Does reducing ischemia time justify to catheterize firstly the culprit artery in every primary PCI?

No consensus exists about which coronary artery should be firstly catheterized in primary PCIs. Initial catheterization of the "culprit artery" could reduce reperfusion time. However, complete knowledge of coronary anatomy could modify revascularization strategy. The objective of the study was to analyze this issue in ST-elevation myocardial infarction patients undergoing primary PCI. PCIs were performed in 384 consecutive patients. Choice of ipsilateral approach (IA): starting with a guiding catheter for the angiography and PCI of the "culprit artery", or contralateral approach (CA): starting with a diagnostic catheter for the "non-culprit artery" and completing the angiography and PCI of the culprit with a guiding catheter was left to the operator. Differences between two approaches regarding reperfusion time, acute events or revascularization strategies were analyzed. There were no differences between two approaches regarding reperfusion time or clinical events. When the left coronary artery was responsible, IA was more frequent (76.4 vs 22.6 %), but when it was the right coronary artery, CA was preferred (20 vs 80 %); p < 0.0001. With CA, bare metal stents (BMS) were more used than drug eluting (DES) (60.8 vs 39.2 %) inversely than with IA (BMS 41.3 vs DES 59.7 %; p < 0.0001). With CA there were more patients with left main or multivessel disease in which revascularization was completed with non-urgent surgery (4.13 vs 2.4 %, p < 0.0001). Initial CA does not involve higher reperfusion time. Furthermore, overall knowledge of coronary anatomy offers more options in revascularization strategy and may imply a change in management. Despite the need to individualize each case, contralateral approach may be the first option with the exception of unstable patients.

Role of hydration in contrast-induced nephropathy in patients who underwent primary percutaneous coronary intervention.

To investigate the role of hydration to prevent contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PPCI), we prospectively included 408 consecutive patients who were randomly assigned to receive either hydration with isotonic saline (1 ml/kg/h since the beginning of the procedure and for 24 hours after it: NS+ group) or not (NS- group). All patients received an iso-osmolar nonionic contrast medium. The primary end point was the development of CIN: ≥25% or ≥0.5 mg/dl increase in serum creatinine within 3 days after the procedure. CIN was observed in 14% of patients: 21% in the NS- group and 11% in the NS+ group (p=0.016). CIN was significantly associated with death (15.2% vs 2.8%; p<0.0001) and need for dialysis (13.4% vs 0%; p<0.0001). In multivariate analysis, the only predictors of CIN were hydration (OR=0.29 [0.14 to 0.66]; p=0.003) and the hemoglobin before the procedure (OR=0.69 [0.59 to 0.88]; p<0.0001). In conclusion, intravenous saline hydration during PPCI reduced the risk of CIN to 48%. Patients with CIN had increased mortality and need for dialysis. Given the higher incidence of CIN in emergent procedures, and its morbidity and mortality, preventive hydration should be mandatory in them unless contraindicated.

Coronary artery perforation: don't rush, IVUS may be useful.

Coronary artery perforation (CAP) is a rare but potentially fatal complication of percutaneous coronary intervention. Polytetrafluoroethylene-covered stents prevent blood leakage between struts with a high rate of success. However, they lack elasticity and rapid and correct deployment is difficult. They have also a higher rate of stent restenosis and thrombosis. For these reasons, optimal deployment is essential. Although severe CAP needs an emergent solution, after stabilizing the patient, intracoronary imaging techniques may be useful to ensure correct expansion and reduce further adverse events. We present a case that shows the potential role of intravascular ultrasound in the resolution of a CAP.

Post-resuscitation electrocardiograms, acute coronary findings and in-hospital prognosis of survivors of out-of-hospital cardiac arrest.

BACKGROUND: Identification of acute coronary lesions amenable to urgent intervention in survivors of out-of-hospital cardiac arrest is crucial. We aimed to compare the clinical and electrocardiographic characteristics to urgent coronary findings, and to analyze in-hospital prognosis of these patients. METHODS: From January 2005 to December 2012 we retrospectively identified consecutive patients resuscitated from out-of-hospital cardiac arrest, and analyzed the clinical characteristics, post-resuscitation electrocardiogram and coronary angiogram of those who underwent emergent angiography. Mortality and neurologic status at discharge were also assessed. RESULTS: Patients with ST-elevation more frequently had obstructive coronary artery disease (89% vs. 51%, p<0.001) or acute coronary occlusions (83% vs. 8%, p<0.001) than patients without ST-elevation. Independent predictors of an acute coronary occlusion were chest pain before arrest (OR 0.16, 95% CI 0.04-0.7, p=0.01), a shockable initial rhythm (OR 0.16, 95% CI 0.03-0.9, p=0.03), and ST-elevation on the post-resuscitation electrocardiogram (OR 0.02, 95% CI 0.004-0.13, p<0.001). Survival with favorable neurologic recovery at discharge was 59%. Independent predictors of mortality or unfavorable neurological outcome at discharge were absence of basic life support (OR 0.2, 95% CI 0.06-0.9, p=0.04), prolonged resuscitation time (OR 0.9, 95% CI 0.8-0.9, p=0.01), and necessity of vasopressors (OR 14.8, 95% CI 3.3-65.4, p=0.001). CONCLUSIONS: Most patients with ST-elevation on the post-resuscitation electrocardiogram had an acute coronary occlusion, as opposed to patients without ST-elevation. Absence of basic life support, prolonged resuscitation time and use of vasopressors were independent predictors of worse in-hospital outcome.