), serum creatinine >1.5 mg/dl (OR=12.7, p=0.003), uric acid >6.5 mg/dl (OR=6.7, p=0.016), lactate >6.5 mmol/l (OR=54, p<0.0001), age > or =75 years (OR=8.5, p=0.002), history of hypertension (OR=8.3, p=0.003) and TIMI flow post PCI < or = 2 (OR=12.9, p=0.02). At multivariate analysis, after adjustment for sex, age, hypertension and diabetes, lactate >6.5 mmol/l and TIMI flow post PCI < or = 2 were still independent predictors of in-hospital mortality (OR=295, p=0.01; OR=19.5, p=0.04, respectively). Hyperlactatemia, hyperglycemia and increased levels of uric acid on CCU admission are univariate predictors of in-hospital death. Moreover, at multivariate analysis, hyperlactatemia (>6.5 mmol/l) is an independent indicator of in-hospital death in CS patients complicating STEMI.

The predictive value of admission glucose for the prognosis of AMI post primary percutaneous coronary intervention

The predictive value of admission glucose for the prognosis of AMI post primary percutaneous coronary intervention