Procedural and Clinical Outcomes in Management of Bifurcational Lesions in ST Elevation Myocardial Infarction.

BACKGROUND: Bifurcation percutaneous coronary intervention (PCI) remains a challenging frontier in interventional cardiology, especially in the setting of ST-elevation myocardial infarction (STEMI). We examined the procedural and clinical outcomes of this patient subset. METHODS: We conducted a retrospective case-control study. Between February 2006 and March 2011, 129 patients with STEMI underwent bifurcation PCI at our institution. One hundred and twenty-nine (129) control STEMI patients with non-bifurcation PCI were selected from the institutional database, matched for age, gender, culprit vessel, and lesion location. Patients with cardiac arrest, cardiogenic shock, or who required mechanical ventilation were excluded. Twelve (12)-month follow-up data were collected by telephone calls and examination of the medical records. RESULTS: The average age of patients presenting with STEMI was 61.6 ± 13.1 in the bifurcation group and 61.5 + 31.1 in the non-bifurcation group. There was no difference in lesion type, use of thrombus aspiration catheters, or glycoprotein inhibitors (GPI) among them. Also, the use of drug eluting stent (DES), total cumulative length of stent used, and diameter of the post-dilation balloon were similar. Final kissing balloon post-dilation was performed in 40.3% of bifurcation PCI cases. The incidence of procedural failure (TIMI 0 flow) was 1.5% vs. 0%; p = 0.478. At 12-months follow-up, the bifurcation PCI group had higher incidence of target lesion revascularisation (TLR) (10.9% vs. 3.9%, p = 0.050), mortality (10.1% vs. 2.3%, p = 0.020), and stent thrombosis (9.3% vs. 1.6%; p = 0.013); comprising one acute, nine subacute, and two late vs. two subacute stent thromboses. CONCLUSIONS: During acute STEMI, bifurcation PCI has excellent acute procedural outcomes, but significantly increased incidence of TLR, stent thrombosis and mortality at 12 months.

Outcomes After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Caused by Ectatic Infarct Related Arteries.

BACKGROUND: There is minimal published data on outcomes of patients presenting with ST elevation myocardial infarction (STEMI) due to an ectatic infarct-related artery (EIRA). The aim of this study was to analyse the clinical characteristics and outcomes of these patients presenting for primary percutaneous coronary intervention (P-PCI) in comparison with non-EIRA. METHODS: Of the 1834 patients who presented at our institution for P-PCI between February 2008 and November 2013, 25 (1.4%) were identified as having an EIRA. These patients were compared with those with non-EIRA (80 patients) who were age, gender and lesion matched. Further sub-group analysis on in-hospital and long-term outcomes was done comparing EIRA stented and non-stented patients. Clinical events evaluated include death, recurrent infarction, unstable angina, or target lesion revascularisation (TLR). RESULTS: Baseline characteristics were similar between patients with EIRA and non-EIRA although none of those with EIRA had diabetes mellitus. By comparison to the non-EIRA group, the major procedural differences for patients with EIRA were (1) a greater incidence of large thrombus burden (96.0% vs 22.5%, p=0.0001), (2) increased usage of peri-procedural glycoprotein IIb/IIIa inhibitors (72.0% vs 37.5%, p=0.01) and post-procedural anticoagulation (28.0% vs 5.0%, p=0.004), (3) larger mean stent dimension (3.9±0.8mm vs 3.4±0.6mm, p=0.04) and (4) a higher percentage of P-PCI cases that did not have stent deployment (44.0% vs 7.5%, p=0.0001). Patients with STEMI from EIRA had similar in-hospital outcomes but a higher long-term incidence of composite cardiovascular events at mean follow-up of 36.6±14.1months (44.0% vs 16.3% for non-EIRA, p=0.01). Although patients with EIRA who received stenting had better in-hospital outcomes than the non-stented cohort (composite cardiovascular event rate: 0.0% vs 36.4%, p=0.03), long-term outcomes were comparable (35.7% vs 54.6%, p=0.59) due to a relatively high frequency of non-fatal MI and unstable angina in both groups. CONCLUSION: Patients with STEMI due to EIRA carry worse long-term outcomes than those with non-EIRA. While successful stent deployment in the setting of EIRA improves procedural and inpatient success rates, it does not necessarily convey benefit to long-term event rates due to recurrent acute coronary syndromes.

Persistent type III cavity-spilling coronary perforation due to covered stent malapposition.

Coronary perforations are a rare but potentially catastrophic complication of percutaneous coronary intervention. We report a rare case of a large cavity-spilling perforation from the left anterior descending coronary artery into the left ventricle, which was successfully treated with a covered stent. However, repeating angiography 1 week later demonstrated persistence of the perforation due to stent malapposition.