Use Of Radial Access Research Articles

Trends in percutaneous coronary intervention from 2004 to 2013 according to the Portuguese National Registry of Interventional Cardiology

Introduction and ObjectivesThe aim of the present paper is to report trends in Portuguese interventional cardiology from 2004 to 2013 and to compare them with other European countries. MethodsBased on the Portuguese National Registry of Interventional Cardiology and on official data from the Directorate-General of Health, we give an overview of developments in coronary interventions from 2004 to 2013. ResultsIn 2013, 36810 diagnostic catheterization procedures were performed, representing an increase of 34% compared to 2007 and a rate of 3529 coronary angiograms per million population. Coronary interventions increased by 65% in the decade from 2004 to 2013, with a total of 13897 procedures and a rate of 1333 coronary interventions per million population in 2013. Primary percutaneous coronary intervention (PCI) increased by 265% from 2004 to 2013 (1328 vs. 3524), an adjusted rate of 338 primary PCIs per million, representing 25% of total angioplasties. Stents were the most frequently used devices, drug-eluting stents being used in 73% in 2013. Radial access increased from 4.1% in 2004 to 57.9% in 2013. ConclusionInterventional cardiology in Portugal has been expanding since 2004. We would emphasize the fact that in 2013 all Portuguese interventional cardiology centers were participating in the National Registry of Interventional Cardiology, as well as the growth in primary PCI and increased use of radial access.

Evolução da intervenção coronária percutânea entre 2004‐2013. Atividade em Portugal segundo o Registo Nacional de Cardiologia de Intervenção

Introduction and ObjectivesThe aim of the present paper is to report trends in Portuguese interventional cardiology from 2004 to 2013 and to compare them with other European countries. MethodsBased on the Portuguese National Registry of Interventional Cardiology and on official data from the Directorate‐General of Health, we give an overview of developments in coronary interventions from 2004 to 2013. ResultsIn 2013, 36 810 diagnostic catheterization procedures were performed, representing an increase of 34% compared to 2007 and a rate of 3529 coronary angiograms per million population. Coronary interventions increased by 65% in the decade from 2004 to 2013, with a total of 13 897 procedures and a rate of 1333 coronary interventions per million population in 2013. Primary percutaneous coronary intervention (PCI) increased by 265% from 2004 to 2013 (1328 vs. 3524), an adjusted rate of 338 primary PCIs per million, representing 25% of total angioplasties. Stents were the most frequently used devices, drug‐eluting stents being used in 73% in 2013. Radial access increased from 4.1% in 2004 to 57.9% in 2013. ConclusionInterventional cardiology in Portugal has been expanding since 2004. We would emphasize the fact that in 2013 all Portuguese interventional cardiology centers were participating in the National Registry of Interventional Cardiology, as well as the growth in primary PCI and increased use of radial access.

GW26-e4772 Use of Radial Access in Emergency PCI

GW26-e4772 Use of Radial Access in Emergency PCI

The comparative efficacy of bivalirudin is markedly attenuated by use of radial access: insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium

The purpose of our study was to evaluate the relative impact of bivalirudin on bleeding outcomes associated with trans-radial interventions (TRI) in real world practice. Data for patients undergoing percutaneous coronary intervention (PCI) between January 2010 and March 2014 at the 47 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) were utilized. Propensity matching was used within cohorts defined by access site. The impact of bivalirudin use on in-hospital outcomes was evaluated with Fisher's exact tests. Among patients undergoing trans-femoral interventions (TFI), use of bivalirudin was associated with a reduction in bleeding compared with both glycoprotein IIb/IIIa inhibitors (GPI; 1.67 vs. 3.46%, absolute risk reduction (ARR) 1.79%, odds ratio, OR, 0.47, confidence interval, CI, 0.41-0.54, number needed to treat, NNT 56, P < 0.001) and heparin (1.26 vs. 1.76%, ARR 0.5%, OR 0.71, CI 0.61-0.82, NNT 197, P < 0.001). Among patients undergoing TRI, there was a more modest absolute reduction in bleeding with bivalirudin compared with GPI (0.79 vs. 1.41%, ARR 0.62%, OR 0.56, CI 0.34-0.90, NNT 161, P = 0.016) and no difference in bleeding compared with heparin (0.46 vs. 0.46%, OR 1, CI 0.54-1.84, P = 1). Bivalirudin is markedly efficacious in reducing bleeding in patients undergoing TFI. The reduction in bleeding associated with bivalirudin use is minimal to absent in patients undergoing TRI. Given its lower cost and comparable outcomes, heparin should be the preferred anticoagulation strategy in those undergoing radial PCI.

Incidence and consequence of major bleeding in primary percutaneous intervention for ST-elevation myocardial infarction in the era of radial access: an analysis of the international randomized Acute myocardial infarction Treated with primary angioplasty and intravenous enoxaparin Or unfractionated heparin to Lower ischemic and bleeding events at short- and Long-term follow-up trial

The aims of the study are to compare the outcome with and without major bleeding and to identify the independent correlates of major bleeding complications and mortality in patients described in the ATOLL study. The ATOLL study included 910 patients randomly assigned to either 0.5 mg/kg intravenous enoxaparin or unfractionated heparin before primary percutaneous coronary intervention. Incidence of major bleeding and ischemic end points was assessed at 1 month, and mortality, at 1 and 6 months. Patients with and without major bleeding complication were compared. A multivariate model of bleeding complications at 1 month and mortality at 6 months was realized. Intention-to-treat and per-protocol analyses were performed. The most frequent bleeding site appears to be the gastrointestinal tract. Age >75 years, cardiac arrest, and the use of insulin or >1 heparin emerged as independent correlates of major bleeding at 1 month. Patients presenting with major bleeding had significantly higher rates of adverse ischemic complications. Mortality at 6 months was higher in bleeders. Major bleeding was found to be one of the independent correlates of 6-month mortality. The addition or mixing of several anticoagulant drugs was an independent factor of major bleeding despite the predominant use of radial access. This study shows that major bleeding is independently associated with poor outcome, increasing ischemic events, and mortality in primary percutaneous coronary intervention performed mostly with radial access.

14 Bivalirudin Versus Unfractioned Heparin in Patients Receiving Percutaneous Coronary Intervention for Acute Coronary Syndromes

Background In the setting of percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), bivalirudin has been shown to be superior to unfractionated heparin (UFH) in reducing major adverse cardiac events, driven by a reduction in major bleeding. With increasing use of radial access and potent anti-platelet therapy, recent trials suggest that the previous benefit observed with bivalirudin may now be substantially reduced. ACS encompasses both ST-elevation ACS (STE-ACS), with generally high thrombus burden and non-ST-elevation ACS (NSTE-ACS), with lower thrombus burden. Whether bivalirudin offers differential clinical benefit in these two groups, is unknown. Methods We conducted a meta-analysis of randomised trials comparing bivalirudin and UFH in patients receiving PCI for ACS divided into STE-ACS and NSTE-ACS groups. Overall estimates of effect were calculated with a fixed-effects model or random-effects model. Results In STE-ACS, 6 trials (10,368 patients) were identified. Compared to UFH, bivalirudin increased the risk of myocardial infarction (MI) (OR 1.41; CI 1.02–1.95; p = 0.04) and acute stent thrombosis (ST) (OR 3.81; CI 2.15–6.74; p Conclusions Although in STE-ACS, bivalirudin is associated with an increased risk of ischaemic events, it may confer an advantage over UFH in NSTE-ACS patients undergoing PCI, with a reduction in major bleeding and without an increase in ischaemic events. Large scale multi-centre randomised trials are needed to elucidate the optimal anti-thrombotic regimen in patients presenting with STE-ACS undergoing PCI in the contemporary era.

Abstract 161: National Trends in Use of Radial Access for Percutaneous Coronary Intervention in China: 2001-2011

Background: The use of radial access for percutaneous coronary intervention (r-PCI) is associated with reduced risk of bleeding complications and higher patient satisfaction. However, the use of r-PCI differs greatly by country and is unknown in China. We examined trends in the adoption of r-PCI in China over the past decade and identified factors associated with its use. Methods: We used a two-stage random sampling strategy to create a nationally representative sample of 5,462 patients undergoing percutaneous coronary intervention (PCI) in China in 2001 (n=402; 24 sites), 2006 (n=1,390; 44 sites), and 2011 (n=3,670; 54 sites). We calculated the weighted proportion of patients receiving r-PCI in each time period and conducted multivariable analysis to identify the patient and hospital characteristics associated with not receiving r-PCI in 2011. Results: Among 5,462 patients who underwent PCI, the use of r-PCI increased markedly over time (2001: 3.4% [95% CI 0.0%-8.5%]; 2006: 36.5% [95% CI 34.2%-38.9%], 2011: 74.7% [95% CI 73.9-75.6]; P for trend &lt;0.001). Increases in r-PCI use were widespread, including high-risk subgroups such as the elderly, women, and patients with acute coronary syndromes (Figure). In multivariable analysis of 3,670 patients undergoing PCI in 2011, cardiogenic shock and emergency PCI were strongly associated with failure to use r-PCI in 2011. Conclusion: Over a recent ten-year period, radial access became the predominant strategy for PCI in China, even among high-risk patients. This study demonstrates the responsiveness of the interventional cardiology community to emerging evidence. A deeper understanding of the factors facilitating r-PCI adoption in China may help increase its usage in countries in which r-PCI use remains low.

Underutilization of Radial Access in Patients Undergoing Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

The purpose of this study was to evaluate the frequency and temporal trends in use of transradial access (TRA) for percutaneous coronary intervention (PCI) in ST-segment-elevation myocardial infarction (STEMI). The use of TRA has been associated with less bleeding and improved clinical outcomes in patients undergoing PCI for STEMI. The frequency of TRA compared with transfemoral access for patients undergoing PCI for STEMI or other indications (non-ST-segment-elevation myocardial infarction, unstable angina, and non-acute coronary syndrome) in The Blue Cross Blue Shield of Michigan Cardiovascular Consortium database between 2010 and 2013 was evaluated. Propensity matching was used to assess the relationship of TRA with in-hospital clinical end points of major bleeding, transfusion, and death. The TRA cohort of patients was stratified into deciles based on their predicted bleeding risk and compared with PCI indication. Of 122,728 PCI procedures, 17,912 (14.6%) were via TRA. Among patients with STEMI cases, 8.3% of the PCI cases were performed via TRA. The use of TRA increased over the study period although the growth was slower for STEMI than for other indications, P<0.001. The use of TRA for PCI in STEMI was associated with a lower rate of bleeding (11.7% versus 20.0%; P<0.001) and vascular complications (0.7% versus 2.6%; P=0.001), but no mortality difference (1.25% versus 2.33%; P=0.175). There was a strong negative association between the predicted risk of bleeding and the use of TRA (P<0.001). The use of radial access for PCI in STEMI is increasing but at a slower pace than for patients with other indications. TRA was associated with a reduction in bleeding and transfusion, but there is a strong negative correlation between the predicted risk of bleeding and actual use of TRA in STEMI.

Rational use of rotational atherectomy in calcified lesions in the drug-eluting stent era: Review of the evidence and current practice.

Percutaneous coronary interventions of calcified coronary lesions are associated with worse clinical outcomes compared with noncalcified lesions and are still considered a technical challenge for interventional cardiologists. Rotational atherectomy (RA) can effectively optimize lesion preparation through plaque modification of heavily calcified coronary lesions. However, in conventional balloon angioplasty and bare metal stent eras, the use of RA was not associated with a significant improvement in restenosis and target lesion revascularization in patients with calcified lesions. Drug-eluting stents (DES) dramatically reduced the rates of restenosis and major adverse cardiac events. In the DES era, the need for RA is therefore questionable. Recently, some studies have reported clinical outcomes of patients with calcified lesions treated with DES and RA. In this article, we aim to critically review results from these randomized and observational clinical studies assessing the use of RA in the DES era.

Heavily calcified plaques in acutely angulated coronary segment: high risk features of rotablation resulting in Rotawire transection and coronary perforation

Percutaneous treatment of complex coronary disease not only is challenging but also paves the road for constantly evolving treatment modalities. Percutaneous transluminal rotational atherectomy (PTRA) has been shown to be particularly beneficial when treating highly calcified lesions and as a useful adjunct to balloon angioplasty and stent placement [ [1] Tomey M.I. Kini A.S. Sharma S.K. Current status of rotational atherectomy. JACC Cardiovasc. Interv. 2014; 7: 345-353 Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar ]. With the improvement of devices and the accumulation of operator's experiences, PTRA has a high successful rate with low risk of complications. We present a case of Rotawire fracture during rotational ablation through a long and severely calcified segment with acute angulation of the left anterior descending artery (LAD), resulting in coronary perforation and cardiac tamponade. The patient was treated with emergent pericardiocentesis and coronary bypass surgery. Despite the high successful rates, to our knowledge, there were few published cases of guide-wire fracture during PTRA [ 2 Woodfield S.L. Lopez A. Heuser R.R. Fracture of coronary guidewire during rotational atherectomy with coronary perforation and tamponade. Catheter. Cardiovasc. Diagn. 1998; 44: 220-223 Crossref PubMed Scopus (32) Google Scholar , 3 Sakakura K. et al. Comparison of frequency of complications with on-label versus off-label use of rotational atherectomy. Am. J. Cardiol. 2012; 110: 498-501 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar ]. Selection of appropriate lesions and recognition of possible high-risk feature of long, highly calcified and highly angulated segment of coronary artery can potentially reduce the complication risks.

Comparação do Tempo de Fluoroscopia Durante Cateterismo Cardíaco pelas Vias Radial e Femoral

Introducao: O uso da via radial em intervencoes cardiacas associa-se a reducao das complicacoes vasculares, porem requer maior curva de aprendizado e pode aumentar a exposicao do paciente e da equipe a radiacao. Este estudo teve como objetivo avaliar o tempo de fluoroscopia, como variavel substituta para a exposicao a radiacao, durante cateterismo cardiaco diagnostico pelas vias radial e femoral. Metodos: Estudo retrospectivo observacional que incluiu pacientes submetidos ao cateterismo cardiaco entre julho de 2013 e outubro de 2014. Foram comparados os grupos radial e femoral quanto ao tempo total do procedimento, tempo de fluoroscopia, relacao tempo de fluoroscopia/procedimento e complicacoes vasculares. Resultados: Foram incluidos 1.915 procedimentos, sendo 11,2% realizados por via radial e 88,8% realizados por via femoral. Observou-se predominio do sexo masculino no grupo radial (80% vs. 54,1%; p < 0,01), mas a media de idades (61,6 ± 9,7 vs. 62,4 ± 11,6; p = 0,13), o tempo do procedimento (8,7 ± 3,8 vs. 8,1 ± 4,1 minutos; p = 0,91), o tempo de fluoroscopia (4,8 ± 2,7 vs. 4,1 ± 2,6 minutos; p = 0,89), a relacao tempo de fluoroscopia/procedimento (0,56 ± 0,24 vs. 0,49 ± 0,32; p = 0,89) e as complicacoes maiores (0,0% vs. 0,3%; p = 0,55) foram semelhantes entre os grupos. Conclusoes: A utilizacao da via radial para procedimentos diagnosticos por operadores experientes pode ser feita com um tempo de procedimento aceitavel, sem aumentar a exposicao radiologica do paciente e da equipe, e com baixo numero de complicacoes.

RADIAL VERSUS FEMORAL ACCESS FOR CORONARY ANGIOGRAPHY/INTERVENTION IN WOMEN WITH ACUTE CORONARY SYNDROMES: INSIGHTS FROM THE RIVAL TRIAL

To determine the efficacy and safety of radial versus femoral access for coronary angiography/intervention in women in the RIVAL trial. Radial access is more challenging in women due to smaller radial arteries, possibly resulting in reduced procedural success. In a pre-specified RIVAL subgroup analysis, we compared outcomes in patients randomized to radial versus femoral access in women (N=1861). There was no difference in the primary composite endpoint of death, myocardial infarction, stroke, and non-CABG bleeding at 30 days in women (radial 3.96%; femoral 5.04%; HR 0.78; 95%CI 0.50-1.20; p=0.250), and men (radial 3.54%; femoral 3.55%; HR 0.99; 95%CI 0.74-1.33; p=0.971; p for interaction=0.356). Major vascular complications were significantly reduced with the radial access use (in women: radial 3.2%; femoral 6.2%; HR 0.51; 95%CI 0.33-0.81; p=0.003; in men: radial 0.77%; femoral 2.81%; HR 0.27; 95%CI 0.17-0.45; p<0.0001; p for interaction=0.064). Cross-over rates were higher with radial access in both women and men (women: HR 5.49; 95% CI 3.37-8.97; p<0.0001;men: HR 3.20; 95%CI 2.36-4.38; p<0.0001; p for interaction=0.063). PCI success rates were similar irrespective of access site (women: HR 1.03; 95%CI 0.91-1.16; p=0.686;men: HR 1.00; 95%CI 0.94-1.01; p=0.948; p for interaction = 0.808), with no differences in PCI complications. In a multivariable analysis, women versus men was an independent predictor of major vascular complications (HR 2.397; 95%CI 1.76-3.250; p<0.0001) and access-site cross over (HR 1.395; 95%CI 1.04-1.85; p=0.0233). Women have a higher risk of vascular complications compared to men and radial access is an effective method to prevent these complications.

TCT-825 Bleeding events are reduced and survival improved by use of radial access during primary percutaneous coronary intervention for patients receiving glycoprotein inhibitors

access during primary percutaneous coronary intervention for patients receiving glycoprotein inhibitors Control Number: 2917 Submission Type: Abstract Presentation Format: Poster Only New Device/Innovation: No Author(s): Adam J Brown, Nikil K Rajani, Liam M McCormick, Stephen P Hoole, Nick E West Institution(s): University of Cambridge, Cambridge, United Kingdom, Papworth Hospital, Cambridge, United Kingdom Presenter Poster: Dr Adam J Brown, MB BChir View Disclosure University of Cambridge Background: Use of glycoprotein IIb/IIIa inhibitors (GPI) during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) is known to improve myocardial perfusion and reduce further ischemic events, but is associated with an increase in bleeding risk. Performing PPCI via radial access (rPPCI) is thought to reduce post-procedural bleeding complications and may improve overall survival. We sought to assess whether rPPCI is associated with improved outcomes in patients receiving GPI at our institution. Methods: Consecutive patients undergoing PPCI for STEMI over a four-year period were included. All patients were preloaded with 600mg clopidogrel and 300mg aspirin en-route to PPCI. Interventional strategy and GPI use were left to operator discretion. Patient data and outcome measures were obtained by interrogation of notes and national databases. Bleeding complications were categorized using Bleeding Academic Research Consortium (BARC) definitions. Results: 2,019 patients were included in the analysis (mean age 64.2±12.4yrs, 75.9% male), with 863 receiving GPI. Patients that received GPI were younger (62.7±11.8yrs vs. 64.8±12.6yrs, p< 0.001), more likely to be male (80.5% vs. 73.9%, p< 0.001) but had a higher incidence of cardiogenic shock (5.6% vs. 2.7%, p=0.002). Other baseline demographics were similar. Overall, BARC defined bleeding was more prevalent in those receiving GPI (BARC ≥2 3.0% vs. 0.7%, p< 0.001; BARC ≥3 2.6% vs. 0.2%, p< 0.001). However, patients undergoing rPPCI with GPI had lower bleeding rates when compared with femoral access (0.8% vs. 3.7%, p=0.05). For patients receiving GPI, rPPCI resulted in a significant improvement in 1-year survival (99.2% vs. 93.5%, p=0.01; OR 0.12, 95%CI 0.02-0.87, p=0.04). However, in patients not receiving GPI, no survival benefit for rPPCI was observed (94.4% vs. 93.7%, p=0.70; OR 0.87, 95%CI 0.44-1.71, p=0.69). Conclusions: rPPCI results in lower rates of bleeding and improved survival in patients receiving GPI during PPCI. rPPCI should be considered in patient groups where subsequent use of GPI is likely. CORONARY: STEMI and NSTEMI

Change in hospital-level use of transradial percutaneous coronary intervention and periprocedural outcomes: insights from the national cardiovascular data registry.

Whether increasing use of radial access has improved percutaneous coronary intervention outcomes remains unknown. We sought to determine the relationship between increasing facility-level use of transradial percutaneous coronary intervention (TRI) and periprocedural outcomes. Within the National Cardiovascular Data Registry CathPCI Registry, we estimated the risk-adjusted association between hospital category of change in TRI use (during the 3-year period from 2009 to 2012) and trends in access site and overall bleeding, fluoroscopy time, and contrast use among 818 facilities with low baseline TRI use. There were 4 categories of hospital change in TRI use: very low (baseline, 0.2% increasing to 1.8% at the end of 3 years), low (0.9% increasing to 8.9%), moderate (1.6% increasing to 27.2%), and high (1.0% increasing to 45.1%). Risk-adjusted access site bleeding decreased over time for all hospital categories; however, the rate of decline varied across hospital categories (P for interaction, <0.001). The decrease in access site bleeding was significantly greater for hospitals with moderate or high increases in TRI use (relative risk, 0.45, 95% confidence interval, 0.36-0.56) when compared with that of very low or low hospitals (relative risk, 0.65; 95% confidence interval, 0.58-0.74; P for comparison, 0.002). Similar findings were observed for overall bleeding. An increase in fluoroscopy time (≈1.3 minutes) was noted at hospitals with moderate and high use of TRI (P=0.01). Trends in contrast use were similar across hospital categories. In a national sample of hospitals performing percutaneous coronary intervention, bleeding rates decreased over time for all hospital categories of change in TRI use. The decline in bleeding outcomes was larger at hospitals with increased adoption of TRI when compared with hospitals with minimal or no change in TRI use.

Is Radial Access and Transradial Cardiac Catheterization Feasible without the Use of Any Vasodilator?

This is a "proof of concept" study to assess feasibility of transradial access without use of vasodilators. Radial artery spasm (RAS) is an important cause of patient discomfort and procedural failure with use of radial access. Vasodilators are routinely used to prevent RAS. However, the use of vasodilators may not be appropriate in substantial groups of patients. These include patients with myocardial infarction and low blood pressure who will benefit from radial access the most. No specific recommendations about use of vasodilators in these settings are stated on consensus documents on radial access. During a short period of shortage of verapamil in our country, 15 consecutive patients underwent cardiac catheterization by transradial route without the use of vasodilators. Procedural success, and pain perceived by the patients along with radial occlusion after the procedure were assessed. In 14 of the 15 patients, the procedure was completed successfully without the use of vasodilators. In one patient, RAS developed and the procedure could be completed after injection of verapamil. Mean pain score was 5.3 on a scale of 0 to 10. No radial occlusion was detected early after the procedure. In three of the patients, a reason that would otherwise preclude use of a vasodilator was identified. Radial access can safely and effectively be performed without the use of vasodilators. Consideration of this approach when use of vasodilators is not appropriate should be formally discussed by the interventional cardiology community.

Meta-analysis of randomized trials on access site selection for percutaneous coronary intervention in ST-segment elevation myocardial infarction.

IntroductionSuperior outcomes with transradial (TRPCI) versus transfemoral coronary intervention (TFPCI) in the setting of acute ST-segment elevation myocardial infarction (STEMI) have been suggested by earlier studies. However, this effect was not evident in randomized controlled trials (RCTs), suggesting a possible allocation bias in observational studies. Since important studies with heterogeneous results regarding mortality have been published recently, we aimed to perform an updated review and meta-analysis on the safety and efficacy of TRPCI compared to TFPCI in the setting of STEMI.Material and methodsElectronic databases were searched for relevant studies from January 1993 to November 2012. Outcome parameters of RCTs were pooled with the DerSimonian-Laird random-effects model.ResultsTwelve RCTs involving 5,124 patients were identified. According to the pooled analysis, TRPCI was associated with a significant reduction in major bleeding (odds ratio (OR): 0.52 (95% confidence interval (CI) 0.38–0.71, p < 0.0001)). The risk of mortality and major adverse events was significantly lower after TRPCI (OR = 0.58 (95% CI: 0.43–0.79), p = 0.0005 and OR = 0.67 (95% CI: 0.52–0.86), p = 0.002 respectively).ConclusionsRobust data from randomized clinical studies indicate that TRPCI reduces both ischemic and bleeding complications in STEMI. These findings support the preferential use of radial access for primary PCI.

Le syndrome coronarien aigu chez le sujet âgé : expérience du centre hospitalier d’Aix-en-Provence

IntroductionCardiovascular causes are the first causes of death in elderly patients. Nevertheless, elderly patients are underrepresented in randomized studies of acute coronary syndromes although treatment of ACS for elderly patients has specificities that need special attention. Methods and resultsTo discuss these specificities, we realized a retrospective study involving patients aged more than 75years old and admitted for ACS in the cardiology department of Aix-en-Provence General Hospital in the first six months of 2010 (Group A) and 2012 (Group B) which we compared. Initial presentation was chest pain in only 78.6% of Group A versus 81.6% in Group B (NS), renal insufficiency was found in 41.4% of the patients of Group A versus 50.5% of the patients in Group B (NS), anaemia was found in 34.3% of Group A patients versus 40.2% of Group B (NS), invasive strategy is less systematic with 74.2% of Group A patients having a revascularization versus 73.6% of Group B (NS), Drug Eluting Stents were less frequently used with 14.3% of Group A patients versus 14.7% of Group B (NS), radial access was used for angioplasty in 61.2% of Group A patients versus 80.2% of Group B (P=0.02), unfractioned heparin was used in 74.3% of the cases in Group A versus 68% in Group B (NS). Discussion and conclusionAcute coronary syndrome of the elderly patients has numerous specificities, first there are frequent unusual presentation making diagnosis more difficult, second they have frequent co morbidities making them frail patients with higher risk of hemorrhagic complications and lesser tendency to invasive evidence based treatment. In the absence of specific recommendations, their treatment should not differ from younger patients. This work allowed us also to evaluate our professional practices in order to improve them; we note a positive evolution with the significant raise in the use of radial access, invasive strategy though should be more systematic and use of low molecular weight heparin and Fondaparinux should be more frequent.

Comparison of Outcomes Using the Sirolimus-Eluting Stent in Calcified Versus Non-Calcified Native Coronary Lesions in Patients On- Versus Not On-Chronic Hemodialysis (from the j-Cypher Registry)

The impact of lesion calcium on long-term outcomes after drug-eluting stent implantation has not been adequately addressed. In 10,595 patients (16,803 lesions) who were exclusively treated with sirolimus-eluting stents in the j-Cypher registry, 5-year outcomes were compared between patients with ≥1 lesion with moderate or severe calcification (the calcium group) and those with noncalcified lesions only (the noncalcium group). Analyses were stratified by hemodialysis (HD) status (non-HD stratum [calcium n = 3,191, noncalcium n = 6,824] and HD stratum [calcium n = 415, noncalcium n = 165]). Adjusted risk in the calcium group for death and target lesion revascularization was significant in the non-HD stratum (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.18 to 1.52, p <0.0001, and HR 1.2, 95% CI 1.07 to 1.36, p = 0.003) and the HD stratum (HR 1.4, 95% CI 1.06 to 1.86, p = 0.02, and HR 2.25, 95% CI 1.51 to 3.36, p <0.0001). Risk for definite stent thrombosis tended to be higher in the calcium group in the HD stratum (HR 5.05, 95% CI 0.66 to 38.9, p = 0.12) but not in then non-HD stratum (HR 1.16, 95% CI 0.81 to 1.67, p = 0.41). The use of rotational atherectomy in patients with severe calcification did not have a significant impact on the cumulative incidence of target lesion revascularization in the non-HD stratum (17.7% [n = 268] with vs 18.2% [n = 588] without rotational atherectomy, p = 0.68) and the HD stratum (54.7% [n = 115] with vs 51.9% [n = 118] without rotational atherectomy, p = 0.19). In conclusion, regardless of HD status, patients with calcified lesions have increased long-term risk for death and target lesion revascularization after sirolimus-eluting stent implantation.

A year in the life of a cardiologist: an interview with Dr Ganesh Manoharan

Interview by Louise Rishton (Commissioning Editor) and Tanya Stezhka (Assistant Commissioning Editor)Ganesh Manoharan graduated with Distinction from Queens University of Belfast (UK) in 1993. He completed his training in Cardiology in Belfast and his Advanced Interventional Cardiology Fellowship at the OLV Hospital, Aalst, Belgium. He was appointed as a Consultant Cardiologist at the Royal Victoria Hospital (Belfast, UK) in 2004. Since 2004, he has written service development business cases towards successful implementation of four clinical procedures in Northern Ireland, namely the use of rotational atherectomy (Rotablator®), intracardiac ultrasound (Accunav System®), increased use of PressureWire™ and, more recently, transcatheter aortic valve replacement (TAVR). Dr Manoharan is the clinical lead for the TAVR programme in Northern Ireland and functions as a Clinical Proctor for the Medtronic CoreValve® and the St Jude TAVR Programs. He has successfully started up and trained over 50 Regional Cardiology Centres in Europe, Asia and Australia, and has been involved in over 1000 cases to date. Dr Manoharan also functions as the Educational Supervisor for Cardiology and supervisors both Clinical and Research Fellows. He is actively involved in clinical and experimental research, with numerous publications.

RELATIONSHIP BETWEEN TRANSRADIAL PCI EXPERIENCE AND PROCEDURAL METRICS

Low use of radial access for percutaneous coronary intervention (PCI) in the U.S. has been partly attributed to concern about the technique's learning curve. Data regarding associations between transradial intervention (TRI) experience and procedural metrics are sparse. We used CathPCI Registry®