Successful Percutaneous Intervention Research Articles

Successful Percutaneous Lymphatic Intervention for Chylothorax after Pediatric Heart Transplantation

Purpose Chylothorax after pediatric heart transplantation (HTX) is a highly morbid and challenging disease often refractory to therapies including thoracic duct ligation or pleurodesis. We report our novel approach to lymphatic imaging and percutaneous intervention for chylothorax after HTx in children. Methods We reviewed our center's data on children with post-HTx chylothorax who underwent dynamic contrast-enhanced magnetic resonance lymphangiography (DCRL) and lymphatic embolization between November 2014 and November 2017. Results Four children (50% male, median age 5 ± 45 months) were referred for post-HTx chylothorax. Three underwent HTx for congenital heart disease (including 1 single ventricle) and 1 for dilated cardiomyopathy. Three had chylothorax immediately post-HTx associated with superior caval anastomosis obstruction or diastolic dysfunction and 1 developed chylothorax 6 months post-HTx during antibody-mediated rejection. Lymphatic imaging demonstrated abnormal pulmonary lymphatic perfusion syndrome in all 4 patients, with percutaneous interventions performed including thoracic duct or channel embolization (Figure: right - fluoroscopic image of contrast injected into thoracic duct; left - DCMRL inguinal lymph node injection; arrow highlight abnormal pulmonary perfusion; arrowhead identify thoracic duct). All 4 patients with chylothorax had complete resolution with a median 6.5 days from intervention to chest tube removal. Conclusion Chylothorax after pediatric HTx may result from abnormal pulmonary lymphatic perfusion that can be successfully treated with percutaneous lymphatic embolization. Factors associated with pulmonary lymphatic diseases after pediatric HTx include congenital heart disease and elevated central venous pressure due to SVC obstruction or rejection-mediated diastolic dysfunction. Chylothorax after pediatric heart transplantation (HTX) is a highly morbid and challenging disease often refractory to therapies including thoracic duct ligation or pleurodesis. We report our novel approach to lymphatic imaging and percutaneous intervention for chylothorax after HTx in children. We reviewed our center's data on children with post-HTx chylothorax who underwent dynamic contrast-enhanced magnetic resonance lymphangiography (DCRL) and lymphatic embolization between November 2014 and November 2017. Four children (50% male, median age 5 ± 45 months) were referred for post-HTx chylothorax. Three underwent HTx for congenital heart disease (including 1 single ventricle) and 1 for dilated cardiomyopathy. Three had chylothorax immediately post-HTx associated with superior caval anastomosis obstruction or diastolic dysfunction and 1 developed chylothorax 6 months post-HTx during antibody-mediated rejection. Lymphatic imaging demonstrated abnormal pulmonary lymphatic perfusion syndrome in all 4 patients, with percutaneous interventions performed including thoracic duct or channel embolization (Figure: right - fluoroscopic image of contrast injected into thoracic duct; left - DCMRL inguinal lymph node injection; arrow highlight abnormal pulmonary perfusion; arrowhead identify thoracic duct). All 4 patients with chylothorax had complete resolution with a median 6.5 days from intervention to chest tube removal. Chylothorax after pediatric HTx may result from abnormal pulmonary lymphatic perfusion that can be successfully treated with percutaneous lymphatic embolization. Factors associated with pulmonary lymphatic diseases after pediatric HTx include congenital heart disease and elevated central venous pressure due to SVC obstruction or rejection-mediated diastolic dysfunction.

Better Outcomes with New P2Y12 Antiplatelet Agents in ACS Patients in Australia

Objective: To determine the outcome of patients who received new P2Y12 antiplatelet agents (Ticagrelor or Prasugrel) compared with Clopidogrel following successful percutaneous intervention (PCI) for acute coronary syndrome (ACS). Methods: Retrospective analysis on patients undergoing successful PCI for ACS between January 2006 and June 2017. Follow-up was after one year with letter, phone call and file review. Results: 4941 patients (76% male) underwent successful PCI (57% BMS vs 43% DES) for ACS. In addition to aspirin, 87% of patients received Clopidogrel compared with 13% treated with new agents (mean age 64.4 and 59.3 years respectively). The use of new P2Y12 agents increased from 3.2% in 2010 to 28.5% in 2017. In 2017, new P2Y12 agents were used in 58% of STEMI, 32% of NSTEMI and 10% of unstable angina patients. Univariate analysis demonstrated that new P2Y12 agents were associated with lower incidence of death (2.44% vs 4.58% p = 0.01) and major adverse cardiac events (MACE) (7.46% vs 9.90% p = 0.04) but increased bleeding risk (BARC 2–3) (2.13% vs 1.05% p = 0.0176) at 1 year. There was no significant difference in myocardial infarction (2.74% vs 2.85% p = 0.87) or target lesion revascularisation (2.28% vs 3.13% p = 0.2). On multivariate analyses (including STEMI, cardiac arrest and shock), the new agents were an independent predictor of lower mortality (HR 1.85; 95%CI 1.11–3.28). Conclusions: The use of new P2Y12 agents in ACS was associated with lower mortality and MACE, but higher bleeding events. The higher bleeding rates with new P2Y12 agents may partly explain why these agents were under-utilised.

In-hospital major arrhythmias, arrhythmic death and resuscitation after successful primary percutaneous intervention for acute transmural infarction: a retrospective single-centre cohort study

BackgroundTransmural acute myocardial infarction (AMI) is associated with a high risk for ventricular arrhythmia before, during and after treatment. Consequently, it is recommended that patients diagnosed with transmural AMI be monitored in a cardiac care unit (CCU) so life-threatening arrhythmias can be treated promptly. We examined the incidence and timing of in-hospital malignant ventricular arrhythmias, sudden cardiac or arrhythmic death (SCD/AD) and resuscitation requirements in patients with transmural AMI recovering from percutaneous coronary intervention (PCI) undertaken within 12 h of symptom onset and without antecedent thrombolysis.MethodsThis was a retrospective cohort study using the Duisburg Heart Center (Germany) cardiac patient registry. In total, 975 patients met the inclusion criteria. The composite endpoint was post-PCI ventricular fibrillation or tachycardia, SCD/AD or requirement for resuscitation. We compared the demographic and clinical characteristics of patients who met the composite endpoint with those who did not, recorded the timing of endpoint episodes, and used multivariable logistic regression analysis to identify factors associated with the endpoint criteria.ResultsThere was no significant difference in the length of CCU or hospital stay between the groups. In-hospital mortality was 6.5%, and the composite endpoint was met in 7.4% of cases. Malignant ventricular tachyarrhythmia occurred in 2.8% of the patients, and SCD/AD occurred in 0.3% of the cases. There was a biphasic temporal distribution of endpoint events; specifically, 76.7% occurred < 96 h after symptom onset, and 12.6% occurred 240–360 h after symptom onset. Multivariable regression analysis identified positive associations between an endpoint episode and the following: age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05] per year); left ventricular ejection fraction (LVEF) < 30% (OR 3.66, 95% CI 1.91–6.99); peak serum creatine phosphokinase concentration (OR 1.01, 95% CI 1.00–1.02 per 100 U/dl); leucocytosis (OR 1.86, 95% CI 1.04–3.32), and coronary thrombus (OR 1.85, 95% CI 1.04–3.27).ConclusionsMost post-PCI malignant ventricular arrhythmias, SCD/AD and resuscitation episodes occurred within 96 h of transmural AMI (76.7%). A substantial minority (12.6%) of these events arose 240–360 h after symptom onset. Further study is needed to establish the influence of age, LVEF < 30%, peak serum creatine phosphokinase concentration, leucocytosis and coronary thrombus on post-PCI outcomes after transmural AMI.

Successful Percutaneous Intervention for Chronic Total Occlusion of Left Subclavian Artery

Introduction: Subclavian artery stenosis is most commonly caused by atherosclerotic disease. Surgical treatment is associated with high morbidity and mortality. Intervention is generally reserved for the management of symptomatic patients who present with upper limb ischemia, Vertebrobasilar symptoms and subclavian steal syndrome. Endovascular stenting is preferred over surgery because of high success rate, less invasive and minimal complications. Case report: Here we report a case of 56-year-old female patient with history of hypertension and diabetes presented with dizziness, vertigo and left arm claudication with use of her left upper extremity since last six months. She was diagnosed as a case of subclavian steal syndrome. Treatment: Patient underwent successful Percutaneous Transluminal Angioplasty (PTA) of the left subclavian artery with marked improvement of symptoms at follow-up. Patient was monitored with Duplex ultrasound of left subclavian artery, measurement of BP and examination of pulse at each visit. Conclusion: PTA is an effective and safe with high success rate, less invasive and minimal complications when compared to surgery for the treatment of symptomatic subclavian artery stenosis. However, regular clinical and duplex ultrasound assessment of subclavian artery is necessary after angioplasty for monitoring restenosis.

Factors influencing no-reflow phenomenon in patients with ST-segment myocardial infarction treated with primary percutaneous coronary intervention

Background/Aim. It is not know which factors influence no-reflow phenomenon after successful primary percutaneous intervention (pPCI) in patients with myocardial infarction with ST elevation (STEMI). The aim of this study was to estimate predictive value of some admission characteristics of patients with STEMI, who underwent pPCI, for the development of no-reflow phenomenon. Worse clinical outcome in patients with no-reflow points to importance of selection and aggressive treatment in a group at high risk. Methods. This was retrospective and partly prospective study which included 491 consecutive patients with STEMI, admitted to a single centre, during the period from 2000 to September 2015, who underwent pPCI. Descriptive characteristics of the patients, presence of classical risk factors for cardiovascular disease, total ischemic time and clinical features at admission were all estimated as predictors for the development of no-reflow phenomenon. No-reflow phenomenon is defined as the presence of thrombolysis in myocardial infarction (TIMI) &lt; 3 coronary flow at the end of the pPCI procedure, or ST-segment resolution by less than 50% in the first hours after the procedure. The significance of the predictive value of some parameters was evaluated by univariate and multivariate regression analysis. In univariate analysis, we used the ?2 test and Mann Whitney and Student's t-tests. Results. No-reflow phenomenon was detected in 84 (17.1%) patients (criteria used: TIMI &lt; 3 coronary flow) and in 144 (29.3%) patients (criteria used: STsement resolution &lt; 50%). Patients older than 75 years [odds ratio (OR) = 2.53; 95% confidence interval (CI) 1.48? 4.33; p = 0.001] and those who had Killip class at admission higher than 1 had increased risk to achieve TIMI-3 flow after pPCI. Killip class higher than 1 (OR 1.59; 95% CI 1.23? 2.04; p &lt; 0.001), left anterior descendent artery (LAD) as infarct related artery (IRA) and total ischemic time higher than 4 hour were associated with increased risk to failure of rapid ST segment resolution after pPCI. Conclusion. Older age and Killip class were main predictors of TIMI &lt; 3 flow, and Killip class, LAD as IRA and longer total ischemic time were predictors for the failure of rapid ST segment resolution after pPCI.

Balloon dilatation for treatment of hepatic venous outflow obstruction following pediatric liver transplantation

AIMTo assess the efficacy and safety of balloon dilatation for the treatment of hepatic venous outflow obstruction (HVOO) following pediatric liver transplantation.METHODSA total of 246 pediatric patients underwent liver transplantation at our hospital between June 2013 and September 2016. Among these patients, five were ultimately diagnosed with HVOO. Seven procedures (two patients underwent two balloon dilatation procedures) were included in this analysis. The demographic data, types of donor and liver transplant, interventional examination and therapeutic outcomes of these five children were analyzed. The median interval time between pediatric liver transplantation and balloon dilatation procedures was 9.8 mo (range: 1-32).RESULTSFive children with HVOO were successfully treated by balloon angioplasty without stent placement, with seven procedures performed for six stenotic lesions. All children underwent successful percutaneous intervention. Among these five patients, four were treated by single balloon angioplasty, and these patients did not develop recurrent stenosis. In seven episodes of balloon angioplasty across the stenosis, the pressure gradient was 12.0 ± 8.8 mmHg before balloon dilatation and 1.1 ± 1.5 mmHg after the procedures, which revealed a statistically significant reduction (P < 0.05). The overall technical success rate among these seven procedures was 100% (7/7), and clinical success was achieved in all five patients (100%). The patients were followed for 4-33 mo (median: 15 mo). No significant procedural complications or procedure-related deaths occurred.CONCLUSIONBalloon dilatation is an effective and safe therapeutic option for HVOO in children undergoing pediatric liver transplantation. Venous angioplasty is also recommended in cases with recurrent HVOO.

Management and predictors of outcome in unselected patients with cardiogenic shock complicating acute ST-segment elevation myocardial infarction: results from the Bremen STEMI Registry.

Patients with ST-segment elevation myocardial infarction (STEMI) and consecutive cardiogenic shock (CS) represent a challenge in clinical practice. Only few 'real-world' data on therapeutic management and outcome exist. The present analysis focuses on changes of clinical management of STEMI-patients with CS and analyzes predictors of outcome using the Bremen-STEMI registry. Out of 7865 patients with STEMI, 981 patients (13%) presented with CS. Most CS patients (88%) underwent an early percutaneous intervention (PCI). Intraaortic balloon pumps (IABP) were less implanted since 2013 (p < 0.001), the rate of drug-eluting stents and periprocedural prasugrel or ticagrelor therapy increased over the years. Overall in-hospital mortality of patients with CS was 37%, 1year mortality was 50%. A significantly reduced 1-year mortality (2006-2009: 55%, 2010-2013: 50%; 2014-2015: 43%, p = 0.027) was observed. In a multivariate analysis significant predictors of an increased 1-year mortality were acute renal failure (OR 3.6; 95% CI 1.9-7.0), atrial fibrillation (OR 2.8; 95% CI 1.3-6.0), three-vessel disease (OR 2.5; 95% CI 1.3-4.7), age ≥ 75years (OR 2.4, 95% CI 1.3-4.4) and anemia (OR 1.9; 95% CI 1.1-3.3). A successful performed PCI (OR 0.5, 95% CI 0.2-0.9) was associated with a significantly reduced 1-year mortality. management of patients with CS changed with a steep decrease of IABP implantations. Mortality of patients with CS decreased over the last 10years. Especially, performance of successful PCI was associated with a reduction of mortality, indicating the crucial role of early revascularization to improve prognosis in this high-risk cohort of STEMI-patients.

TCT-723 Clinical and Angiographic Predictors of No-Reflow Phenomenon in ST Segment Elevation Myocardial Infarction Treated with Successful Primary Percutaneous Intervention

In ST segment elevation myocardial infarction (STEMI) primary percutaneous coronary intervention remains the optimal treatment modality to restore normal epicardial coronary artery blood flow. However, despite successful PCI a small, but still significant proportion of patients continue to present

Successful Percutaneous Intervention of the Left Main and Right Coronary Arteries in the Same Session

Left main coronary artery (LMCA) stenosis is a relatively infrequent but important cause of symptomatic coronary artery disease. Patients who have LMCA stenosis experience a high rate of complications during or shortly after catheterization. In this case, we present a 84 years old woman with subacute inferior myocardial infarction and confirmed diagnosis of both LMCA and right coronary ostial severe stenosis who was successfully managed with percutaneous coronary intervention in the same session due to the sudden development of cardiogenic shock.

Factors Affecting Patency following Successful Percutaneous Intervention for Dysfunctional Hemodialysis Vascular Access

This study aimed to investigate the patency following initial successful percutaneous transluminal angioplasty (PTA) for untreated dysfunctional hemodialysis vascular access and to identify predictors of PTA durability. This retrospective observational study included data of 132 consecutive initial PTA of hemodialysis vascular access in 126 patients who showed immediate technical and clinical success and had at least 1year of follow-up data. The mean duration of primary and secondary patency post-PTA was 16 and 27months, respectively. On multivariate adjusted Cox regression analysis, dyslipidemia (P<0.001), use of insulin (P=0.016), and arteriovenous graft (AVG) (P=0.016) were significantly associated with shorter primary patency. Dyslipidemia (P<0.001), use of antiplatelet medication (P=0.013), and failed vascular access (P=0.004) were significant predictors of secondary patency loss. Use of statin was the only clinical variable associated with increased primary and secondary patency (P<0.001). According to a subgroup analysis on the type of vascular access and dysfunction, primary and secondary patency rates were significantly higher in the arteriovenous fistula (AVF) and failing vascular access groups than AVG and failed vascular access groups, respectively. Early dysfunction (within 6months) was significantly higher in the AVG and failed vascular access groups after initial PTA, but there was no significant difference after multiple PTAs. Post-PTA primary and secondary patency rates were significantly higher with AVF and failing vascular access. The use of statin was associated with increased primary and secondary patency after initial successful PTA in this study.

Prognostic Association of Circulating Neutrophil Count with No-Reflow in Patients with ST-Segment Elevation Myocardial Infarction following Successful Primary Percutaneous Intervention.

Objective The aim of the present study was to investigate the predictive value of neutrophil count for no-reflow in patients with ST-segment elevation myocardial infarction (STEMI) who underwent successful primary percutaneous intervention (PCI). Methods We conducted a retrospective study of 361 patients diagnosed with acute STEMI between 2011 and 2015. All patients underwent successful PCI within 12 h from the onset of symptoms. Angiographic no-reflow was diagnosed based on a post-PCI thrombolysis in myocardial infarction flow grade ≤ 2 without mechanical obstruction. According to a neutrophil count cut-off determined by receiver operating characteristic curve analysis, patients were divided into two groups: group A (neutrophil count < 9.14 × 109/L) and group B (neutrophil count ≥ 9.14 × 109/L). Results Compared to patients in the normal reflow group, patients with no-reflow had higher neutrophil counts (P < 0.05). The incidence rate of no-reflow in group A (18, 9.3%) was significantly lower than that in group B (38). Multivariate logistic regression analysis revealed that a neutrophil count ≥ 9.14 × 109/L was independently predictive for no-reflow (odds ratio = 4.474, 95% confidence interval: 1.610–12.433, P = 0.004) after adjusting for potential confounders. Conclusions A circulating neutrophil count ≥ 9.14 × 109/L is independently associated with no-reflow in patients with acute STEMI following primary PCI.

Modifying risks to improve outcome in cardiac surgery: An anesthesiologist's perspective.

Challenging times are here for cardiac surgical and anesthesia team. The interventional cardiologist seem to have closed the flow of ‘good cases’ coming up for any of the surgery,; successful percutaneous interventions seem to be offering reasonable results in these patients, who therefore do not knock on the doors of the surgeons any more. It is a common experience among the cardiac anesthesiologists and surgeons that the type of the cases that come by now are high risk. That may be presence of comorbidities, ongoing medical therapies, unstable angina, uncontrolled heart failure and rhythm disturbances; and in patients with ischemic heart disease, the target coronaries are far from ideal. Several activities such as institution of preoperative supportive circulatory, ventilatory, and systemic disease control maneuvers seem to have helped improving the outcome of these ‘high risk ‘ patients. This review attempts to look at various interventions and the resulting improvement in outcomes. Several changes have happened in the realm of cardiac surgery and several more are en route. At times, for want of evidence, maximal optimization may not take place and the patient may encounter unfavorable outcomes.. This review is an attempt to bring the focus of the members of the cardiac surgical team on the value of preoperative optimization of risks to improve the outcome. The cardiac surgical patients may broadly be divided into adults undergoing coronary artery bypass graft surgery, valve surgery and pediatric patients undergoing repair/palliation of congenital heart ailments. Optimization of risks appear to be different in each genre of patients. This review also brings less often discussed issues such as anemia, nutritional issues and endocrine problems. The review is an attempt to data on ameliorating modifiable risk factors and altering non modifiable ones.

Sağ Sinüs Valsalva'dan Köken Alan Anormal Sirkumfleks Sol Artere Perkütan Koroner Girişim

Coronary artery anomalies are rarely diagnosed during cardiac catheterization. The most common anomaly is anomalous left circumflex artery arising from the right sinus of Valsalva. In general they are asymptomatic and benign, however some patients can present with myocardial ischemia, myocardial infarction or sudden death. Treatment of atherosclerotic lesions of anomalous coronary arteries by means of percutaneous coronary intervention has rarely been reported in the literature. We present a case of a patient who was diagnosed with acute coronary syndrome and underwent an early coronary angiography followed by a successful percutaneous intervention with stenting of an anomalous left circumflex artery arising from the right sinus of Valsalva through the femoral route.

Successful Percutaneous Intervention for Chronic Total Occlusion of Left Subclavian Artery

Introduction: Subclavian artery stenosis is most commonly caused by atherosclerotic disease. Surgical treatment is associated with high morbidity and mortality. Intervention is generally reserved for the management of symptomatic patients who present with upper limb ischemia, Vertebrobasilar symptoms and subclavian steal syndrome. Endovascular stenting is preferred over surgery because of high success rate, less invasive and minimal complications. Case report: Here we report a case of 56-year-old female patient with history of hypertension and diabetes presented with dizziness, vertigo and left arm claudication with use of her left upper extremity since last six months. She was diagnosed as a case of subclavian steal syndrome. Treatment: Patient underwent successful Percutaneous Transluminal Angioplasty (PTA) of the left subclavian artery with marked improvement of symptoms at follow-up. Patient was monitored with Duplex ultrasound of left subclavian artery, measurement of BP and examination of pulse at each visit. Conclusion: PTA is an effective and safe with high success rate, less invasive and minimal complications when compared to surgery for the treatment of symptomatic subclavian artery stenosis. However, regular clinical and duplex ultrasound assessment of subclavian artery is necessary after angioplasty for monitoring restenosis.

Transient Brugada phenocopy during evolving ischemic right bundle branch block

A “Brugada phenocopy” (BrP) is a clinical presentation exhibiting the same electrocardiographic characteristics of true Brugada syndrome (BrS) in different clinical scenarios. We report the clinical case of a 59-year-old male patient with acute chest pain depicting BrP followed by extensive convex ST-segment elevation due to proximal thrombosis of the left descending coronary artery. Following successful percutaneous intervention and drug-eluting stent implantation, a classical right bundle branch block pattern emerged. We discussed possible mechanism and clinical implications of this unusual electrical sequence during acute myocardial injury.

Determinants and Prognostic Significance of Periprocedural Myocardial Injury in Patients With Successful Percutaneous Chronic Total Occlusion Interventions.

This study sought to evaluate the determinants and prognostic implications of periprocedural myocardial injury (PMI) in successful percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). There are limited studies addressing the risk factors and clinical implication of PMI in patients undergoing CTO-PCI. We examined 1,058 consecutive CTO patients who underwent successful drug-eluting stent implantation and serial measurements of creatine kinase-myocardial band (CK-MB) values between March 2003 and August 2014. PMI was defined as elevations of CK-MB >3 times the upper reference limit (URL). PMI occurred in 121 patients (11.4%). Multivariable analysis revealed that the presence of renal failure (odds ratio [OR]: 4.25; 95% confidence interval [CI]: 1.59 to 11.35; p= 0.004), attempted retrograde approach (OR: 2.27; 95% CI: 1.34 to 3.84; p= 0.002), concomitant non-target lesion intervention (OR: 1.74; 95% CI: 1.17 to 2.59; p= 0.006), and stent number (OR: 1.38; 95% CI: 1.08 to 1.77; p= 0.011) were predictors associated with PMI. During a median follow-up of 4.4 years, PMI was associated with an increased risk of mortality (adjusted hazard ratio: 1.86; 95% CI: 1.09 to 3.17; p=0.02). These findings were also consistent when higher CK-MB cutoff was used to define PMI. Although there was atrend toward higher all-cause mortality with increasing peak CK-MB levels, in multivariable analyses, this association was statistically significant only for peak CK-MB levels of >10 times the URL. PMI was associated with an increased risk of long-term mortality after successful CTO-PCI. Patients with renal insufficiency, those who require more stents, multiple lesion treatment, and retrograde approach have a higher likelihood of having PMI.

TCTAP A-064 Determinants and Prognostic Significance of Periprocedural Myocardial Injury in Patients with Successful Percutaneous Chronic Total Occlusion Interventions

TCTAP A-064 Determinants and Prognostic Significance of Periprocedural Myocardial Injury in Patients with Successful Percutaneous Chronic Total Occlusion Interventions

Successful Primary Percutaneous Intervention with Stenting in Anomalous Right Coronary Artery Arising from left Coronary sinus in case of Acute Inferior wall Myocardial Infarction Complicated by Cardiac Tamponade

Anomalous origin of the right coronary artery (RCA) from the left sinus of valsalva is a rare congenital abnormality. The unusual location and noncircular orifice of this anomaly poses a great technical challenge for selective catheterization and percutaneous coronary intervention (PCI). Hemopericardium leading to tamponade complicating acute MI is rare and leads to hemodynamic instability. We report a case of acute inferior wall MI with a moderate pericardial effusion in cardiac tamponade who was treated with immediate pericardiocentesis followed by PCI and stenting of an anomalously arising RCA from the left sinus. Key words: Anomalous coronary artery, Primary PCI, Tamponade, Hemopericardium, Inferior wall MI.

Randomized Control of Sympathetic Drive With Continuous Intravenous Esmolol in Patients With Acute ST-Segment Elevation Myocardial Infarction: The BEtA-Blocker Therapy in Acute Myocardial Infarction (BEAT-AMI) Trial.

This study sought to evaluate the role of esmolol-induced tight sympathetic control in patients with ST-segment elevation myocardial infarction (STEMI). Elevated sympathetic drive has a detrimental effect on patients with acute STEMI. The effect of beta-blocker-induced heart rate mediated sympathetic control on myocardial damage is unknown. The authors conducted a prospective, randomized, single-blind trial involving patients with STEMI and successful percutaneous intervention (Killip class I and II). Patients were randomly allocated to heart rate control with intravenous esmolol for 24 h or placebo. The primary outcome was the maximum change in troponin T release as a prognostic surrogate marker for myocardial damage. A total of 101 patients were enrolled in the study. There was a significant difference between patients allocated to placebo and those who received sympathetic control with esmolol in terms of maximum change in troponin T release: the median serum troponin T concentration increased from 0.2 ng/ml (interquartile range [IQR] 0.1 to 0.7 ng/ml) to 1.3 ng/ml (IQR: 0.6 to 4.7 ng/ml) in the esmolol group and from 0.3 ng/ml (IQR: 0.1 to 1.2 ng/ml) to 3.2 ng/ml (IQR: 1.5 to 5.3 ng/ml) in the placebo group (p = 0.010). The levels of peak creatine kinase (CK), CK subunit MB (CK-MB), and n-terminal brain natriuretic peptide (NT-proBNP) were lower in the esmolol group compared with placebo (CK 619 U/l [IQR: 250-1,701 U/l] vs. 1,308 U/l [IQR: 610 to 2,324 U/l]; p= 0.013; CKMB: 73.5 U/l [IQR: 30 to 192 U/l]vs. 158.5 U/l [IQR: 74 to 281 U/l]; p= 0.005; NT-proBNP: 1,048 pg/ml (IQR: 623 to 2,062 pg/ml] vs. 1,497 pg/ml [IQR: 739 to 3,318 pg/ml]; p= 0.059). Cardiogenic shock occurred in three patients in the placebo group and in none in the esmolol group. Esmolol treatment statistically significantly decreased troponin T, CK, CK-MB and NT-proBNP release as surrogate markers for myocardial injury in patients with STEMI. (Heart Rate Control After Acute Myocardial Infarction; DRKS00000766).

IN-HOSPITAL AND LONG TERM RESULTS OF PERCUTANEOUS CORONARY INTERVENTION WITH BIVENTRICULAR SUPPORT AND EXTRACORPOREAL MEMBRANE OXYGENATION

Patients, due to various reasons not indicated for coronary bypass (CABG), usually have extremely high risk of complications in percutaneous intervention (PCI) as well. Recently it was shown that extracorporeal membrane oxygenation (ECMO) might provide a necessary support in the case of high risk PCI. ECMO can be effective in PCI in patients with refractory cardiogenic shock too, however evidence base for the technological approach in high risk PCI remains underdeveloped. Aim. To evaluate in-hospital and long-term results of high risk PCI with biventricular bypass and ECMO in patients not fitted for CABG. Material and methods. We conducted a retrospective analysis of the treatment of 12 patients having extremely high risk of complications in CABG. In all cases PCI was done in conditions of biventricular bypass and ECMO. Stable angina and non-STelevation acute coronary syndrome occurred in 42 and 58% cases, respectively. Clinical picture of cardiogenic shock was the criteria of exclusion. All patients had severe comorbidity with high score by “EuroScore” — 6,3±4,9%. In all cases there was multivessel disease with high level of coronary lesion involvement by “Syntax Score” (30,1±10,1). Mean level of left ventricle ejection fraction was satisfactory — 51±12,6%. Ten patients (83%) had significant (≥50 %) lesion of unprotected stem of the left coronary artery (SLCA). Results. All procedures were successful. As a success of PCI we meant the opened artery with the flow rate not worse than TIMI 3 and absent of significant cardiovascular complications. Mean quantity of the implanted drug-eluting stents was 2,4±1. Full revascularization was reached in 42% cases. Residual value of “Syntax Score” was at the level about 6,33±6,88. Significant adverse cardiovascular complications (death, myocardial infarction, repeated non-planned revascularization) during inhospital phase were not registered. In one case there was an iliac artery dissection, that did not lead to necessity of surgery. Hemorrhagic complications were found just in one patients (8%, 2nd type by “BARC”). All patients were discharged. There were no any fatal cases or myocardial infarction (MI) in 6 months after observation. Two patients required another revascularization (17%). In long-term period there were no and signs of “definite” or “probable” stent thrombosis. Conclusion. PCI in the conditions of biventricular bypass and ECMO might be effective alternative strategy of revascularization in a cohort of patients not indicated for CABG due to high complications risk.