Postdilatation after stent deployment during primary percutaneous coronary intervention: a systematic review and meta-analysis.

BACKGROUND: The utilization of postdilatation in primary percutaneous coronary intervention (PCI) is feared to induce suboptimal coronary blood flow and compromise the outcome of the patients. This meta-analysis sought to verify whether postdilatation during primary PCI is associated with worse angiographic or long-term clinical outcomes. METHODS: Systematic literature searches were conducted on PubMed, The Cochrane Library, ClinicalTrials.gov, EBSCO, and Europe PMC on 10 March 2024. Eligible studies reporting the outcomes of postdilatation among ST-segment elevation myocardial infarction patients were included. The primary outcome was no-reflow condition during primary PCI based on angiographic finding. The secondary clinical outcome was major adverse cardiovascular events (MACEs) comprising all-cause death, myocardial infarction, target vessel revascularization (TVR), and stent thrombosis. RESULTS: Ten studies were finally included in this meta-analysis encompassing 3280 patients, which was predominantly male (76.6%). Postdilatation was performed in 40.7% cases. Postdilatation was associated with increased risk of no-reflow during primary PCI [Odd Ratio (OR) = 1.33, 95% Confidence Interval (CI): 1.12-1.58; P = .001)]. Conversely, postdilatation had a tendency to reduce MACE (OR = 0.70, 95% CI: 0.51-0.97; P = .03) specifically in terms of TVR (OR = 0.41, 95% CI: 0.22-0.74; P = .003). No significant differences between both groups in relation to mortality (OR = 0.58, 95% CI: 0.32-1.05; P = .07) and myocardial infarction (OR = 1.5, 95% CI: 0.78-2.89; P = .22). CONCLUSIONS: Postdilatation after stent deployment during primary PCI appears to be associated with an increased risk of no-reflow phenomenon after the procedure. Nevertheless, postdilatation strategy has demonstrated a significant reduction in MACE over the course of long-term follow-up. Specifically, postdilatation significantly decreased the occurrence of TVR. Key messages: What is already known on this topic?  Optimizing stent deployment by performing postdilatation during percutaneous coronary intervention (PCI) is essential for long-term clinical outcomes. However, its application during primary PCI is controversial due to the fact that it may provoke distal embolization and worsen coronary blood flow. What this study adds?  In this systematic review and meta-analysis of 10 studies, we confirm that postdilatation during primary PCI is associated with worse coronary blood flow immediately following the procedure. On the contrary, this intervention proves advantageous in improving long-term clinical outcomes, particularly in reducing target vessel revascularization. How this study might affect research, practice, or policy?  Given the mixed impact of postdilatation during primary PCI, this strategy should only be applied selectively. Future research should focus on identifying patients who may benefit from such strategy.

Cardiac tamponade associated with primary myelofibrosis: a case report.

Background: Cardiac tamponade is a life-threatening condition that occurs when an abnormal amount of fluid accumulates in the pericardial sac and impedes the cardiac filling process. Although extremely rare, haematological diseases have the potential to trigger an extramedullary haematopoiesis (EMH) process within the pericardium, resulting in a substantial build-up of pericardial effusion. Case summary: We present the case of a 29-year-old male previously diagnosed with primary myelofibrosis (PMF), who presented to the emergency unit with cardiac tamponade. An emergent pericardiocentesis procedure was performed, successfully evacuating 850 mL of haemorrhagic fluid. Over the course of 3 days, a total of 1.5 L of haemorrhagic effusion were drained from the pericardial space. Analysis of the pericardial fluid revealed evidence of haematopoietic activity, suggesting a potential association with the EMH process occurring within the pericardium. Following a 7-day hospitalization, the patient was discharged in stable condition but later experienced the development of constrictive pericarditis. Discussion: Haemorrhagic pericardial effusion is a rare occurrence. The majority of cases stems from complications of medical procedures (iatrogenic), malignancies, or side effects of antiplatelet/anticoagulant medications. In patients with PMF, the impaired haematopoietic ability caused by the fibrotic process in the bone marrow compels the body to produce blood components elsewhere, a phenomenon known as EMH. On very rare occasions, EMH can develop in the pericardial space, potentially leading to life-threatening cardiac tamponade. Our patient was successfully managed through pericardial fluid evacuation and drainage but later developed constrictive pericarditis.

Myocardial fibrosis in rheumatic heart disease: emerging concepts and clinical implications.

Rheumatic heart disease (RHD) remains a significant cardiovascular burden in the world even though it is no longer common in affluent countries. Centuries of history surrounding this disease provide us with a thorough understanding of its pathophysiology. Infections in the throat, skin, or mucosa are the gateway for Group A Streptococcus (GAS) to penetrate our immune system. A significant inflammatory response to the heart is caused by an immunologic cascade triggered by GAS antigen cross-reactivity. This exaggerated immune response is primarily responsible for cardiac dysfunction. Recurrent inflammatory processes damage all layers of the heart, including the endocardium, myocardium, and pericardium. A vicious immunological cycle involving inflammatory mediators, angiotensin II, and TGF-ß promotes extracellular matrix remodeling, resulting in myocardial fibrosis. Myocardial fibrosis appears to be a prevalent occurrence in patients with RHD. The presence of myocardial fibrosis, which causes left ventricular dysfunction in RHD, might be utilized to determine options for treatment and might also be used to predict the outcome of interventions in patients with RHD. This emerging concept of myocardial fibrosis needs to be explored comprehensively in order to be optimally utilized in the treatment of RHD.

Comparison between radial versus femoral percutaneous coronary intervention access in Indonesian hospitals, 2017-2018: A prospective observational study of a national registry.

BACKGROUND: Coronary heart disease is a leading cause of death in Indonesia and percutaneous coronary intervention (PCI) is a routinely performed procedure. The aim of this study is to provide real-world insight on the demographics of coronary artery disease and comparison between radial compared to femoral PCI in Indonesia, which performed radial access whenever possible. METHODS: This is a prospective cohort study involving 5420 patients with coronary artery disease who underwent PCI at 9 participating centers in the period of January 2017-December 2018. RESULTS: Radial access rate was performed in 4038 (74.5%) patients. Patients receiving femoral access has a higher rate of comorbidities and complex lesions compared to radial access. The incidence of in-hospital mortality, cardiogenic shock, major arrhythmia, and tamponade were higher in femoral group. The incidence of in-hospital mortality was 114 (2.1%). New-onset angina (OR 3.412), chronic renal failure (OR 3.47), RBBB (OR 4.26), LBBB (OR 6.26), left main stenosis PCI (OR 3.58), cardiogenic shock (OR 4.9), and arrhythmia (OR 15.59) were found to be independent predictors of in-hospital mortality. Radial access did not independently affect in-hospital mortality. In propensity-matched cohort, radial access was not associated with lower in-hospital mortality in both bivariable and multivariable model. However, radial access was associated with reduced in-hospital mortality in STEMI subgroup (OR 0.31). CONCLUSION: Higher rate of adverse events was noted on the femoral access group. However, it might stem from the fact that patients with more comorbidities and complex lesions are more likely to be assigned to femoral access-group. Neither radial or femoral access is superior in terms of in-hospital mortality upon propensity-score matching/multivariable analysis.