Patient Characteristics, Procedural Details, and Outcomes of Contemporary Percutaneous Coronary Intervention in Real-World Practice: Insights from Nationwide Thai PCI Registry.

Background: Percutaneous coronary intervention (PCI) practice and outcomes vary substantially in different parts of the world. The contemporary data of PCI in Asia are limited and only available from developed Asian countries. Objectives: To explore the pattern of practice and results of PCI procedures in Thailand as well as a temporal change of PCI practice over time compared with the registry from other countries. Methods: Thai PCI Registry is a prospective nationwide registry that was an initiative of the Cardiac Intervention Association of Thailand (CIAT). All cardiac catheterization laboratories in Thailand were invited to participate during 2018-2019, and consecutive PCI patients were enrolled and followed up for 1 year. Patient baseline characteristics, procedural details, equipment and medication use, outcomes, and complications were recorded. Results: Among the 39 hospitals participated, there were 22,741 patients included in this registry. Their mean age (standard deviation) was 64.2 (11.7) years and about 70% were males. The most common presentation was acute coronary syndrome (57%) with a high proportion of ST-elevation myocardial infarction (28%). Nearly two-thirds of patients had multivessel disease and significant left main stenosis was reported in 11%. The transradial approach was used in 44.2%. The procedural success rate was very high (95.2%) despite the high complexity of the lesions (56.9% type C lesion). The incidence of procedural complications was 5.3% and in-hospital mortality was 2.8%. Conclusion: Thai PCI Registry provides further insights into the current practice and outcomes of PCI in Southeast Asia. The success rate was very high, and the complications were very low despite the high complexity of the treated lesions.

Visual-functional mismatch and results of fractional flow reserve guided percutaneous coronary revascularization.

OBJECTIVE: To identify mismatches in the significance ofcoronary artery stenosis determined by physician 's visual estimation (VE) vs. quantitative coronary angiography (QCA), by VE vs. fractional flow reserve (FFR), and independent predictors for mismatch between VE and FFR. Second objective was to evaluate the clinical outcomes ofpatients receiving FFR-guided percutaneous coronary intervention (PCI). MATERIAL AND METHOD: Two hundreds eighty consecutive patients (338 coronary lesions including non-left main (non-LM) 316 lesions and left main (LM) 22 lesions) underwent coronary angiography, offline edge detection QCA, and FFR measurement between August 2011 and December 2013 were included in the present study. Baseline patient data, lesion characteristics, and clinical outcomes were recorded and analyzed. Coronary lesions were then divided into four groups according to FFR results and treatment (FFR <0.75 and PCI, FFR 0.75-0.80 and PCI, FFR 0.75-0.80 and defer PCI, FFR >0.80 and defer PCI). Mismatches in the significance of coronary artery stenosis determined by VE vs. QCA, VE vs. FFR, independent predictors of VE-FFR mismatch, and clinical outcomes after FFR-guided treatment were reported. RESULTS: Lesions with VE-QCA mismatch were seen in 64% of non-LM lesions and in 87% of the LM lesions. Conversely, lesions with VE-QCA reverse mismatch were seen in 13% of non-LM lesions and in 0% of the LM lesions. Lesions with VE-FFR mismatch were seen in 42% of non-LM lesions and in 53% of the LM lesions. Lesions with VE-FFR reverse mismatch were seen in 15% of non-LM lesions and in 14% of the LM lesions. The independent predictors for VE-FFR mismatch in non-LM lesions were shorter lesion and greater minimal lumen diameter. After FFR guided-treatment and dividing coronary lesions into four groups, all patients were followed-up for a median period of 11.6 (IQR; 7.3, 17.6) months. Major adverse cardiovascular events (excluded one death) of 338 lesions were not significantly different in the four groups (1.7% vs. 5.1% vs. 5.3% vs. 2.7%, p = 0.717). The median cost ofprocedure of lesions undergone FFR plus additional PCI was significantly higher than lesions undergone FFR only (140,000 vs. 137,000 vs. 45,000 vs. 45,000 Baht, p<0.001). CONCLUSION: Mismatches between visually-estimated significance of angiographic coronary stenosis and QCA or FFR are frequently encountered. Visual estimation of coronary angiography alone cannot entirely predict functional significance of coronary stenosis. FFR measurement provides a helpful strategy for decision making before further revascularization.

Cases report: Experience with rheolytic thrombectomy device (Angiojet) in acute ST elevation myocardial infarction with large amount of coronary thrombus.

BACKGROUND: Primary percutaneous coronary intervention (PCI) in acute ST elevation myocardial infarction (STEMI) is a clinical challenge. Adequate thrombus removal before stenting is an important factor that predicts procedural success, and finally reflects to clinical outcomes. CASES REPORT: In the present report, 2 cases of acute STEMI underwent primary PCI. Coronary angiogram (CAG) in both cases showed a large amount of coronary thrombus (TIMI thrombus grade 4 & grade 5), with no response to several attempts of manual aspiration with thrombus aspiration catheter Then, Angiojet rheolytic thrombectomy, a catheter-based, device was used antegradely. Repeated CA G showed thrombus was significantly eliminated. Both patients were successfully stented with direct stent technique at culprit arteries, resulted in good angiographic results and inhospital outcomes. CONCLUSION: Angiojet, a rheolytic thrombectomy device, is a viable option to remove thrombus in primary PCI, especially in cases with massive thrombus load and failed manual aspiration.

Percutaneous coronary intervention in patients with anomalous origin of coronary artery.

Percutaneous coronary intervention in patients with anomalous origin of right coronary artery from left sinus of Valsalva was performed in Central Chest Institute during 2005-2009. The diagnosis of this type of congenital anomaly is always difficult, since it requires high operator's consideration and experience. Standard catheter curve desired for general coronary angiography is also not suitable for the abnormal origin of artery, especially when coronary intervention is to be performed. The authors report a series of these anomalous coronary patients with atherosclerotic disease who underwent transcatheter coronary intervention using Extra Backup left coronary guiding catheters, which help cannulation of the anomalous ostium and enhance the operation success.

Factors related to in-hospital heart failure are very different for unstable angina and non-ST elevation myocardial infarction.

Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) resulted in different degrees of damage to the heart muscle, and yet, when factors related to in-hospital outcomes were examined, these two subsets were often lumped together as non-STelevation acute coronary syndrome. Therefore, we investigated predictors of in-hospital heart failure (HF) in UA and NSTEMI separately. Factors related to HF (Killip > or = 2) were analyzed for NSTEMI and UA in a Thai Acute Coronary Syndrome (ACS) registry conducted in 17 institutions between 2002 and 2005. The registry comprised of 9373 single admissions age 65.1 +/- 12.3 years, 40.2% women, and 45.1% with HF. There were 3548 NSTEMI and 1989 UA with HF prevalence of 56.2% and 27.4%, respectively. Heart failure patients were older, more were women, sicker (as shown by more of those with shock, postcardiac arrest, and breathless on admission), more with diabetes mellitus (DM), received less intervention and medication, and showed higher total death (19.3% vs 5.3% for NSTEMI with and without HF; and correspondingly, 5.9% and 1.9% for UA). Independent predictors (at presentation) for the development of HF following NSTEMI or UA were age (not sex), breathlessness, and less prevalence of chest pain. However, shock and DM were risks only for NSTEMI but not UA. Heart failure was found to be a factor for in-hospital death for NSTEMI only, with odds ratio of 2.84 (confidence interval 2.11-3.82) and 3.23 (2.25-4.64) for total and cardiac deaths, respectively. Non-ST-elevation myocardial infarction and UA showed substantial differences in factors related to predictors for in-hospital outcome such that these should be examined separately.

Experience of percutaneous mechanical mitral commissurotomy using metallic commissurotome in patients with mitral stenosis at chest disease institute.

BACKGROUND: Percutaneous metallic mitral commissurotomy (PMMC) has been accepted as an alternative to the traditional balloon technique. The advantage of the metallic commissurotome is that it is designed for several reuse and resterization and it is an interesting tool as seen by the authors. OBJECTIVE: To evaluate the efficacy and safety of PMMC among a wide range of patients with severe mitral stenosis. MATERIAL AND METHOD: Between July 2000 and August 2003, patients with severe mitral stenosis who underwent PMMC were enrolled Interatrial septum was punctured under transesophageal echocardiography guidance in all cases. Demographic data and baseline characteristics were collected Mitral valve area (MVA) was evaluated by echocardiography and hemodynamic parameters pre and post PMMC were compared RESULTS: PMMC was performed in 304 patients with a broad range of severe mitral stenosis. Mean age was 38.7 +/- 10. 9 years and 79% was female. Most were in functional class 11 (94%) and 43 patients (14%) had prior commissurotomy. Atrial fibrillation was found in 41%. Twenty-six patients were crossed over to the Inoue balloon technique. The rate of success was 81% in all patients (246/304) and 89% in patients when PMMC was actually done (246/278). The MVA increased from 84 +/- 22 to 170 +/- 36 mm2 (p < 0.0001). Transvalvular gradient decreased from 17 +/- 6 to 7 +/- 4 mmHg (p < 0.0001) and mean left atrial pressure from 26 +/- 7 to 15 +/- 6 mmHg (p < 0.0001). Separation of both commissures was found in 25% and 61% had symptom relief by a reduction in functional class at least one level (p < 0.0001). Complications developed in 16 patients (5.3%) including three serious events, one death caused by severe mitral regurgitation followed by emergency surgery, another survivor after surgical repair of left ventricular free wall rupture and the last one with surgical removal of the malfunctioned device stuck in the left atrium. CONCLUSION: Results of PMMC is not as encouraging as shown in previous studies. The risk of cardiac tamponade is minimized by interatrial septal puncture using transesophageal echocardiography (TEE) monitoring but this technique increased the possibility of crossover. Deterioration of the metallic commissurotome after a few procedures is demonstrated in the author's real practice.

Effect of un-fractionated heparin and low molecular weight heparin on hospital mortality in patients with non ST elevation acute coronary syndrome (ACS).

BACKGROUND: The Thai ACS registry is a multi-center prospective registration that describes the epidemiology, management practices and in-hospital outcomes of patients with acute coronary syndromes. OBJECTIVE: Study the registry difference in hospital outcomes about cardiac death and length of stay between low molecular weight heparin (LMWH) and un-fractionated heparin (UFH). MATERIAL AND METHOD: This is an observational descriptive study. The authors collected data from the database of the Thai ACS registry. RESULTS: There were 233 of 3963 cases (5.9%) with cardiac death in the present study. Cardiac death in the non-ST elevated myocardial infraction (NSTEMI) group was larger than in the UA group (7.6% vs. 2.4%, p-value < 0.001). The heparin group had more cardiac death than the LMWH group (9.3% vs. 5.2%, p-value < 0.001). NSTEMI with heparin treatment had more cardiac deaths than LMWH treatment (11.8% vs. 6.8%, odd ratio 1.8). UA with heparin treatment had more cardiac deaths than LMWH treatment (4.0% vs. 2.0%, odd ratio 2.0). NSTEMI had a longer length of stay than UA (56.9% vs. 44.7%, p-value = 0.001). The heparin group had a longer stay than LMWH (58.8% vs. 51.7%, p-value < 0.001). CONCLUSION: Low molecular weight heparin had benefit over un-fractionated heparin in reduction of hospital mortality and length of stay in both unstable angina and non-ST elevation myocardial infarction.

Significance of lead aVR ST segment elevation in acute coronary syndrome.

OBJECTIVES: To study the relation between lead aVR ST segment elevation (aVRSTE) and angiographic_coronary artery lesions in patients with acute coronary syndrome (ACS). MATERIAL AND METHOD: From January 2001 to December 2001, the authors retrospectively studied 26 consecutive patients who were admitted to the coronary care unit, Chest Disease Institute with ACS. The admission 12-lead EKGs,chest X-ray, troponin T, creatine phosphokinase (CPK), creatine kinase MB fraction (CK MB) and blood chemistry including fasting blood sugar, renal function test (BUN and creatinine), electrolytes and lipid profiles were obtained and analyzed before coronary angiogram. CAG was performed in all within 48 hours after admission. The admission 12-lead EKGs and angiographic coronary artery lesions were analyzed. RESULTS: There were 26 patients (M:F = 21:5) with a mean age of 64 +/- 9 yr. The culprit lesions were located at the left main coronary artery (LM) in 5 (19%), the left anterior descending artery (LAD) in 8 (31%), the right coronary artery (RCA) in 11 (42%) and the left circumflex artery (LCX) in 2 (8%). Of these, aVRSTE (> 0.1 mV) was detected in 9 (35%), 4 in the LM group (80%). 3 in the RCA group (27%) and 2 in the LAD group (25%). The findings of aVRSTE distinguished the LM group from the non LM group (LAD, RCA and LCX), with 80% sensitivity, 76% specificity and 77% accuracy. CONCLUSION: In patients with acute coronary syndrome, lead AVR ST segment elevation is associated with the culprit left main coronary lesion.