Effectiveness of primary percutaneous coronary intervention for acute ST-elevation myocardial infarction from a 5-year single-center experience.

Primary percutaneous coronary intervention (PCI) is currently viewed as the preferred reperfusion strategy in patients with ST-elevation acute myocardial infarction (STEMI). This method was introduced in our hospital in 2000. From January 1, 2000, to December 31, 2004, a total of 2,393 consecutive patients with STEMI were admitted (27% transferred from 9 non-PCI hospitals and 31 prehospital emergency units/outpatient clinics). Of these patients, 1,666 (70%) underwent urgent coronary angiography and primary PCI. Platelet glycoprotein llb/llla inhibitors were used in 40% and stent placement, in 78%. Postprocedural Thrombolysis In Myocardial Infarction (TIMI) 3 flow was documented in 86%. Intra-aortic balloon counterpulsation was used in 6%; mechanical ventilation, in 8.6%; and inotropic drugs/vasopressors, in 15.8%. Mortality rates in patients with Killip's class I or II ranged from 1% to 4.9% without negative influence of ischemic time. In patients with Killip's class III or IV, mortality rates increased from 18% to 54% with increasing ischemic delay up to 6 hours (p = 0.06) and remained at around 40% afterward. Independent predictors of mortality were age (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01 to 1.64, p = 0.04), resuscitated cardiac arrest (OR 2.44, 95% CI 1.18 to 5.05, p = 0.02), and postprocedural TIMI flow (OR 0.31, 95% CI 0.16 to 0.59). Overall mortality rates of patients who underwent a primary PCI strategy from 2000 to 2004 were significantly lower than in the control group of 152 consecutive patients who underwent thrombolysis from 1995 to 1996 (6.2% vs 16.4%; p <0.001). In conclusion, introduction of a primary PCI strategy significantly decreased hospital mortality in our unselected group of patients with STEMI compared with the thrombolytic era. Our study further emphasized the importance of shortening myocardial ischemic time, particularly in the presence of severe heart failure on admission.

Cardiac granulocytic sarcoma diagnosed by intracardiac echocardiography-guided biopsy.

A 52-year-old man presented with clinical and echocardiographic signs of cardiac tamponade. A transthoracic echocardiogram revealed a large right atrial mass that obstructed the superior vena cava flow. Cardiac magnetic resonance imaging and computed tomography demonstrated extracardiac tumour invasion of the free atrial wall extending to the right pulmonary hilus. Intracardiac echocardiography-guided biopsy of the tumour revealed the tissue diagnosis-granulocytic sarcoma of the heart. The patient was effectively treated with radiotherapy, chemotherapy and allogeneic haematopoietic stem cell transplantation. He has remained free of the disease for 12 months after treatment.

Sympathetic reinnervation after heart transplantation, assessed by iodine-123 metaiodobenzylguanidine imaging, and heart rate variability.

OBJECTIVE: Complete allograft denervation occurs during heart transplantation. Partial ventricular sympathetic reinnervation may develop one year or later after transplantation and can be measured with iodine-123-meta-iodobenziylguanidine (MIBG) uptake. Aim of this study was to assess sinus node sympathetic reinnervation measured with heart rate variability and ventricular sympathetic reinnervation evaluated with MIBG. METHODS: Twelve patients and 14 healthy controls were included. In patients, MIBG scintigraphy with early and late imaging was performed. Heart to mediastinum ratio (HMR) was calculated and patients were divided in groups with (HMR>1.3) and without left ventricular reinnervation (HMR<1.3). Bipolar ECG with high sampling rate and resolution was recorded over 8.5 min in supine position and in upright position after 10 min interval. R-R intervals in time domain and heart rate variability in frequency domain through spectral power analysis of R-R intervals were analysed to evaluate sinus node reinnervation. Spectral power in low frequency range (0.04-0.15 Hz) above 4.5 ms(2) was considered as sinus node sympathetic reinnervation. RESULTS: Six (50%) patients had evidence of left ventricular sympathetic reinnervation on scintigraphy. Sinus node sympathetic reinnervation based on heart rate variability was detected in 6 (50%) patients in supine, and in 4 (33%) patients in upright body position. Four patients groups were discerned: (1) with ventricular and sinus node sympathetic reinnervation, (2) with sinus node sympathetic reinnervation, (3) with ventricular sympathetic reinnervation and (4) without atrial or ventricular sympathetic reinnervation. Ventricular reinnervation process was time dependent and sinus node reinnervation was not. CONCLUSIONS: Simultaneous ventricular sympathetic reinnervation assessed by MIBG and sinus node sympathetic reinnervation assessed by heart rate variability in supine as in upright position were detected only in two patients (17%). The results of our study show that eventual sinus node sympathetic reinnervation and left ventricular sympathetic reinnervation do not occur simultaneously.

Severe coronary ectasia and tortuosity--an unpleasant finding during percutaneous revascularization in acute coronary syndrome.

Percutaneous coronary revascularization plays an important role in the management of acute coronary syndrome. Unpredictable angiographic findings of severe coronary ectasia and tortuosity may, however, compromise the otherwise high and predictable success rates of this intervention. We report on two patients with acute coronary syndrome in whom difficult anatomy precluded successful percutaneous recanalization of the culprit vessel.

Coronary balloon angioplasty in a severe takotsubo syndrome.

ABSTRACT: We reported a patient with Takotsubo syndrome, with severe symptoms, prolonged angina with hemodynamic compromise, in the context of severe coronary artery spasm, without response to full medical treatment, which was successfully managed with coronary balloon angioplasty. A 49-year old woman was admitted with chest pain, ECG changes and elevated myocardial necrosis markers suggestive for acute coronary syndrome. First coronary angiography revealed normal epicardial arteries and typical left ventricular apical ballooning, strongly suggestive for Takotsubo syndrome. Forty-eight hours later, with standard medical treatment, patient developed again severe angina with hemodynamic consequences. Second angiography showed total occlusive spasm of one coronary artery, without response to full medical treatment. Coronary balloon angioplasty was performed with final good result. Two month later, angiography revealed normal coronary arteries and normal ventricular shape. The patient is currently asymptomatic.As far as we know, no other examples of similar cases were published in medical literature. Therefore, interventional treatment can be taken into consideration for some particular types of patients with Takotsubo syndrome, non-responsive to medical treatment; despite of balloon angioplasty or stenting of coronary vasospasm is not a standard of care.

CTSS activation coexists with CD40 activation in human atheroma: evidence from plasma mRNA analysis.

OBJECTIVES: By the analysis of plasma mRNA levels, we tested the hypothesis that, in human atheroma, CTSS activation coexists with activation of CD40. DESIGN AND METHODS: mRNAs were isolated from plasma of patients with coronary atherosclerosis and quantified by real-time RT-PCR. RESULTS: CTSS mRNA levels correlated with CD40 mRNA levels, independently of observed traditional risk factors for atherosclerosis and pharmacological treatment. CONCLUSIONS: Our results suggest that CTSS mediated atherogenesis may be associated with a CD40 mediated inflammatory and immune response. Further invasive atheroma analysis is reasonable.

Increased DAPK1 but decreased CCL2 plasma levels of nucleic acids in patients with stable angina.

INTRODUCTION: We hypothesized that patients with stable angina have increased plasma levels of mRNA from genes responsible for atherosclerotic plaque development and destabilisation, i.e. from death-associated protein kinase (DAPK1) and monocyte chemotactic protein-1 (CCL2). MATERIALS AND METHODS: Nucleic acids were isolated from plasma of patients with stabile angina and healthy subjects as controls. mRNAs were transcribed to cDNAs, quantified by real-time PCR and standardized to the amount of a reference gene. Reagents for PCR quantification are declared to be mRNA specific, but in our test conditions DNA was found to interfere in both assays. RESULTSs: Patients had 5.1-times higher plasma level of DAPK1 nucleic acids (mRNA and DNA) than controls (P < 0.001) and the highest levels were associated with the presence of diabetes. However, plasma levels of CCL2 tended to be lower than in controls, and in statin-treated patients the decrement reached significance (-66.3%; P = 0.041). CONCLUSION: The estimated levels are explicable in terms of current knowledge. Further studies with specific assays for mRNA PCR quantification are reasonable to access whether this approach offers non-invasive in vive assessment and monitoring of gene expression profile in atherosclerotic vascular beds.

Increased plasma levels of CATS mRNA but not CATB mRNA in patients with coronary atherosclerosis.

BACKGROUND: We hypothesized that patients with coronary atherosclerosis have increased plasma levels of cathepsin S (CATS) and cathepsin B (CATB) mRNA, the genes that are involved in atherosclerotic plaque development and destabilization. METHODS: mRNAs were isolated from plasma of 67 patients with coronary atherosclerosis (29 with stable angina, 38 with acute coronary syndrome) and 33 healthy subjects as controls, transcribed to cDNA and quantified by real-time PCR. RESULTS: Plasma levels were successfully measured in all samples. Patients with coronary atherosclerosis had 2.75 times higher plasma levels of CATS mRNA than controls (median 6.10 vs. 2.22; p<0.001). No difference was observed in CATB mRNA levels (median 5.62 vs. 6.19; p=0.866). Patients on therapy with statins and aspirin tended to have higher plasma levels of CATS mRNA than patients without statins and aspirin (median 6.41 vs. 4.27; p=0.028). CONCLUSIONS: Further evaluation of plasma CATS mRNA levels in patients with coronary atherosclerosis is reasonable.

Successful percutaneous septal alcohol ablation after surgical myectomy.

Hypertrophic obstructive cardiomyopathy (HOCM) is a primary, usually familial and genetically fixed myocardial hypertrophy, with dynamic left ventricular outflow tract obstruction. An alternative to surgical myectomy in the treatment of severe, drug refractory, HOCM is percutaneous transluminal septal myocardial ablation (PTSMA). We report a case of 24 year old female patient who had the first septal myectomy but because of progression of her disease, the percutaneous treatment of hypertrophic obstructive cardiomyopathy was performed. A year after the PTSMA the patient was without of symptoms.

Percutaneous coronary interventions in Europe 1992-2003.

AIMS: The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe. We report the data of the year 2003 and give an overview of the development of coronary interventions since 1992, when the first data collection was performed. METHODS AND RESULTS: Questionnaires were distributed yearly to delegates of all national societies of cardiology represented in the European Society of Cardiology to collect the case numbers of all local institutions and operators. The overall numbers of coronary angiographies increased from 1992 to 2003 from 684,000 to 1,993,000 (from 1,250 to 3,500 per million inhabitants). The respective numbers for percutaneous coronary interventions (PCI-coronary angioplasty) and coronary stenting procedures increased from 184,000 to 733,000 (from 335 to 1,300) and from 3,000 to 610,000 (from 5 to 1,100), respectively. Germany has been the most active country for the past years with 653,000 angiographies (7,800), 222,000 angioplasties (2,500), and 180,000 stenting procedures (2,200) in 2003. The indication has shifted towards acute coronary syndromes, as demonstrated by raising rates of interventions for acute myocardial infarction over the last decade. The procedures are more readily performed and safer, as shown by increasing rate of "ad hoc" PCI and decreasing need for emergency coronary artery bypass surgery (CABG). In 2003, use of drug-eluting stents had further increased. However, an enormous variability is reported with the highest rate in Portugal (55%). CONCLUSION: Interventional cardiology in Europe is still expanding, mainly but not exclusively due to rapid growth in the eastern European countries. A number of new coronary revascularization procedures introduced over the years have all but disappeared. Only stenting has experienced an exponential growth. The same can be forecast for drug-eluting stenting.