Reperfusion Strategy Research Articles

Abstract 15445: Extracorporeal Membrane Oxygenation and Reperfusion Strategies in High-Risk Pulmonary Embolism Hospitalizations

Introduction: Extracorporeal membrane oxygenation (ECMO) offers potentially life-saving circulatory support in patients with high-risk pulmonary embolism (PE) and refractory hemodynamic instability. Optimal reperfusion strategies in combination are unclear. Hypothesis: To investigate the contemporary use of ECMO in conjunction with reperfusion strategies in high-risk PE. Methods: We identified high-risk PE hospitalizations in the Nationwide Inpatient Sample (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Results: Among 122,735 hospitalizations for high-risk PE ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, with thrombolysis-based reperfusion in 0.4%, and with mechanical reperfusion in 0.5%. Compared to neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted OR, 0.60; 95% CI, 0.38-0.97), whereas no difference was found with ECMO plus mechanical reperfusion (1.02; 0.66-1.59), and ECMO stand-alone was associated with increased in-hospital mortality (1.59; 1.21-2.09). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (0.71; 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (0.54; 0.32-0.90), and mechanical reperfusion showed a trend (0.74; 0.47-1.18) towards reduced in-hospital mortality compared to no reperfusion, without increases in major bleeding. Conclusions: In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as stand-alone treatment especially for patients suffering from cardiac arrest.

Sex differences in ischemic stroke during COVID-19 first outbreak in northern Italy

IntroductionCOVID-19 pandemic had a great impact on outcome in SARS-CoV-2 positive patients with ischemic stroke during the first wave in Italy. Few data are available on outcome stratified by sex. MethodsThe Italian Society of Hospital Neuroscience conducted a multi-center, retrospective, observational study on neurological complications in COVID-19 patients with ischemic stroke. All the patients admitted from March 1st to April 30th, 2020 in 20 Neurology Units in Northern Italy were recruited. Demographical and clinical features, treatment and outcome data were compared focusing on sex differences. Results812 patients with ischemic stroke were enrolled, of whom 129 with COVID-19; males were 53.8%. In-hospital mortality in COVID-19 patients was 35.3% in males and 27.9% in females while 8.5% in male and 5.8% in female patients without COVID-19. SARS-CoV-2 positive patients had a higher frequency of stroke of undetermined etiology, than negative ones (32.8% vs 22.5%; p = 0.02), especially in females compared to males (36.1% vs 27.9%), albeit without statistical significance. Male patients with SARS-CoV-2 were more likely to require cPAP (30.9% vs 14.8%; p = 0.03), endotracheal tube (14.9% vs 3.3%; p = 0.02) and reperfusion strategies (29.4% vs 11.5%; p = 0.01) than females, as well as to have a higher CRP and D-dimer. These elements together with older age, a total anterior circulation stroke and lymphopenia were predictors of a worse outcome. DiscussionOur study detected some differences due to sex in ischemic stroke with and without COVID-19, supporting the possibility to perform sex analyses for SARS-CoV-2 positive patients for a better clinical management.

Anagrelide alleviates myocardial ischaemia–reperfusion injury by inhibiting reticulated platelets

Ischaemia–reperfusion injury (IRI) has been a major challenge during acute coronary syndrome (ACS) with reperfusion therapy. But despite consistent therapeutic improvements in terms of optimized reperfusion strategies and novel antithrombotic medications, IRI still remains highly prevalent. Platelets play a pivotal role in the IRI. Expression ofreticulated platelets (RPs), is found among patients with ACS, which is associated with increased activity and contributes to an impaired response to antiplatelet drugs. RPs might play a more important role in IRI than mature platelets, regarded as a potential therapeutic target for myocardial IRI. Anagrelide, an antithrombopoietic drug indicating for essential thrombocythemia, decreases newly formed platelets by inhibiting the proliferation and differentiation of megakaryocytes in bone marrow. We hypothesize that RPs play a major role in platelet-mediated IRI and that anagrelide alleviates IRI primarily by reducing the number of RPs in the peripheral circulation. To investigate this hypothesis, we have designed animal experiments and clinical trials. Ultimately, we have thoroughly examined potential limitations in confirming this hypothesis and have put forth strategies to effectively address and mitigate these challenges.

Troponin level at presentation as a prognostic factor among patients presenting with non-ST-segment elevation myocardial infarction.

Timely reperfusion within 120 min is strongly recommended in patients presenting with non-ST-segment myocardial infarction (NSTEMI) with very high-risk features. Evidence regarding the use of high-sensitivity cardiac troponin (hs-cTn) concentration upon admission for the risk-stratification of patients presenting with NSTEMI to expedite percutaneous coronary intervention (PCI) and thus potentially improve outcomes is limited. All patients admitted to a tertiary care center ICCU between July 2019 and July 2022 were included. Hs-cTnI levels on presentaion were recorded, dividing patients into quartiles based on baseline hs-cTnI. Association between initial hs-cTnI and all-cause mortality during up to 3 years of follow-up was studied. A total of 544 NSTEMI patients with a median age of 67 were included. Hs-cTnI levels in each quartile were: (a) ≤122, (b) 123-680, (c) 681-2877, and (d) ≥2878 ng/L. There was no difference between the initial hs-cTnI level groups regarding age and comorbidities. A higher mortality rate was observed in the highest hs-cTnI quartile as compared with the lowest hs-cTnI quartile (16.2% vs. 7.35%, p = .03) with hazard ratio (HR) for mortality of 2.6 (95% confidence interval [CI]: 1.23-5.4; p = .012) in the unadjusted model, and HR of 2.06 (95% CI: 1.01-4.79; p = .047) with adjustment for age, gender, serum creatinine, and significant comorbidities. Patients with NSTEMI and higher hs-cTnI levels upon admission faced elevated mortality risk. This underscores the need for further prospective investigations into early reperfusion strategies' impact on NSTEMI patients' mortality, based on admission troponin elevation.

Long-Term Prognosis of Different Reperfusion Strategies for ST-Segment Elevation Myocardial Infarction in Chinese County-Level Hospitals: Insight from China Acute Myocardial Infarction Registry

ObjectiveTo evaluate the long-term prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with different reperfusion strategies in Chinese county-level hospitals MethodsA total of 2,514 patients with STEMI from 32 hospitals participated in the China Acute Myocardial Infarction registry between January 2013 and September 2014. The success of fibrinolysis was assessed according to indirect measures of vascular recanalization. The primary outcome was 2-year mortality. ResultsReperfusion therapy was used in 1,080 patients (42.9%): fibrinolysis (n = 664, 61.5%) and primary percutaneous coronary intervention (PCI) (n = 416, 38.5%). The most common reason for missing reperfusion therapy was a prehospital delay > 12 h (43%). Fibrinolysis [14.5%, hazard ratio (HR): 0.59, 95% confidence interval (CI) 0.44–0.80] and primary PCI (6.8%, HR = 0.32, 95% CI: 0.22–0.48) were associated with lower 2-year mortality than those with no reperfusion (28.5%). Among fibrinolysis-treated patients, 510 (76.8%) achieved successful clinical reperfusion; only 17.0% of those with failed fibrinolysis underwent rescue PCI. There was no difference in 2-year mortality between successful fibrinolysis and primary PCI (8.8% vs. 6.8%, HR = 1.53, 95% CI: 0.85–2.73). Failed fibrinolysis predicted a similar mortality (33.1%) to no reperfusion (33.1% vs. 28.5%, HR = 1.30, 95% CI: 0.93–1.81). ConclusionIn Chinese county-level hospitals, only approximately 2/5 of patients with STEMI underwent reperfusion therapy, largely due to prehospital delay. Approximately 30% of patients with failed fibrinolysis and no reperfusion therapy did not survive at 2 years. Quality improvement initiatives are warranted, especially in public health education and fast referral for mechanical revascularization in cases of failed fibrinolysis.

The Efficacy and Safety of Mechanical Thrombectomy in Posterior Circulation Large Vessel Occlusion as Compared to Anterior Circulation Large Vessel Occlusion: A Systematic Review.

Mechanical thrombectomy (MT) has been established as a standard of care for patients with stroke due to anterior circulation large vessel occlusion (AC-LVO). Due to a lack of robust evidence for the effectiveness of mechanical thrombectomy, intravenous thrombolysis (IVT) is still the only approved first-line acute reperfusion strategy for posterior circulation large vessel occlusion (PC-LVO). This systematic review analyzes and reports on the effectiveness and safety of MT in PC-LVO. A literature review was performed to identify all studies of patients with acute ischemic stroke due to PC-LVO who underwent MT with second-generation devices (stent retrievers and/or aspiration devices) that were reported between January 2017 and January 2023. The primary outcome was functional independence at 90 days, defined as a modified Rankin (mRS) score of ≤2. Secondary outcomes were successful recanalization (modified treatment in cerebral infarction score (mTICI) 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality at 90 days post-procedure. We looked at 13 studies with a total of 30,407 participants in four meta-analyses and 5951 participants in nine observational studies. In most studies, patients in the PC-LVO group were male and younger than the AC-LVO group. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score, lower rates of IVT, longer onset-to-groin puncture time, lower likelihood of sICH, higher 90-day mortality rates, and higher futile recanalization rates were frequently observed in the PC-LVO group with a large discrepancy in the likelihood of functional independence at 90 days with majority studies showing comparable rates. Hence, in patients with acute ischemic stroke caused by the PC-LVO, successful reperfusion can be achieved via MT, though at the cost of higher mortality rates. Such futile recanalization can be avoided with the refinement of procedures through technical improvements, skills training, and recognition of reliable predictors associated with it, which might help increase the efficacy of MT in PC-LVO. Additionally, future large-scale RCTs comparing patient selection and interventional strategies to avoid futile interventions are also needed.

Comparative Analysis of Patients With STEMI and COVID-19 Between Canada and the United States.

Important health care differences exist between the United States (US) and Canada, which may have been exacerbated during the pandemic. We compared clinical characteristics, treatment strategies, and clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19 (STEMI-COVID) treated in the US and Canada. The North American COVID-19 Myocardial Infarction registry is a prospective, investigator-initiated study enrolling patients with STEMI with confirmed or suspected COVID-19 in the US and Canada. The primary end point was in-hospital mortality. Additionally, we explored associations between vaccination and clinical outcomes. Of 853 patients with STEMI-COVID, 112 (13%) were enrolled in Canada, and compared with the US, patients in Canada were more likely to present with chest pain and less likely to have a history of heart failure, stroke/transient ischemic attack, pulmonary infiltrates or renal failure. In both countries, the primary percutaneous coronary intervention was the dominant reperfusion strategy, with no difference in door-to-balloon times; fibrinolysis was used less frequently in the US than in Canada. The adjusted in-hospital mortality was not different between the 2 countries (relative risk [RR], 1.0; 95% CI, 0.46-2.72; P = 1.0). However, the risk of in-hospital mortality was significantly higher in unvaccinated compared with vaccinated patients with STEMI-COVID (RR, 4.7; 95% CI, 1.7-11.53; P = .015). Notable differences in morbidities and reperfusion strategies were evident between patients with STEMI-COVID in the US compared with Canada. No differences were noted for in-hospital mortality. Vaccination, regardless of region, appeared to associate with a lower risk of in-hospital mortality strongly.

Mortality Trends After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

BackgroundObservational studies have reported that mortality rates after ST-segment elevation myocardial infarction (STEMI) have been stable since 2006 to 2010. ObjectivesThe aim of this study was to evaluate the temporal trends in 1-year, 30-day, and 31- to 365-day mortality after STEMI in Western Denmark where primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003. MethodsUsing the Western Denmark Heart Registry, the study identified first-time PCI-treated patients undergoing primary PCI (pPCI) for STEMI from 2003 to 2018. Based on the year of pPCI, patients were divided into 4 time-interval groups and followed up for 1 year using the Danish national health registries. ResultsA total of 19,613 patients were included. Median age was 64 years, and 74% were male. One-year mortality decreased gradually from 10.8% in 2003-2006, 10.4% in 2007-2010, 9.1% in 2011-2014, to 7.7% in 2015-2018 (2015-2018 vs 2003-2006: adjusted HR [aHR]: 0.71; 95% CI: 0.62-0.82). The largest absolute mortality decline occurred in the 0- to 30-day period with a 2.3% reduction (aHR: 0.69; 95% CI: 0.59-0.82), and to a lesser extent in the 31- to 365-day period (risk reduction: 1.0%; aHR: 0.71; 95% CI: 0.56-0.90). ConclusionsIn a high-income European country with a fully implemented pPCI strategy, 1-year mortality in pPCI-treated patients with STEMI decreased substantially between 2003 and 2018. Approximately three-quarters of the absolute mortality reduction occurred within the first 30 days after pPCI. These results indicate that optimization of early management of pPCI-treated patients with STEMI offers great opportunities for improving overall survival in contemporary clinical practice.

Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials

Intravenous thrombolysis is recommended before endovascular treatment, but its value has been questioned in patients who are admitted directly to centres capable of endovascular treatment. Existing randomised controlled trials have indicated non-inferiority of endovascular treatment alone or have been statistically inconclusive. We formed the Improving Reperfusion Strategies in Acute Ischaemic Stroke collaboration to assess non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. We conducted a systematic review and individual participant data meta-analysis to establish non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. We searched PubMed and MEDLINE with the terms "stroke", "endovascular treatment", "intravenous thrombolysis", and synonyms for articles published from database inception to March 9, 2023. We included randomised controlled trials on the topic of interest, without language restrictions. Authors of the identified trials agreed to take part, and individual participant data were provided by the principal investigators of the respective trials and collated centrally by the collaborators. Our primary outcome was the 90-day modified Rankin Scale (mRS) score. Non-inferiority of endovascular treatment alone was assessed using a lower boundary of 0·82 for the 95% CI around the adjusted common odds ratio (acOR) for shift towards improved outcome (analogous to 5% absolute difference in functional independence) with ordinal regression. We used mixed-effects models for all analyses. This study is registered with PROSPERO, CRD42023411986. We identified 1081 studies, and six studies (n=2313; 1153 participants randomly assigned to receive endovascular treatment alone and 1160 randomly assigned to receive intravenous thrombolysis and endovascular treatment) were eligible for analysis. The risk of bias of the included studies was low to moderate. Variability between studies was small, and mainly related to the choice and dose of the thrombolytic drug and country of execution. The median mRS score at 90 days was 3 (IQR 1-5) for participants who received endovascular treatment alone and 2 (1-4) for participants who received intravenous thrombolysis plus endovascular treatment (acOR 0·89, 95% CI 0·76-1·04). Any intracranial haemorrhage (0·82, 0·68-0·99) occurred less frequently with endovascular treatment alone than with intravenous thrombolysis plus endovascular treatment. Symptomatic intracranial haemorrhage and mortality rates did not differ significantly. We did not establish non-inferiority of endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment in patients presenting directly at endovascular treatment centres. Further research could focus on cost-effectiveness analysis and on individualised decisions when patient characteristics, medication shortages, or delays are expected to offset a potential benefit of administering intravenous thrombolysis before endovascular treatment. Stryker and Amsterdam University Medical Centers, University of Amsterdam.

Effect of Intracoronary Adenosine on No Reflow in Patients with Acute ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Abstract Background When total coronary artery occlusion was found in the early hours of transmural myocardial infarction, most of our research interest and treatment strategies focused on epicardial coronary arteries. Little attention, however, is paid to the coronary microvasculature. When a coronary artery is occluded, detrimental changes occur in the cardiac capillaries and arterioles. After relief of the occlusion, blood flow to the ischemic tissue may still be impeded, a phenomenon known as no reflow. This abstract attempt to provide an in-depth understanding of this phenomenon and comparative review of intracoronary adenosine used in no reflow settings. Aim and objectives The aim of the study was to evaluate the impact of intracoronary adenosine on preventing no-reflow phenomenon as being assessed by tissue perfusion TIMI flow and myocardial blush grade as the primary objective in patients presented with ST elevation myocardial infarction (STEMI) undergoing primary PCI as the strategy of reperfusion and its effect on Left ventricular ejection fraction and LV dimensions as the secondary objective. Patients and Methods This study included 200 patients presented to emergency departments of Ain shams university hospitals from January 2021 till June 2022 and diagnosed with STEMI as being defined as Patients with ST elevation myocardial infarction defined as having symptoms of ischemia and ST-segment elevation of at least two contiguous leads with ST-segment elevation ≥ 2.5 mm in men < 40 years, ≥2 mm in men ≥ 40 years, or ≥ 1.5 mm in women in leads V2–V3 and/or ≥ 1 mm in the other leads [1.2], that had been revascularized by primary PCI as per the recommendations of The European society of cardiology guidelines for diagnosis and management of ST elevation myocardial infarction published in 2017 [2]. The patients were randomized using dedicated software programme into two groups. Group A including 100 patients was the adenosine group. Group B including 100 patients was the standard control group. Results Our study had demonstrated that There was a statistically significant difference between the two groups, group A (Adenosine group) and group B (control group), regarding the occurrence of no reflow as there were 12 no reflow cases in group A versus 23 no reflow cases in group B with P value of 0.041). Off note, in our study no reflow was defined as TIMI score of < 3 and MBG grade of 0, 1, 2 in the absence of evident vessel dissection, obstruction or distal vessel embolic cutoff. There was a highly significant difference between the two groups in the tissue perfusion post primary PCI as being assessed by TIMI flow classification and myocardial blush grade. As for TIMI flow grading; TIMI I flow was achieved in 4 patients in group A versus 7 patients in group B, TIMI II flow was achieved in 10 patients in group A versus 44 patients in group B, TIMI III flow was achieved in 86 patients in group A versus 49 patients in group B, with P value of 0.000. As regard myocardial blush grade; MBG 0 was achieved in 3 patients in group A versus 5 patients in group B, MBG I was achieved 2 patients in group A versus 5 patients in group B, MBG II was achieved in 27 patients in group A versus 48 patients in group B, MGB III was achieved in 68 patients in group A versus 42 patients in group B, with P value of 0.003. Conclusion We concluded that intracoronary adenosine may be used for prevention of no reflow in patients presented with STEMI undergoing primary PCI as reperfusion strategy. Intracoronary adenosine was associated with better myocardial salvage in the context of left ventricular ejection fraction and dimensions. Tissue perfusion as being assessed by TIMI flow grade and MBG was inversely related to the reduction of LVEF.

Comparison between Deflated Balloon-Facilitated Direct Stenting and Balloon Pre-Dilatation in ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Abstract Background PPCI is considered to be the preferred reperfusion strategy for acute coronary syndrome (ACS). The goal of reperfusion is to resume normal blood flow to the cardiac tissues, and not just to achieve an open epicardial artery. Although no-reflow may occur regardless of the method of revascularization, it is easily diagnosed with certainty during acute percutaneous coronary intervention (PCI) in STEMI. Objective To evaluate the efficacy of Deflated Balloon-Facilitated Direct Stenting in comparison with routine Balloon Pre-dilatation in STEMI Patients undergoing PPCI. Patients and Methods It included 160 patients who were presented with ST segment elevation myocardial infarction (STEMI) and underwent primary PCI at Ain Shams University Hospitals and Misr University for Science and Technology (MUST) university hospital in the period of March 2021 to december 2021. Results In our study group 2 showed the best results as regards No-reflow (23.33% vs 6.67% vs 27.5% in group 1, 2 and 3 respectively) with p-value (0.011), final MBG (II-III) (76.67% vs 93.33% vs 72.5% in group 1, 2 and 3 respectively) with p-value (0.011) and final TIMI III (91.67% vs 95% vs 90% in group 1, 2 and 3 respectively) with p-value (0.838). It was found that group 1 showed the shortest procedure time (measured in minutes) (46.83±15.43 vs 52±13.54 vs 59.75±14.59, in group 1, 2 and 3 respectively) with p-value (0.054) and smallest contrast volume (measured in milliliters) (101±19.09 vs 120.67±28.99 vs 136.25±24.67, in group 1, 2 and 3 respectively) with p-value (<0.001). While group 3 had the worst outcomes among all groups. Conclusion Routine predilatation technique is associated with better results when compared with deflated balloon-facilitated direct stenting technique. One of the major disadvantages of deflated balloon-facilitated direct stenting is not being able to restore the flow distal to the lesion, which necessitate using balloon dilatation, leading to more incidence of no-reflow (we aquire the disadvantages of both techniques combined) Abbreviations ACS: Acute coronary syndrome; CAD: Coronary artery disease; CBC: Complete blood picture; CKD: Chronic kidney disease; CVS: cerebrovascular disease; DBDS: Deflated balloon facilitated direct stenting; DM: Diabetes Mellitus; DS: Direct stenting; ECG: Electrocardiogram; EF: Ejection fraction; FH: Family history; GP: Glycoprotein; HTN: Hypertension; IRA: Infarct related artery; LAD: Left anterior descending artery; LCX: Left circumflex artery; MACE: Major adverse cardiac events; MBG: Myocardial blush grade; MI: Myocardial infarction; NR: No reflow phenomenon; PAD: Peripheral arterial disease; PCI: Percutaneous coronary intervention; PD: Predilatation; PPCI: Primary percutaneous coronary intervention; RCA: Right coronary artery; STEMI: ST-segment elevation myocardial; SWMA: Segmental wall motion abnormalities; TIMI: Thrombolysis in myocardial infarction risk score

ST-segment elevation myocardial infarction heart of Charlotte one-year (STEMI HOC-1) study: a prospective study protocol

BackgroundST-segment elevation myocardial infarction (STEMI) is a clinically distinguishable yet lethal sequela of ischaemic heart disease (IHD). In sub-Saharan Africa (SSA), death due to acute STEMI is increasing. In South Africa, there is a paucity of data available on the clinical outcomes of acute STEMI within one year for individuals treated in the public healthcare sector. This study primarily seeks to determine the one-year all-cause mortality rate of acute STEMI. The study also assesses the value of serum cardiac biomarkers of myocardial damage and serum uric acid in predicting all-cause mortality in STEMI.MethodsThis is a single-centre observational prospective cohort of all consecutive individuals presenting with an acute STEMI to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa. Research data will be sourced on admission through electronic medical records, blood laboratory results and coronary angiography reports, and at follow-up through periodic telephonic interviews and standardised echocardiograms. At least 355 eligible participants will be continuously followed over one year, and clinical outcomes will be measured 30 days, three months, six months and one year after the index hospitalisation.DiscussionThis study provides insights into the demographic, risk factors and clinical profiles of individuals with STEMI in South Africa. Its findings may improve the risk stratification, prognostication, and therapeutic management of STEMI patients in our setting. By comparing the clinical outcomes between the different coronary reperfusion strategies, our results may guide clinicians in providing better patient treatment, particularly in sub-Saharan Africa, where access to percutaneous coronary intervention may be limited. Furthermore, the study offers insights into the routine use of baseline serum uric acid as a potential low-cost prognostic biomarker of all-cause mortality in STEMI. Finally, this study’s findings may be of public health significance to local policymakers to aid in reinforcing primary prevention strategies and developing structured referral networks for timely coronary reperfusion of acute STEMI.

Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: A post-hoc analysis of a multicenter retrospective cohort study

IntroductionThis study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA). MethodsThis was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO. ResultsAmong the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21–4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86–3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67–0.97, P = 0.020). ConclusionsFavorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients. Clinical trial registrationhttps://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Changes in process and outcome for ST elevation myocardial infarction in central China from 2011 to 2018.

Limited data are available on the changes in the quality of care for ST elevation myocardial infarction (STEMI) during China's health system reform from 2009 to 2020. This study aimed to assess the changes in care processes and outcome for STEMI patients in Henan province of central China between 2011 and 2018. We compared the data from the Henan STEMI survey conducted in 2011-2012 ( n = 1548, a cross-sectional study) and the Henan STEMI registry in 2016-2018 ( n = 4748, a multicenter, prospective observational study). Changes in care processes and in-hospital mortality were determined. Process of care measures included reperfusion therapies, aspirin, P2Y12 antagonists, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Therapy use was analyzed among patients who were considered ideal candidates for treatment. STEMI patients in 2016-2018 were younger (median age: 63.1 vs . 63.8 years) with a lower proportion of women (24.4% [1156/4748] vs . 28.2% [437/1548]) than in 2011-2012. The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018 (60.9% [5424/8901] vs . 82.7% [22,439/27,129], P <0.001). The proportion of patients treated by reperfusion within 12 h increased from 44.1% (546/1237) to 78.4% (2698/3440) ( P <0.001) with a prolonged median onset-to-first medical contact time (from 144 min to 210 min, P <0.001). The use of antiplatelet agents, statins, and β-blockers increased significantly. The risk of in-hospital mortality significantly decreased over time (6.1% [95/1548] vs . 4.2% [198/4748], odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.50-0.88, P = 0.005) after adjustment. Gradual implementation of the guideline-recommended treatments in STEMI patients from 2011 to 2018 has been associated with decreased in-hospital mortality. However, gaps persist between clinical practice and guideline recommendation. Public awareness, reperfusion strategies, and construction of chest pain centers need to be further underscored in central China.

A proposal for better visualization of Aslanger pattern

In the context of reporting a case of a patient with Aslanger pattern, the application of additional leads in the frontal plane is proposed to facilitate the recognition of this condition - indicating occlusive myocardial infarction - as eligible for the current ST-segment elevation myocardial infarction (STEMI) criteria and consequently for immediate reperfusion strategy recommendation.

Mechanisms regulating vascular and lymphatic regeneration in the heart after myocardial infarction.

Myocardial infarction, caused by a thrombus or coronary vascular occlusion, leads to irreversible ischaemic injury. Advances in early reperfusion strategies have significantly reduced short-term mortality after myocardial infarction. However, survivors have an increased risk of developing heart failure, which confers a high risk of death at 1 year. The capacity of the injured neonatal mammalian heart to regenerate has stimulated extensive research into whether recapitulation of developmental regeneration programmes may be beneficial in adult cardiovascular disease. Restoration of functional blood and lymphatic vascular networks in the infarct and border regions via neovascularisation and lymphangiogenesis, respectively, is a key requirement to facilitate myocardial regeneration. An improved understanding of the endogenous mechanisms regulating coronary vascular and lymphatic expansion and function in development and in adult patients after myocardial infarction may inform future therapeutic strategies and improve translation from pre-clinical studies. In this review, we explore the underpinning research and key findings in the field of cardiovascular regeneration, with a focus on neovascularisation and lymphangiogenesis, and discuss the outcomes of therapeutic strategies employed to date. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

P142 EARLY MANAGEMENT OF STEMI PATIENTS DURING COVID–19 PANDEMIC: THE ROLE OF AN EMERGENCY DEPARTMENT–BASED CARDIOLOGY UNIT IN SAN RAFFAELE SCIENTIFIC INSTITUTE

Abstract During COVID–19 pandemic, a critical issue for cardiologists was to provide early access to the standard of care for patients with time–dependent diseases such as ST–segment elevation myocardial infarction (STEMI), while making efforts to prevent their exposure to SARS CoV–2. Aims: The aim of our research project was to evaluate the role of an Emergency Department–based operative unit directly managed by the Cardiology Department in providing a prompt cardiological evaluation to STEMI patients at first medical contact, which we assumed might positively impact on the reperfusion strategy and timing and thus on the extent of myocardial salvage. Methods We retrospectively included a group of STEMI patients admitted by our ED with a definitive diagnosis of STEMI from March 2020 to November 2021 and a control group admitted from January 2019 to February 2020. The groups were compared in terms of critical time intervals, rate of PCI or initial non–invasive conservative management, pre–discharge characteristics and in–hospital clinical outcomes, including all cause mortality and complications. Results Throughout the study period, a total of 211 patients were admitted to our institution with a diagnosis of STEMI. The number of patients presenting late (at least twelve hours since symptoms onset) was significantly higher and time from symptoms onset to hospital admission was significantly longer during the first COVID–19 pandemic peak, compared with the previous year. Almost all patients in both cohorts underwent invasive coronary angiography with subsequent primary PCI. Remarkably, despite the time–consuming hygiene practices and policies necessary to prevent patients’ exposure to SARS CoV–2 virus, door–to–balloon time was comparable between the two cohorts. No statistically significant differences were found regarding the occurrence of STEMI–related complications. The in–hospital mortality was comparable between the two cohorts, as was predischarge LVEF. The high–sensitivity Troponin–T peak was significantly lower after the introduction of the ED–based cardiology unit. Total in–hospital stay was shorter after the introduction of the ED cardiology unit. Conclusions Our experience has shed light on the potential advantages of an ED–based unit directly managed by the Cardiology Department: despite the confirmation of a longer time from symptoms onset to hospital admission, no significant differences were found in terms of hard outcomes between the groups.

A prediction model for ventricular arrythmias in the acute phase of infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF) in the acute phase of infarction (first 24-48 hours) has declined over recent decades, probably due to the uptake of reperfusion strategies and the early use of beta-blockers. However, according to some series, 6–8% of patients still develop hemodynamically significant VT or VF during this phase. Purpose The objective of our study was to evaluate the baseline characteristics of patients who suffered VT or VF in the acute phase of the infarction and to create a predictive model of ventricular arrhythmias in this setting which allow us to anticipate arrhythmic events. Methods We performed an observational, retrospective, and single-centre study carried out through the review of clinical records of patients who suffered an acute myocardial infarction with ST-segment elevation (STEMI) and were admitted in our Coronary Care Unit between July 2011 and August 2022. Results In our cohort we observed 179 episodes of VT/VF (10,7%) in a population of 1668 patients underwent STEMI. The mean age in this subgroup was 61,69±12,61 years old, 78% were males and 56% smokers. Approximately a quarter of the patients were diabetic or obese. There was a very low percentage of previous myocardial infarction (12%) and heart failure (3%) (Table 1). We estimated the best prediction model (Mallows’ Cp=5.12) for VT/VF. The variables included in our model (LL=-435,43) were: male sex, absence of diabetes, smoking habit, use of fibrinolysis, worst Killip at admission and hypotension at admission (Table 2). Conclusion The presence of VT or VF in the acute phase of infarction is still considered a controversial factor in the prognosis of these patients. In our cohort we identified that males, smokers, non-diabetics, and the use of fibrinolysis and the worst haemodynamical situation at admission were independent predictors of developing VT/VF in this context.

Percutaneous coronary interventions in patients over 80 years old age with acute coronary syndrome

Age is an important non-modifi able risk factor for cardiovascular disease. Both European and American guidelines recommend offering an invasive reperfusion strategy in elderly patients with ACS, taking into account the patients&amp;lsquo; comorbidities and baseline level of functioning. Materials and methods: All patients over 80 years of age with acute coronary syndrome, treated in the Department of Invasive Cardiology of the National Heart Hospital for the period between January 1, 2016. and December 31, 2018, are retrospectively analyzed. The primary endpoint was defi ned as all-cause mortality during the hospital stay and at follow-up. Predictors of mortality were assessed and independent predictors were identifi ed. Results: During the study period, 179 patients aged 80 years or older were identifi ed as being treated for ACS with PCI. In the study population, in hospital mortality for the index event was 11.8%. At a mean follow-up time of 20.19 &amp;plusmn; 11.9 months, mortality rose signifi cantly to 64.6%. When evaluating in-hospital mortality on multivariate analysis, the two independent predictors were Cardiogenic shock (HR 0.005, 95% CI 0.01&amp;ndash;0.44; p &lt; 0.001) and acute/exacerbated renal failure (0.986 95% CI 0.984-0.997; p = 0.015). Conclusion: The present study provides important information regarding characteristics and outcomes in very elderly patients undergoing PCI for ACS. In the future, this subset of patients is predicted to grow, meaning that their approach must be evidence-based to ensure safe and effective treatment options.

Left Ventricular Global Longitudinal Strain Following Acute ST-Elevation Myocardial Infarction - A Comparison of Primary Coronary Angioplasty and Tenecteplase-Based Pharmacological Reperfusion Strategy.

In the setting of acute ST-elevation myocardial infarction (STEMI), reperfusion therapy with primary percutaneous coronary intervention (PCI) performed by an experienced team or pharmacological reperfusion with thrombolytic therapy is highly recommended. Standard echocardiographic measurement of the left ventricular ejection fraction (LVEF) is widely used to assess left ventricular global systolic function. This study was designed to compare the assessment of global left ventricular function by standard LVEF and global longitudinal strain (GLS) in the two well-known reperfusion strategies. We conducted a retrospective single-center observational study in 50 patients with acute STEMI who underwent primary PCI (n = 25) and Tenecteplase (TNK)-based pharmacological reperfusion therapy (n = 25). The primary outcome was left ventricle (LV) systolic function after primary PCI, as assessed by two-dimensional (2D) GLS using speckle-tracking echocardiography (STE), as well as LVEF using standard 2D echocardiogram using Simpson's biplane method. Overall mean age was 53.7 ± 6.9 years with 88% male gender. The mean door-to-needle time was 29.8 ± 4.2 min in the TNK-based pharmacological reperfusion therapy arm, and the mean door-to-balloon time was 72.9 ± 15.4 min in the primary PCI arm. LV systolic function was significantly better in the primary PCI arm as compared to the TNK-based pharmacological reperfusion therapy, both by 2D STE (mean GLS: -13.6 ± 1.4 vs. -10.3 ± 1.2, P ≤ 0.001) and LVEF (mean LVEF: 42.2 ± 2.9 vs. 39.9 ± 2.7, P = 0.006). There were no significant differences in mortality and inhospital complications in both groups. Global LV systolic function is significantly better after primary coronary angioplasty as compared to TNK-based pharmacological reperfusion therapy when assessed by routine LVEF and 2D GLS in the setting of acute STEMI.