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.

Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled analysis at the patient-level of 4 registries.

OBJECTIVES: This study sought to investigate the clinical impact of the use of intravascular ultrasound (IVUS) during revascularization of patients with left main coronary artery (LM) disease with drug-eluting stents (DES). BACKGROUND: Whether the use of IVUS during the procedure adds a clinical benefit remains unclear. There is only 1 previous observational study, with relevant limitations, supporting the value of this strategy. METHODS: We performed a patient-level pooled analysis of 4 registries of patients with LM disease treated with DES in Spain. A propensity score-matching method was used to obtain matched pairs of patients with and without IVUS guidance. RESULTS: A total of 1,670 patients were included, and 505 patients (30.2%) underwent DES implantation under IVUS guidance (IVUS group). By means of the matching method, 505 patients without the use of IVUS during revascularization were selected (no-IVUS group). Survival free of cardiac death, myocardial infarction, and target lesion revascularization at 3 years was 88.7% in the IVUS group and 83.6% in the no-IVUS group (p = 0.04) for the overall population, and 90% and 80.7%, respectively (p = 0.03), for the subgroups with distal LM lesions. The incidence of definite and probable thrombosis was significantly lower in the IVUS group (0.6% vs. 2.2%; p = 0.04). Finally, IVUS-guided revascularization was identified as an independent predictor for major adverse events in the overall population (hazard ratio: 0.70, 95% confidence interval: 0.52 to 0.99; p = 0.04) and in the subgroup with distal lesions (hazard ratio: 0.54, 95% confidence interval: 0.34 to 0.90; p = 0.02). CONCLUSIONS: The results of this pooled analysis show an association of IVUS guidance during percutaneous coronary intervention with better outcomes in patients with LM disease undergoing revascularization with DES.

[Primary cardiac lymphoma: diagnosis by transjugular biopsy]. / Linfoma cardíaco primario: diagnóstico mediante biopsia transyugular.

Primary cardiac lymphoma, defined as a non-Hodgkin's lymphoma involving only the heart and pericardium, is an extremely rare malignancy. It should be suspected in patients with a heart mass and heart failure, unexplained refractory pericardial effusion or rhythm disturbances. Transvenous intracardiac tumor biopsy under fluoroscopic or transesophageal echocardiographic guidance, is a minimally invasive technique which makes definite diagnosis possible. We describe a patient in whom primary cardiac lymphoma was diagnosed by this technique. He also underwent percutaneous balloon pericardiotomy because of severe refractory pericardial effusion. Seven months after diagnosis and treatment with standard chemotherapy, the patient remained free of disease.