Aspiration thrombectomy during primary percutaneous coronary intervention as adjunctive therapy to early (in-ambulance) abciximab administration in patients with acute ST elevation myocardial infarction: an analysis from Leiden MISSION! acute myocardial infarction treatment optimization program.

BACKGROUND: The benefits of early abciximab administration and thrombus aspiration in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI) have previously been elaborated. However, whether there is an adjunctive effect of thrombus aspiration among STEMI patients, with angiographic evidence of thrombus, receiving early prehospital abciximab remains unclear. METHODS: In the context of a fixed protocol for PPCI, 158 consecutive patients with STEMI were enrolled, in whom abciximab was started early before hospital arrival (in-ambulance); 79 patients who had PPCI with thrombus aspiration (thrombectomy-facilitated PCI group), were compared to 79 who had PPCI without thrombus aspiration (conventional PCI group) in a prospective nonrandomized study. The primary end-point was complete ST-segment resolution within 90 minutes. Secondary end points included distal embolization, enzymatic infarct size as well as left ventricular ejection fraction (LVEF) assessed by gated single-photon emission computed tomography. Major adverse cardiac events (MACEs) were evaluated up to 12 months. RESULTS: Both groups were comparable for baseline characteristics. ST-segment resolution was significantly higher in the thrombectomy-facilitated group (P = 0.002), and multivariate analysis identified thrombectomy as an independent predictor of ST-segment resolution (OR = 9.4, 95% CI = 2.6-33.5, P = 0.001). Distal embolization was higher in the conventional PCI group among patients with higher thrombus grades. No difference was observed between both groups in infarct size assessed by peak creatine kinase (p = 0.689) and peak Tn-T levels (P = 0.435). Also, the LVEF at 3 months was similar (P = 0.957). At 12 month clinical follow-up, thrombus aspiration was, however, associated with reduced all-cause mortality (log-rank p = 0.032). CONCLUSION: Among STEMI patients treated with PPCI and in-ambulance abciximab, it appears that a selective strategy of thrombus aspiration still has additive benefit.

Prognostic importance of strain and strain rate after acute myocardial infarction.

AIMS: Recently, strain and strain rate have been introduced as novel parameters reflecting left ventricular (LV) function. The purpose of the current study was to assess the prognostic importance of strain and strain rate after acute myocardial infarction (AMI). METHODS AND RESULTS: A total of 659 patients after AMI were evaluated. Baseline echocardiography was performed to assess LV function with traditional parameters and strain and strain rate. During follow-up, 51 patients (8%) reached the primary endpoint (all-cause mortality) and 142 patients (22%) the secondary endpoint (a composite of revascularization, re-infarction, and hospitalization for heart failure). Strain and strain rate were both significantly related with all endpoints. After adjusting for clinical and echocardiographic parameters, strain was independent related to all endpoints and was found to be superior to LV ejection fraction (LVEF) and wall motion score index (WMSI). Patients with global strain and strain rate higher than -15.1% and -1.06 s(-1) demonstrated HRs of 4.5 (95% CI 2.1-9.7) and 4.4 (95% CI 2.0-9.5) for all-cause mortality, respectively. CONCLUSION: Strain and strain rate provide strong prognostic information in patients after AMI. These novel parameters were superior to LVEF and WMSI in the risk stratification for long-term outcome.

Time course of global left ventricular strain after acute myocardial infarction.

AIMS: The purpose of the present study was to assess the evolution of left ventricular (LV) function after acute myocardial infarction (AMI) using global longitudinal peak systolic strain (GLPSS) during 1 year follow-up. In addition, patients were divided in groups with early, late, or no improvement of LV function and predictors of recovery of LV function were established. METHODS AND RESULTS: A total of 341 patients with AMI were evaluated. Two-dimensional echocardiography was performed at baseline, 3, 6, and 12 months. At baseline, LV function was assessed with traditional parameters and GLPSS. Global longitudinal peak systolic strain was re-assessed at 3, 6, and 12 months. Improvement of LV function was based on GLPSS and was observed in 72% of the patients. No differences were observed between patients with early and late improvement. The left anterior descending coronary artery as culprit vessel, peak cardiac troponin T level, diastolic function, and baseline GLPSS were identified as independent predictors of recovery of LV function. CONCLUSION: Improvement of LV systolic function occurred in the majority of patients during follow-up. Global longitudinal peak systolic strain, left anterior descending coronary artery as culprit vessel, peak cardiac troponin T level, and diastolic function were independent predictors of recovery of LV function. Quantification of GLPSS may be of important value for the prediction of recovery of LV function in patients after AMI.

Right ventricular stimulation threshold at ICD implant predicts device therapy in primary prevention patients with ischaemic heart disease.

AIMS: Myocardial excitability is known (amongst other reasons) to be related to the degree of ischaemia, contractile dysfunction and heart failure. It was hypothesized that the right ventricular (RV) stimulation threshold has prognostic value with respect to the occurrence of ventricular arrhythmias (VAs) and patient survival in recipients of an implantable cardioverter defibrillator (ICD). METHODS AND RESULTS: Ischaemic heart disease patients receiving an ICD at Leiden University Medical Center as primary prevention for sudden cardiac death were included in this study. Right ventricular thresholds were determined at ICD implant. Data were collected on VAs triggering ICD therapy and on all-cause mortality. A total of 689 consecutive patients were included (87% male, age 63 ± 11 years, left ventricular ejection fraction (LVEF) 29 ± 11%) and followed for a median of 28 months. Post-implant RV-threshold was 0.7 ± 0.5 volt (V) at 0.5 ms pulse duration. Best dichotomous separation was reached at a cut-off of 1 V. During follow-up, 167 (24%) patients received appropriate ICD therapy, 88 (13%) had appropriate shocks and 134 (19%) died. Cumulative appropriate shock incidence for patients with RV threshold ≥ 1 V (n = 166) was 16% at 1 year, 24% at 3 years and 34% at 5 years compared with 4, 11 and 17% for patients with an RV-threshold < 1 V (n = 523). Adjusted hazard ratio of RV threshold ≥ 1 V was 2.0 (95% CI: 1.4-2.9) for appropriate therapy, 3.3 (95% CI: 2.0-5.4) for appropriate shocks and 1.6 (95% CI: 1.1-2.5) for mortality. CONCLUSION: The RV stimulation threshold at ICD implant has a strong independent prognostic value for the occurrence of VAs triggering appropriate ICD therapy, appropriate shocks and mortality.

Structured care for patients after acute myocardial infarction: sudden cardiac death prevention--data from the Leiden MISSION! AMI study.

AIMS: To assess the number of patients in daily clinical practice that meets criteria for implantation of an implantable cardioverter defibrillator (ICD) following acute myocardial infarction (AMI) when treated according to an aggressive treatment protocol. METHODS AND RESULTS: Patients were treated according to the MISSION! protocol. The protocol encompasses pre-hospital, in-hospital, and outpatient clinical framework for the acute and chronic treatment of AMI patients and the decision making regarding primary prevention of sudden cardiac death (SCD). A total of 676 consecutive AMI patients (78% male, mean age 59 +/- 12 years) treated according to the MISSION! protocol were included in this analysis. Left ventricular ejection fraction at 3 months was 54 +/- 10%. Only 39 (6%) patients met criteria for implantation of an ICD <1 year post-MI. These patients suffered more extensive infarctions as indicated by higher peak troponin T values (mean 14.5 +/- 8.3 vs. 6.5 +/- 14.7 microg/L; P < 0.001) and had more left anterior descending artery related infarctions (79 vs. 46%; P < 0.001). Cumulative first appropriate therapy rate was 15% at 3 years follow-up. No SCD was observed in the study population. CONCLUSION: Aggressive treatment of AMI patients and close monitoring after the index event according to a standardized protocol, results in only a small number of patients becoming candidate for prophylactic ICD implantation. An easy-to-use protocol combining aggressive reperfusion, optimal medication, and a risk stratification algorithm tailored to fit within routine practice may help to maintain ICD implantation rates within manageable proportions.

Long-term outcome of second-generation everolimus-eluting stents and Endeavor zotarolimus-eluting stents in a prospective registry of ST-elevation myocardial infarction patients.

AIMS: The optimal drug-eluting stent (DES) in ST-elevation myocardial infarction (STEMI) patients remains unclear. We sought to compare the long-term performance of everolimus-eluting stents (EES) and Endeavor zotarolimus-eluting stents (E-ZES) in STEMI. METHODS AND RESULTS: The current analysis of a prospective registry included consecutive patients treated with EES or E-ZES for STEMI. Adjustment for measured confounders was done using Cox regression. In total, 931 patients met the inclusion criteria (412 EES and 519 E-ZES). Baseline characteristics were balanced, apart from a lower rate of renal insufficiency in EES. Median follow-up duration was 2.4 years (IQR 1.6-3.1). Mortality outcomes were similar. Up to three-year follow-up, the composite endpoint of cardiac death, target vessel-related myocardial infarction and target lesion revascularisation (TLR) was lower in EES; 9.7% vs. 13.7% in E-ZES (HR 0.64, 95% CI: 0.42-0.99), primarily driven by reduced TLR rates; 3.4% in EES vs. 7.3% in E-ZES (HR 0.46, 95% CI: 0.23-0.92). Definite stent thrombosis rates were low and similar between groups (1.1% in EES vs. 1.9% in E-ZES, p=0.190). CONCLUSIONS: Use of EES led to lower rates of the composite endpoint, driven by reduced TLR. This suggests that EES are more efficacious than Endeavor ZES in STEMI. Definite ST rates were low, and the strategy of second-generation DES implantation and the administration of upfront GP IIb/IIIa inhibitors appear to be safe in STEMI.

Five-year clinical follow-up from the MISSION! Intervention Study: sirolimus-eluting stent versus bare metal stent implantation in patients with ST-segment elevation myocardial infarction, a randomised controlled trial.

AIMS: To evaluate the clinical outcomes of sirolimus-eluting stent (SES) versus bare metal stent (BMS) implantation in patients with ST-segment elevation myocardial infarction (STEMI) at long-term follow-up. METHODS AND RESULTS: After five years, 310 STEMI patients randomly assigned to implantation of either SES or BMS, were compared. Survival rates were comparable between groups (SES 94.3% vs. BMS 92.8%, p=0.57), as were the rates of reinfarction (10.6% vs. 13.7%, p=0.40), freedom of death/re-MI (84.4% vs. 79.8%, p=0.29) and target vessel failure (14.9% vs. 21.7%, p=0.11). Likewise, rates of overall stent thrombosis (ST) (5.4% vs. 2.7%, p=0.28) and very late ST (4.1% vs. 0.7%, p=0.07) did not significantly differ between the SES- and BMS-group. In 184 patients with IVUS data, definite and definite/probable VLST was more common in those with late stent malapposition versus those without late stent malapposition (4.3% and 6.6% vs. no events [p=0.018 and p=0.004], respectively). The cumulative incidences of target vessel and target lesion revascularisation (TVR and TLR) were not significantly lower in the SES-group (11.2% vs. 17.9%, p=0.09 and 7.2% vs. 12.9%, p=0.08), as was the rate of clinically driven TLR (6.6% vs. 9.5%, p=0.30). CONCLUSIONS: SES implantation was neither associated with increased rates of major adverse cardiac events, nor with a reduction in re-intervention, compared to implantation of a BMS in patients with STEMI after five years. However, a trend of more very late stent thrombosis was observed after SES implantation (ISRCTN62825862).

Left atrial strain is related to adverse events in patients after acute myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: Left atrial (LA) maximal volume is of prognostic value in patients after acute myocardial infarction (AMI). Recently, LA mechanical function and LA strain have been introduced as alternative methods to assess LA performance more accurately. OBJECTIVE: To evaluate the relation between LA volume, mechanical function and strain, and adverse events in patients after AMI. METHODS: Patients with AMI underwent two-dimensional echocardiography within 48 h of admission. LA volume and LA performance (mechanical function and systolic strain) were quantified. The endpoint was a composite of all-cause mortality, reinfarction and hospitalisation for heart failure. RESULTS: 320 patients (mean age 60±12 years, 78% men) were followed up for 27±14 months. During follow-up, 48 patients (15%) reached the composite endpoint. After adjustment for clinical and echocardiographic parameters, LA maximal volume (HR 1.05, CI 1.00 to 1.10, p=0.04) and LA strain (HR 0.94, CI 0.89 to 0.99, p=0.02) were independently associated with adverse outcome. In addition, LA strain provided incremental value to LA maximal volume (p=0.03) for the prediction of adverse outcome. CONCLUSIONS: After AMI treated with primary percutaneous coronary intervention, LA strain provides additional prognostic value beyond LA maximal volume.

Comprehensive assessment of changes in left atrial volumes and function after ST-segment elevation acute myocardial infarction: role of two-dimensional speckle-tracking strain imaging.

BACKGROUND: Left atrial (LA) size has been associated with adverse outcome in patients after acute myocardial infarction. However, data about the occurrence of late LA enlargement and changes in LA function during follow-up are scarce. The purpose of the current study was to evaluate changes in LA size and function during 1-year follow-up. METHODS: The study population comprised 407 patients with acute myocardial infarction who were treated with primary percutaneous coronary intervention. At baseline and 12 months, two-dimensional echocardiography was performed to assess LA volumes and function using speckle-tracking strain and strain rate. RESULTS: The mean age was 60 ± 11 years, and most patients were men (78%). LA maximal volume increased from 25 ± 8 to 28 ± 8 mL/m(2) (P < .001) from baseline to 1 year. Echocardiographic assessment at 1-year follow-up showed that 92 patients (25%) had developed LA remodeling (defined as an increase of ≥8 mL/m(2) in LA maximal volume). On multivariate analysis, only LA maximal volume at baseline (odds ratio, 0.95; 95% confidence interval, 0.91-0.98; P = .003) and LA strain at baseline (odds ratio, 0.94; 95% confidence interval, 0.92-0.97; P < .001) were independent predictors of LA remodeling during follow-up. Interestingly in patients without LA remodeling, no changes were observed in LA function during follow-up. However, in patients with LA remodeling, LA function significantly worsened during follow-up. In line, LA strain and strain rate were significantly lower at 12 months compared with baseline (24 ± 7% vs 27 ± 6%, P < .001, and 1.8 ± 0.5 vs 2.4 ± 0.7 sec(-1), P < .001, respectively). CONCLUSIONS: LA remodeling occurred in 22% of patients after acute myocardial infarction. In patients without LA remodeling, no changes in LA function were observed, but in patients with LA remodeling, LA function deteriorated significantly.

Distribution of culprit lesions in patients with ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention.

OBJECTIVES: Data regarding the distribution of vulnerable lesions in the coronary arteries are scarce. The aim was to evaluate the frequency and distribution of culprit lesions in patients with ST-segment elevation acute myocardial infarction. In addition, the location of culprit lesions was related to infarct size. METHODS: Consecutive patients (N=1533, mean age 61±12 years) were evaluated. All patients were treated with primary percutaneous coronary intervention and underwent two-dimensional echocardiography less than 48 h after admission. RESULTS: The majority of the culprit lesions were located in the left anterior descending coronary artery (LAD, 45%), followed by the right coronary artery (RCA, 38%), and left circumflex coronary artery (LCX, 14%). Subanalysis demonstrated that patients with a culprit lesion in the LAD and LCX had significantly higher-peak cardiac enzymes compared with patients with culprit lesions in the RCA. In addition, patients with proximal LAD and LCX lesions had significantly worse left ventricular function compared with patients with mid or distal lesions. CONCLUSION: Plaque rupture resulting in acute myocardial infarction is more likely to occur in the proximal parts of the LAD and RCA. In addition, the location of culprit lesions was related to infarct size. Therefore, knowledge of the distribution of vulnerable lesions is important for identifying patients at risk for acute coronary events.

Long-term outcome after ablative therapy of postoperative atrial tachyarrhythmia in patients with congenital heart disease and characteristics of atrial tachyarrhythmia recurrences.

BACKGROUND: Catheter ablation has evolved as a possible curative treatment modality for atrial tachyarrhythmia (AT) in patients with congenital heart defects (CHD). However, data on long-term outcome are scarce. We examined characteristics of recurrent AT after ablation of postoperative AT during long-term follow-up in CHD patients. METHODS AND RESULTS: CHD patients (n=53; 27 men; age, 38+/-15 years) referred for catheter ablation of AT were studied during a follow-up period of 5+/-3 years. After ablative therapy of the first AT (n=53, 27 atrial flutter, cycle length=288+/-81 ms; 22 intra-atrial reentrant tachycardia, cycle length=309+/-81 ms; 5 focal atrial tachycardia, cycle length=380+/-147 ms; success rate, 65%), AT recurred (59% within the first year) in 29 patients; 15 underwent repetitive ablative therapy. Mechanisms underlying recurrent AT were similar in 7 patients (intra-atrial reentrant tachycardia, 2; atrial flutter, 5). The location of arrhythmogenic substrates of recurrent AT (intra-atrial reentrant tachycardia, focal atrial tachycardia) was different for all but 1 patient. After 5+/-3 years, 5 patients died of heart failure, 3 were lost to follow-up, and the remaining patients had sinus rhythm (n=31), AT (n=5), or atrial flutter (n=14). Antiarrhythmic drugs were used by 18 (57%) sinus rhythm patients. CONCLUSIONS: Successive postoperative AT in CHD patients developing over time may be caused by different mechanisms, including focal and reentrant mechanisms. Recurrent AT originated from different locations, suggesting that these new AT were not caused by arrhythmogenicity of previous ablative lesions. Long-term outcome is often complicated by development of atrial fibrillation. Despite frequent need for repeat ablative therapy, most patients are in sinus rhythm.

Prognostic value of right ventricular function in patients after acute myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: Data on the association between right ventricular (RV) function and adverse events after acute myocardial infarction (AMI) are scarce. The purpose of the current study was to evaluate the relation between RV function and adverse events in patients treated with primary percutaneous coronary intervention for AMI. METHODS AND RESULTS: Consecutive patients admitted with AMI treated with primary percutaneous coronary intervention underwent echocardiography within 48 hours of admission to assess left ventricular and RV function. RV function was quantified with RV fractional area change (RVFAC), tricuspid annular plane systolic excursion, and RV strain. The end point was defined as a composite of all-cause mortality, reinfarction, and hospitalization for heart failure. All patients (n=621) were followed prospectively, and during a mean follow-up of 24 months, 86 patients reached the composite end point. RVFAC, tricuspid annular plane systolic excursion, and RV strain were all univariable predictors of worse outcome. After multivariable analysis, only RVFAC (hazard ratio, 0.96; 95% CI, 0.92 to 0.99) and RV strain (hazard ratio, 1.08; 95% CI, 1.03 to 1.13) independently predicted the composite end point. In addition, RV strain provided incremental value to clinical information, infarct characteristics, left ventricular function, and RVFAC. CONCLUSIONS: RV function provides strong prognostic information in patients treated with primary percutaneous coronary intervention for AMI.

Predictive value of total atrial conduction time estimated with tissue Doppler imaging for the development of new-onset atrial fibrillation after acute myocardial infarction.

Patients who develop new-onset atrial fibrillation (AF) after acute myocardial infarction (AMI) show an increased risk for adverse events and mortality during follow-up. Recently, a novel noninvasive echocardiographic method has been validated for the estimation of total atrial activation time using tissue Doppler imaging of the atria (PA-TDI duration). PA-TDI duration has shown to be independently predictive of new-onset AF. However, whether PA-TDI duration provides predictive value for new-onset AF in patients after AMI has not been evaluated. Consecutive patients admitted with AMIs and treated with primary percutaneous coronary intervention underwent echocardiography <48 hours after admission. All patients were followed at the outpatient clinic for > or =1 year. During follow-up, 12-lead electrocardiography and Holter monitoring were performed regularly, and the development of new-onset AF was noted. Baseline echocardiography was performed to assess left ventricular and left atrial (LA) function. LA performance was quantified with LA volumes, function, and PA-TDI duration. A total of 613 patients were evaluated. LA maximal volume (hazard ratio 1.07, 95% confidence interval 1.04 to 1.11), the total LA ejection fraction (hazard ratio 0.96, 95% confidence interval 0.93 to 0.99) and PA-TDI duration (hazard ratio 1.05, 95% confidence interval 1.04 to 1.06) were univariate predictors of new-onset AF. After multivariate analysis, LA maximal volume and PA-TDI duration independently predicted new-onset AF. Furthermore, PA-TDI duration provided incremental prognostic value to traditional clinical and echocardiographic parameters for the prediction of new-onset AF. In conclusion, PA-TDI duration is a simple measurement that provides important value for the prediction of new-onset AF in patients after AMI.

Three-year outcome of sirolimus-eluting versus bare-metal stents for the treatment of ST-segment elevation myocardial infarction (from the MISSION! Intervention Study).

To compare the long-term efficacy and safety of sirolimus-eluting stents (SES) to those of bare-metal stents (BMS) for ST-segment elevation myocardial infarction, outcomes were assessed in 310 patients (mean age age 59 +/- 11 years, 78% men) included in the randomized MISSION! Intervention Study: A Prospective Randomised Controlled Trial to Evaluate the Efficacy of Drug-Eluting Stents Versus Bare-Metal Stents for the Treatment of Acute Myocardial Infarction after a median follow-up period of 38 months. All patients were treated with aspirin (lifelong) and clopidogrel for 1 year after stent implantation. Except for a significant difference between reference vessel diameters (SES 2.76 mm vs BMS 2.92 mm, p = 0.02), there were no significant differences in baseline and angiographic characteristics between the treatment groups (158 SES, 152 BMS). A significant difference between SES and BMS patients for all revascularization end points was found after the first year of follow-up. However, at 3 years of follow-up, although there was still a trend toward better clinical outcomes in SES-treated patients, differences were no longer significant (death 4.4% vs 6.6%, p = 0.41; target vessel-related myocardial infarction 2.5% vs 4.6%, p = 0.32; target vessel revascularization 8.9% vs 15.8%, p = 0.06), target lesion revascularization 6.3% vs 12.5%, p = 0.06; and target vessel failure 12.0% vs 19.7%, p = 0.06). Three cases of very late (definite) stent thrombosis were observed in the SES group (1.9%) versus none in the BMS group (p = 0.14). In conclusion, the significant SES benefit (compared to BMS) in patients with ST-segment elevation myocardial infarctions at 1-year follow-up in terms of target vessel revascularizations decreased to some extent because of more similar target vessel revascularization rates during the 2 subsequent years. Rates of death and nonfatal recurrent MI remained comparable.

Impact of sirolimus-eluting stent implantation compared to bare-metal stent implantation for acute myocardial infarction on coronary plaque composition at nine months follow-up: a Virtual Histology intravascular ultrasound analysis. Results from the Leiden MISSION! intervention study.

AIMS: To evaluate effects of sirolimus-eluting stents (SES) compared to bare-metal stents (BMS) at stent edges in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: Clinical, angiographic, intravascular ultrasound (lVUS) and virtual histology (VH)-IVUS results were obtained and analysed in 20 SES and 20 BMS AMI patients at the index procedure and at nine months follow-up. Quantitative angiography and IVUS showed a trend toward decreases in mean lumen diameter, vessel volume, minimum lumen area and mean lumen area at both stent edges of BMS, and at the proximal edge of SES. At the distal stent edge, a significant difference between BMS and SES treated patients in mean lumen area was found (D-0.8+/-1.6 mm2 versus D0.2+/-0.8 mm2 respectively, p=0.04). Furthermore, in-stent SES had a larger lumen volume (SES: 167.7+/-59.2 mm3 versus BMS: 125.1+/-43.8 mm3; p=0.02) and less neointima volume (7.3+/-9.1 mm3 versus 53.2+/-35.1 mm3; p<0.001). Neither SES nor BMS demonstrated a significant effect on plaque composition at follow-up VH-IVUS analysis. CONCLUSIONS: A significant difference between SES and BMS treated patients was observed with respect to mean lumen diameter distal to the stented segment which suggests a downstream effect of sirolimus elution.