Peripheral venoarterial extracorporeal membrane oxygenation in combination with intra-aortic balloon counterpulsation in patients with cardiovascular compromise.

OBJECTIVES: Patients with profound cardiovascular compromise have poor prognosis despite inotropic and intra-aortic balloon pump (IABP) support. Peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers these patients temporary support as a bridge to various options including the 'bridge to recovery'. METHODS: We studied the outcomes of 135 patients who underwent peripheral V-A ECMO and concomitant IABP implantation in our hospital from 2007 to 2012 for various clinical indications. The ECMO circuit consisted of a centrifugal pump and an oxygenator. RESULTS: V-A ECMO was implanted in the cardiac catheterization laboratory in 51 patients (37.8%), at the bedside in 5 (3.7%) and in the operating room in 79 (58.5%). Mean duration of support was 8.5 ± 7.1 days. Median length of stay was 28 days (interquartile range 14-62). Complications included bleeding at the access site in 14.1%, stroke in 11.1% and vascular complications requiring intervention in 16.3%. Overall inhospital survival was 57.8% with outcomes including heart transplantation (3%), implantable left ventricular assist device (8.1% as bridge to transplantation and 6.7% as destination therapy), surgery (7.4%) and myocardial recovery (40.7%). Prior IABP use and axillary cannulation were independent predictors of reduced inhospital mortality, stroke or vascular injury. CONCLUSIONS: Peripheral V-A ECMO with IABP is an effective therapy for patients with severely compromised cardiovascular function. It offers reasonable survival and a spectrum of definitive options from 'bridge to recovery' to heart transplantation for the management of this critically ill population.

Door-to-balloon time in primary percutaneous coronary intervention predicts degree of myocardial necrosis as measured using cardiac biomarkers.

Reduced door-to-balloon time in primary percutaneous coronary intervention for the treatment of ST-elevation myocardial infarction has been associated with lower cardiac mortality rates. However, it remains unclear whether door-to-balloon time is predominantly a surrogate for overall peri-myocardial infarction care and is not independently predictive of outcomes, particularly when differences in door-to-balloon time have narrowed and previous studies have contained myocardial infarction-selection bias.We analyzed 179 consecutive patients who presented emergently at our cardiac catheterization laboratory with ST-elevation myocardial infarction within 12 hours of symptom onset and who underwent primary percutaneous coronary intervention within 3 hours of presentation. Our curve estimation regression model used the natural logarithm (ln) of area under the curve (AUC) of creatine kinase to evaluate the effect of door-to-balloon time on cardiac biomarker levels. We correlated ln (AUC-creatine kinase) with improvement of left ventricular ejection fraction at follow-up and with the intermediate-term mortality rate.Median door-to-balloon time was 87 minutes (interquartile range, 65-113 min). The ln (AUC-creatine kinase) correlated significantly with door-to-balloon time (r=0.2, P=0.02). Upon propensity-score analysis, door-to-balloon time remained a significant independent predictor of ln (AUC-creatine kinase) (beta=0.15, P=0.03). Upon use of a Cox regression model, ln (AUC-creatine kinase) independently predicted death (P=0.04) and recovery of left ventricular function (P=0.001) at follow-up (mean, 14 mo).Longer door-to-balloon time independently predicts increased myocardial cell damage, and ln (AUC-creatine kinase) predicts improvement in left ventricular systolic function and intermediate-term death after ST-elevation myocardial infarction.

Long-term clinical benefit of sirolimus-eluting stents compared to bare metal stents in the treatment of saphenous vein graft disease.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of sirolimus-eluting stents (SES) in the treatment of saphenous vein graft (SVG) disease. BACKGROUND: Percutaneous coronary intervention (PCI) of SVG lesions with bare metal stents (BMS) is associated with frequent in-stent restenosis, progression of disease in nonstented SVG segments, and suboptimal clinical outcomes. While SES have been shown to reduce restenosis rates in various native lesion subsets, the long-term clinical impact of SES use in SVG lesions is less clear. METHODS: We compared our first 59 patients who underwent SES implantation in SVGs with 50 consecutive patients who received BMS in an equivalent time period prior to SES availability. Clinical outcomes were compared in both groups. RESULTS: Baseline clinical variables between the two groups were similar. Mean graft age in the SES cohort was older than that in the BMS cohort (12.9 years vs. 9.4 years). At follow-up, the SES group had a 24.6% absolute lower incidence of major adverse cardiac events (MACE) (25.4% vs. 50.0%), driven by a 20.7% absolute lower incidence of target vessel revascularization (TVR) (15.3% vs. 36.0%). The SES treatment group had a 24.1% lower rate of clinical restenosis (11.9% vs. 36.0%). The use of a SES was an independent negative predictor of MACE at a mean follow-up of 20 months (odds ratio [OR]= 0.48,P = 0.03). CONCLUSIONS: Despite the placement of longer stents in patients with older, smaller SVGs, the use of SES in the treatment of SVG lesions appears to be safe and is associated with less clinical restenosis and more favorable long-term clinical outcomes as compared with BMS.