Setting Of Percutaneous Coronary Intervention Research Articles

Primary percutaneous intervention of the right coronary artery in a setting of anomalous origination of left coronary artery from the opposite sinus of Valsalva

Introduction. Coronary artery anomalies are infrequent but anticipated findings during percutaneous coronary interventions (PCI). Compared to consistent reporting in angiographic series, they seem to be underreported in interventional studies, and particularly in the setting of primary PCI, where their prompt recognition is of the utmost importance. Case report. We present a 50 years old male with inferior ST-elevation of myocardial infarction (STEMI) and right ventricular involvement with solitary ostium for all three coronary arteries in the right aortic sinus of Valsalva. The patient had an extremely rare variant of coronary artery origination belonging to the type A4b2c2 of Angelini?s classification. Correspondingly, it belongs to the left Anomalous origination of a Coronary Artery from the Opposite Sinus of Valsalva (ACAOS) class with the intraseptal course of left anterior descending artery. We managed successfully to implant a drug eluting stent in the proximal right coronary artery in a lengthy and stormy procedure, with the need for guiding catheter exchange, temporary pacing and dealing with no-reflow phenomenon. Conclusion. We summarize diagnostic hints for angiographic recognition of dominant variants of the left ACAOS and practical aspects of performing PCI in such patients. Also, we debate on the functional significance of coronary anomalies and its further implications from the prognostic and therapeutic aspects. We propose adoption of the novel classification of coronary anomalies of Angelini?s group in the routine clinical practice. Finally, we call for the inclusion of specific training in coronary artery anomalies into the interventional cardiology fellowship curriculum.

High-risk PCI under support of a pulsatile left ventricular assist device – First German experience with the iVAC2L system

BackgroundDuring high-risk percutaneous coronary intervention (PCI) complications may occur, leading to unstable hemodynamic conditions. Circulatory support devices might help to intercept these conditions by supporting cardiac output. We investigated in a prospective trial the performance of the pulsatile iVAC2L system in the setting of high-risk PCI. MethodsCirculatory support by the iVAC2L device was attempted in 20 consecutive patients (three females, mean age 72 ± 9 years, LVEF 44 ± 12%) undergoing high-risk PCI. Aortic pressure data were collected after device placement and immediately after PCI. ResultsSuccessful device placement was achieved in 17 (85%) patients; kinking of iliac artery and device length limited correct device placement in the remaining three patients. PCI success was 100%. With ongoing support (overall support time 122 ± 32min) systolic, diastolic and mean blood pressure increased significantly and kept the higher level until device removal.Critical events occurred in three patients (massive vasospasm, coronary perforation, no-flow in LCA after wire placement), but the iVAC2L device helped to maintain stable hemodynamic conditions with no need for cardiopulmonary resuscitation.Serial controls of hemolysis related parameters in a subgroup of ten patients revealed no significant device related hemolysis after the performance of the iVAC2l system. ConclusionsHigh-risk PCI under hemodynamic support by the iVAC2L device is feasible and safe. Aortic pressure increases with ongoing support. The device helps to stabilize hemodynamic situations if complications occur.

P5536Comparison of safety and effectiveness between right and left radial artery approach in percutaneous coronary intervention for acute coronary syndrome. Propensity score analysis of data from the ORPKI

Abstract Introduction The use of the radial approach (RA) for percutaneous coronary intervention (PCI) has gradually increased. Several studies demonstrated that radial artery is associated with significant reduction in major adverse cardiac events for both coronary angiography and PCI in acute coronary syndrome (ACS). However, it is still unclear if the side of RA has influence on clinical outcomes in an all-comer population in ACS settings. Purpose We sought to evaluate safety, feasibility, and clinical outcomes of right radial approach (RRA) compared to left radial approach (LRA) during PCI in “real-world” patients with ACS. Methods A total of 234,087 consecutive patients with ACS treated with PCI and stent implantation via radial approach between 2014 and 2017 in 151 invasive cardiology centers on the Polish territory. Data was based on the ORPKI Polish National Registry. Patients treated with RRA and LRA were compared using a propensity score analysis to avoid possible selection bias. The analysis was done in an “as-treated” manner. Results Procedure was conducted using RRA and LRA in 180,378 (77.1%) and 53,709 (22.9%) patients, respectively. After propensity score matching higher total amount of contrast (174.28 (±75.56) vs. 166.95 (±70.57) [ml]; P=0.001) and radiation doses were reported in PCI with left radial artery utilization (1210.21 (±1003.53) vs. 1054.07 (±1024.17) [mGy]; p=0.001). No differences were observed between RRA and LRA in rate of periprocedural adverse events such as myocardial infarction (0.08% vs. 0.08%; p=0.9) stroke (0.02% vs. 0.01%; p=0.1), no-reflow phenomenon (0.64%vs. 0.56%; p=0.1) and death (0.25% vs. 0.24%; p=0.7). A trend towards a lower rate of access-site-related bleeding during PCI was observed in RRA group (0.08% vs. 0.05%; p=0.066). Coronary artery perforation (0.21% vs. 0.16%; p=0.05) and cardiac arrest (0.56% vs 0.42%; p=0.01) were reported more often during PCI conducted with LRA. Conclusions Both radial approaches seems to be equally effective in the setting of PCI in ACS. However, utilization of left radial artery was associated with trend toward increased risk of access-site bleeding and higher rate of periprocedural complications as compared to RRA. Higher amount of contrast and radiation doses used in LRA procedures might be equivalent of generally lower experience with this access site. Acknowledgement/Funding None

A Case of Extended Mechanical Circulatory Support with Impella 5.0 in a Patient with Cardiogenic Shock Secondary to Left Ventricular Aneurysm

Introduction Data from the Nationwide Inpatient Sample (NIS) indicate that the incidence of cardiogenic shock (CS) has increased in the last two decades. Despite recent advances in mechanical circulatory support (MCS), CS-attributable morbidity remains high, portending a poor prognosis for patients at risk of developing CS acutely in the setting of percutaneous coronary intervention (PCI), cardiac surgery, or acute decompensated heart failure (ADHF). Herein, we describe the case of a patient maintained on 18 days of Impella 5.0 MCS, following ADHF and CS in the setting of a large LV aneurysm. Case Description A 66 year-old male patient with a history of ischemic cardiomyopathy with two-vessel coronary artery bypass grafts presented to an outside hospital for an episode of ADHF. Left heart catheterization performed at the outside hospital showed left anterior descending (LAD) and left circumflex (LCx) artery disease with patent grafts. There was severe disease of the mid-right coronary artery (RCA) which was treated with PCI. One week following intervention, the patient became acutely hypotensive and hypoxemic at rest. Echocardiography at that time showed possible LV aneurysm, though contained rupture of the LV free wall could not be excluded. The patient was intubated and transferred to our hospital for further management. Upon arrival to our institution, imaging was performed, which confirmed the presence of a large anterolateral/inferolateral LV aneurysm with severely reduced ejection fraction (EF) to 30% (Figure). The patient was noted to be in multiorgan failure secondary to CS, and the decision was made to place an Impella 5.0 as a bridge to decision. The patient was maintained on Impella 5.0 for hemodynamic support for 18 days post-operatively, until, on hospital day 32, the patient expired due to septic shock from C. difficile colitis. Conclusion Impella 5.0 is currently indicated for use in patients with cardiogenic shock and for high risk PCI. Scant literature exists to support the use of Impella as a bridge to decision or namely bridge to permanent left ventricular assist device or bridge to heart transplant; in these investigations, mean duration of support ranges from approximately 0 to 13 days. The utility of Impella has not been studied in patients with LV aneurysm. Our case suggests that the Impella 5.0 can be used in patients with LV aneurysm for hemodynamic support for an extended clinical course.

Predictive ability of ACEF and ACEF II score in patients undergoing percutaneous coronary intervention in the GLOBAL LEADERS study

BackgroundACEF score has been shown to have predictive ability in the patients undergoing percutaneous coronary intervention (PCI). The ACEF II score has recently been developed to predict short-term mortality after cardiac surgery. We compared the predictive ability of the ACEF and ACEF II scores to predict mortality after PCI in the all-comers population. MethodsThe ACEF and ACEF II scores were calculated in 15,968 patients enrolled in the GLOBAL LEADERS study. Discrimination and calibration were assessed for outcomes after PCI. Recalibration of the regression model by updating the intercept and slope were performed to adjust the original ACEF model to the PCI setting. In a stratified approach, patients were divided into quintiles according to the score. Outcomes were compared between quintiles. ResultsThe ACEF and ACEF II score were available in 14,941 and 14,355 patients respectively. Discrimination for 30-day all-cause mortality was acceptable for both scores (C-statistic ACEF 0.75 and ACEF II 0.77). For 2-year all-cause mortality, the discrimination of ACEF score was acceptable (C-statistic 0.72) while the discrimination of ACEF II score was moderate (C-statistic 0.69). Both scores identified patients at high risk of mortality but overestimated all-cause mortality at 30 days in all quintiles. After recalibration, agreement between predicted and observed 30-day all-cause mortality in both scores are close to the identity line. ConclusionsThe ACEF II model did not improve the predictive ability of the ACEF score. Recalibrated ACEF model can be used to estimated all-cause mortality rate at 30 days after PCI.

Successful contemporary reverse controlled antegrade and retrograde subintimal tracking without contrast medium: a case report

BackgroundContrast-induced acute kidney injury is one of the common adverse events related to percutaneous coronary intervention and a predictor for worse outcome. In the setting of percutaneous coronary intervention for chronic total occlusion, large amounts of contrast medium, more than 200–400 mL, are generally injected. A higher dose of contrast medium causes contrast-induced acute kidney injury more frequently. Therefore, patients who undergo chronic total occlusion-percutaneous coronary intervention are at risk for contrast-induced acute kidney injury.Case presentationWe present the case of a 77-year-old Japanese man with post-acute myocardial infarction angina pectoris, heart failure, and chronic kidney disease who underwent percutaneous coronary intervention for chronic total occlusion in his right coronary artery. In the procedure, the retrograde wire was a visible penetration mark that made contrast medium unnecessary. Contemporary reverse controlled antegrade and retrograde subintimal tracking was successfully achieved and stents were implanted without contrast medium. Contrast medium was injected two times after stent implantation to confirm coronary flow and no perforation. The total amount of contrast medium was only 8 mL for chronic total occlusion-percutaneous coronary intervention.ConclusionChronic total occlusion-percutaneous coronary intervention with contemporary reverse controlled antegrade and retrograde subintimal tracking without contrast medium may be safe and feasible in selected patients.

Transcoronary pacing

Transcoronary pacing is auseful therapeutic option for the treatment of unheralded bradycardias in the setting of percutaneous coronary interventions (PCI). In the present study, we investigated the influence of stent implantation and transient myocardial ischemia on the feasibility of transcoronary pacing in aporcine model. 7adult pigs underwent apercutaneous coronary intervention with implantation of acoronary stent under general anaesthesia in an animal catheterization laboratory. Transcoronary pacing was established by using astandard guidewire isolated with an angioplasty balloon positioned in the periphery of the right coronary artery serving as the cathode. As the indifferent anode, askin patch electrode at the back of the animal was used. The reliability of transcoronary pacing was assessed by measurement of threshold and impedance data and the magnitude of the epicardial electrogram at baseline, after implantation of acoronary stent and finally during myocardial ischemia. Effective transcoronary pacing could be demonstrated in all cases with the standard unipolar transcoronary pacing setup yielding alow pacing threshold at baseline of 1.3 ± 0.8 V with an impedance of 283 ± 67 Ω. Implantation of acoronary stent did not influence the pacing threshold (1.0 ± 0.4 V) and impedance (262 ± 63 Ω). Acute myocardial ischemia lead to asignificant but clinically nonrelevant increase of the pacing threshold to 2.0 ± 0.6 V and adrop in pacing impedance (137 ± 39 Ω). Transcoronary pacing in the animal model is not affected by implantation of acoronary stent in the same vessel used for pacing. Despite asignificant increase in pacing threshold, the transcoronary pacing approach is reliable in acute myocardial ischemia during apercutaneous coronary intervention.

Association Between Maximal Activated Clotting Time and Major Bleeding Complications During Transradial and Transfemoral Percutaneous Coronary Intervention

ObjectivesThis study sought to determine whether higher maximal activated clotting time (ACT) during transradial (TR) percutaneous coronary intervention (PCI) is associated with greater bleeding risk. BackgroundHigher maximal ACT during transfemoral (TF) PCI has been associated with a greater bleeding risk. It is unclear whether this relationship exists in the setting of TR PCI. MethodsAmong 14,637 patients undergoing TR or TF PCI with unfractionated heparin monotherapy, the study related maximal ACT to the risk of major bleeding. In secondary analyses, the study related maximal ACT to composites of in-hospital death, myocardial infarction (MI), or stroke and in-hospital death, MI, or urgent target vessel revascularization. Multivariable logistic regression was employed to compare outcomes in the third with the first and second maximal ACT tertiles. ResultsMore major bleeding occurred at ACT >290 s versus ≤290 s following TF (7.7% vs. 5.8%; p = 0.006) but not TR PCI (1.7% vs. 2.4%; p = 0.18). After adjustment, major bleeding risk remained significantly higher at ACT >290 s versus ACT ≤290 s among TF (odds ratio: 1.28; 95% confidence interval: 1.02 to 1.62; p = 0.036) but not TR PCI (odds ratio: 0.72; 95% confidence interval: 0.42 to 1.22; p = 0.22). Maximal ACT was not related to the incidence of composite death, MI, or stroke or death, MI, or urgent target vessel revascularization following TF or TR PCI. ConclusionsHigher maximal ACT is associated with a greater risk of major bleeding following TF PCI than TR PCI.

Evaluation of the safety and efficacy of an edoxaban-based antithrombotic regimen in patients with atrial fibrillation following successful percutaneous coronary intervention (PCI) with stent placement: Rationale and design of the ENTRUST-AF PCI trial

The optimal antithrombotic treatment after percutaneous coronary intervention (PCI) with stenting in patients with atrial fibrillation (AF) is unknown. In the ENGAGE AF-TIMI 48 trial, edoxaban was noninferior to a vitamin K antagonist (VKA) with respect to the prevention of stroke or systemic embolism and was associated with significantly lower rates of bleeding and cardiovascular death in patients with nonvalvular AF. The effects of edoxaban in combination with single- or dual-antiplatelet therapy in the setting of PCI are unexplored. The ENTRUST-AF PCI trial is a multinational, multicenter, randomized, open-label phase 3b trial with blinded end point evaluation involving 1,500 patients on oral anticoagulation for AF. Patients are randomized between 4 hours and 5 days after successful PCI to either an edoxaban-based strategy (experimental arm; 60 mg [or 30 mg according to dose reduction criteria] once daily plus a P2Y12 antagonist [default clopidogrel, 75 mg once daily] for 12 months) or a VKA-based strategy (control arm; VKA plus a P2Y12 antagonist [as above] plus acetylsalicylic acid [100 mg once daily] for 30 days to 12 months). The primary safety end point is the incidence of International Society on Thrombosis and Haemostasis-defined major or clinically relevant nonmajor bleeding. The main efficacy end point is the composite of cardiovascular death, stroke, systemic embolic events, spontaneous myocardial infarction, and definite stent thrombosis. The ENTRUST-AF PCI trial tests the hypothesis that an edoxaban-based antithrombotic strategy reduces the risk of bleeding complications after PCI compared with VKA plus conventional dual-antiplatelet therapy in patients with AF in need of oral anticoagulation. The relative risk of ischemic events between groups will be compared.

Pre-loading therapy with statins in patients with angina and acute coronary syndromes undergoing PCI.

Statins constitute the most powerful class of drugs for cardiovascular risk reduction associated to atherosclerosis. Their important pharmacological properties include reduction of serum lipid concentrations and non-lipid related, pleotropic effects such as anti-inflammatory action. Previous largescale randomized studies have demonstrated the beneficial effects of statin loading prior to elective percutaneous coronary intervention (PCI) for the reduction of periprocedural myocardial infarction and prevention of major adverse cardiac events at 30 days. The present review summarizes the data from major randomized trials that evaluated the clinical benefit of statin pretreatment in the setting of PCI resulting in a better understanding of their impact on reduction of interventional complications.

Comparative Effectiveness and Safety Analysis of Dual Antiplatelet Therapies Within an Integrated Delivery System.

Dual antiplatelet therapy is a mainstay of care for percutaneous coronary intervention (PCI) patients; however, uncertainty exists in real-world practice about comparative effectiveness and safety outcomes. To evaluate outcomes of different oral P2Y12 inhibitors in PCI patients. We retrospectively studied patients treated between July 1, 2010, and December 31, 2013. Patients received clopidogrel, prasugrel, ticagrelor, or more than 1 antiplatelet (switch) during PCI. Outcomes were evaluated for major adverse cardiovascular events (MACE) and bleeding at 1 year. Propensity score matching with Cox proportional hazards analysis was used to determine predictors of MACE and bleeding. A total of 8127 patients were included: clopidogrel (n = 6872), prasugrel (n = 605), ticagrelor (n = 181), and switch (n = 469). Treatment with prasugrel was associated with the lowest risk of MACE using multivariate regression (odds ratio [OR] = 0.57; 95% CI = 0.36-0.92; P = 0.02). In the propensity score-matched analysis, only the prasugrel group was associated with a lower risk of MACE compared with the clopidogrel group. Clopidogrel was associated with the lowest risk of major bleeding using multivariate regression (OR = 0.64; 95% CI = 0.42-0.98; P = 0.042). Both ticagrelor (hazard ratio [HR] = 2.00; 95% CI = 1.11-3.59) and the switch groups (HR = 1.65; 95% CI = 1.09-2.50) were associated with a greater risk of major bleeding compared with clopidogrel. However, no differences were found in the propensity score-matched analysis. Dual antiplatelet therapies differed in both MACE and bleeds in a real-world setting of PCI. Prasugrel was associated with fewer MACE, whereas clopidogrel had fewer major bleeding events.

Comparison of Transradial and Transfemoral Access for Coronary Bypass Graft Angiography

Introduction: Transradial access has been shown to be safe and effective in the setting of percutaneous coronary intervention (PCI) and even being benefi cial in regards to vascular complications and perceived quality of life after the intervention.

Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percutaneous coronary interventions for markedly angulated bifurcated lesions.

In practical settings of percutaneous coronary intervention (PCI), we sometimes encounter difficulty in introducing a guidewire (GW) to the markedly angulated side branch (SB), and the reverse wire technique is considered as a last resort to overcome such a situation. We analyzed 12 cases that underwent PCI with dual-lumen microcatheter-facilitated reverse wire technique between January 2013 and July 2016. We retrospectively investigated the lesion's characteristics and the details of the PCI procedures, and discussed tips about the use of this technique. The SB that exhibits both a smaller take-off angle and a larger carina angle is considered to be the most suitable candidate for this technique. The first step of this technique involves the delivery of the reverse wire system to the target bifurcation. However, most cases exhibit significant stenosis proximal to the bifurcation, which often hampers the delivery of the reverse wire system. Because the sharply curved reverse wire system is easier to pass the stenosis as compared to the roundly curved system, we recommend a sharp curve should be adopted for this technique. On the other hand, it is sure that device delivery is much easier on the GW with a round curve as compared to that with a sharp curve. Therefore, it is important to modify the details of this procedure on a case-by-case basis according to the lesion's characteristics.

Consensus or Controversy?: Evolution of Criteria for Myocardial Infarction After Percutaneous Coronary Intervention.

The definition and the clinical implications of myocardial infarction (MI) occurring in the setting of percutaneous coronary intervention have been subjects of unresolved controversy. As a result of the use of more sensitive diagnostic tools such as cardiac troponin, the expanding evidence, and the ensuing debate, the definition of procedural MI (pMI) has evolved, leading to several revisions, different proposed definitions, and lack of standardization in randomized clinical trials. In this review, we will describe the key clinical data on cardiac biomarkers, creatine kinase isoenzyme MB and cTn, in the setting of percutaneous coronary intervention and the main issues that have lead to various consensus documents with a proposed definition of pMI. We will focus on the rationale of the current "Third Universal Definition of Myocardial Infarction" and of the alternative approach proposed by the Society for Cardiovascular Angiography and Interventions. The definition of pMI is an evolving field where the Third Universal MI definition represents the best attempt to date to incorporate available evidence along with scientific and clinical judgment into criteria to ensure adequate specificity in the diagnosis and the relevant prognostic significance, while trying to maintain sensitivity. Questions on the recommended criteria and their practical implementation remain, but the Third Universal definition document represents an important milestone toward a better standardization and enhanced consensus on the pMI definition.

The double guidewire approach for transcoronary pacing in aporcine model.

Transcoronary pacing is used for treatment of unheralded bradycardias in the setting of percutaneous coronary interventions (PCI). In the present study we introduced anew concept - the double guidewire approach - for transcoronary pacing in aporcine model. Transcoronary pacing was applied in 16adult pigs under general anaesthesia in an animal catheterization laboratory. Aspecial guidewire with electrical insulation by PTFE coating except for the distal part of the guidewire was positioned in the periphery of acoronary artery serving as the cathode. As the indifferent anode, an additional standard floppy tip guidewire was advanced into the proximal part of the same coronary vessel. The efficacy of double guidewire transcoronary pacing was assessed by measurement of threshold and impedance data and the magnitude of the epicardial electrogram compared with unipolar transcoronary pacing using astandard cutaneous patch electrode as indifferent anode. Transcoronary pacing was effective in all cases. Pacing thresholds obtained with the double guidewire technique (1.5± 0.9 V) were similar to those obtained by standard unipolar transcoronary pacing with acutaneous patch electrode (1.2± 0.7 V) and unipolar transvenous pacing against the same cutaneous patch electrode (1.5± 1.0 V). Bipolar transvenous pacing yielded the lowest pacing threshold at 0.8± 0.4 V. Transcoronary pacing in the animal model with the novel "double guidewire approach" is asimple and effective pacing technique with comparable pacing thresholds obtained by standard unipolar transcoronary and transvenous pacing.

TCT-50 Impact of a bifurcation culprit lesion in ST elevation myocardial infarction: procedural success, clinical outcome and 5-year follow-up.

Coronary artery bifurcation is a challenging scenario for percutaneous coronary intervention (PCI). We aimed to assess the impact of a bifurcation culprit lesion in the setting of primary PCI for ST elevation myocardial infarction (STEMI). From 2747 STEMI patients (January 2004 to January 2015)

Use of Dual Antiplatelet Therapy and Patient Outcomes in Those Undergoing Percutaneous Coronary Intervention: The ROCKET AF Trial.

The authors assessed the use of dual antiplatelet therapy (DAPT) and outcomes in patients undergoing percutaneous coronary intervention (PCI) during the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation). The frequency, patterns, and outcomes when adding DAPT to non-vitamin K antagonist oral anticoagulants in the setting of PCI in patients with AF are largely unknown. The study population included all patients in the treatment group of the ROCKET AF trial divided by the receipt of PCI during follow-up. Clinical characteristics, PCI frequency, and rates of DAPT were reported. Clinical outcomes were adjudicated independently as part of the trial. Among 14,171 patients, 153 (1.1%) underwent PCI during a median 806 days of follow-up. Patients treated with rivaroxaban were significantly less likely to undergo PCI compared with warfarin-treated patients (61 vs. 92; p=0.01). Study drug was continued during PCI in 81% of patients. Long-term DAPT (≥30 days) was used in 37% andsingle antiplatelet therapy in 34%. A small number switched from DAPT to monotherapy within 30 days of PCI (n=19 [12.3%]) and 15% of patients received no antiplatelet therapy after PCI. Rates of stroke/systemic embolism and major bleeding events were high in post-PCI patients (4.5/100 patient-years and 10.2/100 patient-years) in both treatment groups. In patients with AF at moderate to high risk for stroke, PCI occurred in<1% per year. DAPT was used in a variable manner, with the majority of patients remaining on study drug after PCI. Rates of both thrombotic and bleeding events were high after PCI, highlighting the need for studies to determine the optimal antithrombotic therapy.

Heparin Versus Bivalirudin in Acute Myocardial Infarction: Unfractionated Heparin Monotherapy Elevated to Primary Treatment in Contemporary Percutaneous Coronary Intervention.

Bivalirudin, a direct thrombin inhibitor, was developed as an antithrombin agent for patients undergoing percutaneous coronary interventions (PCI) with the hypothesis that it would reduce bleeding complications without compromising the rate of ischemic events compared to heparin plus GP IIb/IIIa inhibitors. Although the cumulative evidence makes a strong argument for the use of bivalirudin rather than heparin plus systematic GP IIb/IIIa inhibitors for the great majority of patients with acute myocardial infarction (AMI) undergoing PCI, the benefit observed with bivalirudin was achieved because of the major bleeding complications with the use of heparin plus GP IIb/IIIa inhibitors. When bivalirudin was compared with unfractionated heparin alone there was no benefit in ischemic complications with a decrease in major bleeding. However, in a recent large randomized controlled trial comparing bivalirudin with unfractionated heparin alone in AMI patients undergoing primary PCI, bivalirudin did not reduce bleeding complications and was associated with higher rates of stent thrombosis, myocardial reinfarction, and repeat revascularization compared with heparin. Moreover, a very recent meta-analysis shed more insights on the utilization of bivalirudin versus heparin regimens during PCI. Findings from this meta-analysis suggest that routine use of bivalirudin offers little advantage over heparin among PCI patients. In a detailed analysis of some randomized trials and observational studies with bivalirudin in AMI patients done by myself and published almost five years ago in this journal, I rendered some reflections on the future widespread use of bivalirudin. “In the setting of PCI in AMI patients, and in the absence of GP IIb/IIIa inhibitors, bivalirudin did not offer any beneficial effect in the incidence of the composite end points when compared with heparin alone. For now, in real world practice, one would probably choose a well known cheaper drug that has already passed the test of time, heparin. There may be reinforcement in the sole utilization of heparin confining GP IIb/IIIa inhibitors and other intravenous antithrombotics to bailout therapy for periprocedural PCI complications in AMI patients”. Therefore, instead of being the beginning of a new era with bivalirudin, it sure is a welcome back to an old friend, heparin. Indeed, after more than two decades, it is always good to welcome back an old friend, unfractionated heparin, as monotherapy and preferred anticoagulant regimen for contemporary PCI in AMI patients.

Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

Several antiplatelet medications used during and after percutaneous coronary intervention (PCI) are contraindicated for specific patient groups. A broad assessment of contraindicated medication use and associated clinical outcomes is not well described. Using national Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data for all PCI between 2007 and 2013, we evaluated patients with contraindications to commonly used antiplatelet medications during and after PCI, defined in accordance with package inserts. Adjusted association between contraindicated medication use and outcomes of periprocedural bleeding and 30-day mortality were assessed using Cox proportional hazards with inverse probability weighting. Among 64 294 patients undergoing PCI, 11 315(17.6%) had a contraindication to a common antiplatelet medication and 737 (6.5%) of these patients received a contraindicated medication. In unadjusted analyses, any contraindicated medication use was associated with both increased bleeding and 30-day mortality. In adjusted models, contraindicated abciximab use in patients with thrombocytopenia (hazard ratio, 2.23; 95% confidence interval, 1.58-3.16) and in patients with a previous stroke (hazard ratio, 1.93; 95% confidence interval, 1.37-2.71) remained significantly associated with increased bleeding. Contraindicated abciximab use was not significantly associated with 30-day mortality in adjusted models. Use of eptifibatide in dialysis patients was not significantly associated with an increased risk of bleeding or mortality. In this national cohort, ≈18% of patients undergoing PCI had contraindications to common antiplatelet medications. Approximately 6% of those patients received a contraindicated medication with attendant bleeding risk, although this did not translate into significantly higher risk of 30-day mortality. Continued efforts to reduce contraindicated medication use may help avoid periprocedural complications.

THE HIGH COST OF CONTRAST-INDUCED ACUTE KIDNEY INJURY IN PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTIONS

While contrast-induced acute kidney injury (CI-AKI) in the setting of percutaneous coronary interventions (PCI) is known to be associated with increased morbidity and mortality, the financial cost of this complication is unknown. Risk and price-adjusted 90-day episode costs from the Michigan Value