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Background: Final kissing balloon inflation (FKBI) is a percutaneous coronary intervention (PCI) technique that is considered mandatory to improve outcomes in two-stent strategies, but its use in single-stent bifurcation PCI remains controversial. Methods: In this retrospective cohort study, we identified patients with coronary bifurcation lesions treated with one stent from January 2012 to March 2021 at a single academic medical center. Incidence rates per 1,000 patient-years (IR1000) were calculated for the outcomes of all-cause mortality, myocardial infarction (MI), stent thrombosis (ST), target lesion revascularization (TLR), coronary artery bypass graft (CABG), and cardiac readmission between patients who received FKBI and those who did not over a median follow up of 2.3 years. Studied outcomes were adjusted for all baseline clinical and procedural characteristics. Results: This study included 893 consecutive patients of which 256 received FKBI and 637 did not. The IR1000 for MI were 51.1 and 27.6 for patients who received FKBI and patients who did not, respectively (adjusted HR = 2.44, p = 0.001). The IR1000 for death were 31.2 and 52.3 for patients who received FKBI and patients who did not, respectively (adjusted HR = 0.68, p = 0.141). The incidence rates of ST, TLR, CABG, and cardiac readmissions were similar between patients who received FKBI and those who did not. Conclusions: These results suggest that performing FKBI in a one-stent technique was associated with higher rates of myocardial infarction, particularly in the first 6 months, and no difference in death, ST, TLR, CABG, and cardiac readmission rates.
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There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.
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Transradial access for PCI (TRI) along with same day discharge (SDD) is associated with varying estimates of cost savings depending on the population studied, the clinical scenario and application to low-risk vs high-risk patients. A summary estimate of the true cost savings of TRI and SDD are unknown. We searched the PubMed, EMBASE®, CINAHL® and Google Scholar® databases for published studies on hospitalization costs of TRI and SDD. Primary outcome of interest in all included studies was the cost saving with TRI (or SDD), inflation-corrected US$ 2018 values using the medical consumer price index. For meta-analytic synthesis, we used Hedges' summary estimate (g) in a random-effects framework of the DerSimonian and Laird model, with inverse variance weights. Heterogeneity was quantified using the I2 statistic. The cost savings of TRI from four US studies of 349,757 patients reported a consistent and significant cost saving associated with TRI after accounting for currency inflation, of US$ 992 (95% CI US$ 850-1,134). The cost savings of SDD from six US studies of 1,281,228 patients, after inflation-correcting to the year 2018, were US$ 3,567.58 (95% CI US$ 2,303-4,832). In conclusion, this meta-analysis demonstrates that TRI and SDD are associated with mean cost reductions of by approximately US$ 1,000/patient and US$ 3,600/patient, respectively, albeit with wide heterogeneity in the cost estimates. When combined with the safety of TRI and SDD, this meta-analysis underscores the value of combining TRI and SDD pathways and calls for a wide-ranging practice change in the direction of TRI and SDD.
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Intervención Coronaria Percutánea , Ahorro de Costo , Humanos , Tiempo de Internación , Alta del Paciente , Intervención Coronaria Percutánea/efectos adversos , Resultado del TratamientoRESUMEN
[Figure: see text].
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Intervención Coronaria Percutánea , Arteria Radial , Arteria Femoral , Hemorragia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Arteria Radial/diagnóstico por imagen , Factores de Riesgo , Resultado del TratamientoRESUMEN
Large iatrogenic coronary artery perforations require rapid management; however, operators must be able to recognize guidewire perforation into cardiac veins in order to avoid causing further complications with standard salvage strategies.
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BACKGROUND: Women undergoing percutaneous coronary intervention (PCI) are at higher risk for bleeding and vascular complications than men. Multiple approaches have been utilized to reduce bleeding in the modern era of PCI, including radial access, reduced GP IIb/IIIa inhibitor use, increased vascular closure device use, smaller sheath size and novel antithrombotic regimens. Nevertheless, few studies have assessed the impact of these techniques on the gap between men and women for such complications following PCI. We sought to quantify bleeding and vascular complications over time between men and women. METHODS: We queried The Dartmouth Dynamic Registry for consecutive PCI's performed between January 2003 and June 2016. Demographic information, procedural characteristics, and in-hospital outcomes were collected and compared between men and women over the years. RESULTS: We reviewed 15,284 PCI cases, of which 4384 (29%) were performed in women. Radial access increased from none in 2003 to nearly 40% in 2016. Use of GP IIb/IIIa and femoral access decreased substantially over the same time. Bleeding and vascular complication rates decreased significantly in women (13.2% to 3%; 6.5% to 0.8%, respectively) and men (3.5% to 0.7%, 3.4% to 0.7%, respectively). The overall bleeding and vascular complication rates decreased more for women than men, narrowing the gender gap. CONCLUSIONS: The incidence of bleeding and vascular complications fell between 2003 and 2016 in both men and women. Vascular complications have become less common over time, and based on our analysis, there was no longer any difference between the sexes for this outcome. Bleeding following PCI has decreased in both sexes over time; however, women continue to bleed more than men.
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Intervención Coronaria Percutánea , Femenino , Humanos , Masculino , Intervención Coronaria Percutánea/efectos adversos , Arteria Radial/diagnóstico por imagen , Sistema de Registros , Factores de Riesgo , Caracteres Sexuales , Resultado del TratamientoRESUMEN
OBJECTIVE: As the global burden of cardiovascular disease increases, proactive cardiovascular healthcare by means of accurate, precise, continuous, and non-invasive monitoring is becoming crucial. However, no current device is able to provide cardiac hemodynamic monitoring with the aforementioned criterion. Electrical impedance tomography (EIT) is an inexpensive, non-invasive imaging modality that can provide real-time images of internal conductivity distributions that describe physiological activity. This work explores and compares a standard approach of regular cardiac gated averaging (RCGA) and a newly developed method, cardiac eigen-imaging (CEI), based on the singular value decomposition (SVD) to isolate cardiac activity in thoracic EIT. APPROACH: EIT and heart-rate (HR) data were collected from 20 heart-failure patients preceding echocardiography. Features from RCGA and CEI images were correlated with stroke volume (SV) from echocardiography and image reconstruction parameters were optimized using leave-one-out (LOO) cross-validation. MAIN RESULTS: CEI per-pixel-based features achieved a Pearson correlation coefficient of 0.80 with SV relative to 0.72 with RCGA. CEI had 33 high-correlating pixels while RCGA had 8. High-correlating pixels tend to concentrate in the right-ventricle (RV) when referenced to a general chest model. SIGNIFICANCE: While both RCGA and CEI images had high-correlating pixels, CEI had higher correlations, a larger number of high-correlating pixels, and unlike RCGA is not dependent on the quality of the HR data collected. The observed performance of the CEI approach represents a promising step forward for EIT-based cardiac monitoring in either clinical or ambulatory settings.
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Impedancia Eléctrica , Corazón/diagnóstico por imagen , Corazón/fisiología , Tomografía , Ecocardiografía , Insuficiencia Cardíaca/diagnóstico por imagen , Frecuencia Cardíaca , Humanos , Procesamiento de Imagen Asistido por Computador , Volumen Sistólico , TóraxRESUMEN
Acute kidney recovery (AKR) is a recently described phenomenon observed after transcatheter aortic valve replacement (TAVR) and is more frequent than acute kidney injury (AKI). To determine the incidence and predictors of AKR between surgical aortic valve replacement (SAVR) and TAVR, we examined patients with chronic kidney disease and severe aortic stenosis who underwent SAVR or TAVR procedure between 2007 and 2017; excluding age <65 or >90, dialysis, endocarditis, non-aortic valve stenosis, or patients died within 48-hours postprocedure. AKR was defined as an increase of estimated glomerular filtration rate (eGFR) >25% and AKI as decrease in eGFR >25% at discharge. Stroke, mortality, major bleeding, transfusion, and length of stay were examined. Multivariate logistic regression analysis was used to examine predictors of AKR. There were 750 transcatheter and 1,062 surgical patients and 319 pairs after propensity matching. AKR was observed in 26% TAVR versus 23.2% SAVR, pâ¯=â¯0.062. Highest recovery was in patients with eGFR <30 for both TAVR (33.7%) and SAVR (34.5%) patients. Independent predictors of AKR were ejection fraction <50% (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.02 to 2.71, pâ¯=â¯0.042), female gender (OR 1.66, 95% CI 1.1 to 2.5, pâ¯=â¯0.015), and obesity (OR 1.5, 95% CI 1.04-2.3, pâ¯=â¯0.032). Diabetes was a negative predictor of AKR (OR 0.55, 95% CI 0.36 to 0.84, pâ¯=â¯0.005). AKR was associated with improved secondary clinical outcomes compared with AKI. In conclusion, AKR is a generalizable phenomenon occurring frequently and similarly among transcatheter or surgical aortic valve patients. Diabetes is a negative predictor of AKR, possibly indicative of less reversible kidney disease.
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Estenosis de la Válvula Aórtica/cirugía , Tasa de Filtración Glomerular , Implantación de Prótesis de Válvulas Cardíacas , Mortalidad Hospitalaria , Recuperación de la Función , Insuficiencia Renal Crónica/metabolismo , Reemplazo de la Válvula Aórtica Transcatéter , Lesión Renal Aguda/epidemiología , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/fisiopatología , Transfusión Sanguínea/estadística & datos numéricos , Comorbilidad , Diabetes Mellitus/epidemiología , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Obesidad/epidemiología , Hemorragia Posoperatoria/epidemiología , Insuficiencia Renal Crónica/epidemiología , Índice de Severidad de la Enfermedad , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Volumen Sistólico , Resultado del TratamientoRESUMEN
Disruption of intracoronary plaque with thrombus formation resulting in severe or total occlusion of the culprit coronary artery provides the pathophysiologic foundation for ST-segment elevation myocardial infarction (STEMI). Management of STEMI focuses on timely restoration of coronary blood flow along with antithrombotic therapies and secondary prevention strategies. The purpose of this review is to discuss the epidemiology, pathophysiology, and diagnosis of STEMI. In addition, the review will focus on guideline-directed therapy for these patients and review potential associated complications.
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Infarto del Miocardio con Elevación del ST/terapia , Humanos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/fisiopatología , Resultado del TratamientoRESUMEN
Acute Kidney Recovery (AKR) is a potential benefit of transcatheter aortic valve implantation (TAVI). We determined the incidence and predictors of AKR in a multicenter prospective registry of TAVI. After excluding patients on dialysis or who died within 48 hours postprocedure, we reviewed 1,502 consecutive patients underwent TAVI in Northern New England from 2012 to 2017. Patients were categorized into 3 groups based on the change in postprocedure estimated glomerular filtration rate (eGFR): Acute Kidney Injury (AKI, decrease in eGFR >25%), AKR (increase in eGFR >25%) or no change in kidney function on discharge creatinine following TAVI. We then focused in patients with baseline chronic kidney disease (CKD defined as eGFR ≤60 ml/min; nâ¯=â¯755) and developed multivariate predictor models to determine the clinical and procedural variables associated with AKR. For the TAVI cohort (nâ¯=â¯1,502), the overall incidence of AKR was 17.8%. AKR was threefold higher in patients with eGFR ≤60 ml/min as compared to those with eGFR >60 ml/min (26.6% vs 8.9%, p < 0.001). In the CKD population, hospital complications were similar among patients with no change in renal function and AKR; patients with AKI had a higher rate of hospital mortality, pacemaker implantation, length of hospitalization, and transfusions. Using multivariable logistic regression, moderate to severe lung disease, eGFR < 50 ml/min and previous aortic valve surgery were found to be independent predictors of AKR. Patients with diabetes mellitus, baseline anemia, and Society of thoracic surgeons score >6.1 were less likely to develop AKR. In conclusion, AKR occurred in 1 of 4 of all TAVI patients with baseline CKD and was a more frequent phenomena than AKI. Patients with decreased lung function, previous aortic valve surgery and worse baseline renal function were more likely to demonstrate AKR, whereas patients with diabetes mellitus, baseline anemia, and higher Society of thoracic risk scores were less likely to see improvements in renal function after TAVI.
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Recuperación de la Función , Insuficiencia Renal Crónica/terapia , Reemplazo de la Válvula Aórtica Transcatéter , Lesión Renal Aguda/etiología , Anciano , Anciano de 80 o más Años , Transfusión Sanguínea/estadística & datos numéricos , Creatinina/análisis , Femenino , Tasa de Filtración Glomerular , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Enfermedades Pulmonares/epidemiología , Masculino , New England/epidemiología , Marcapaso Artificial , Sistema de Registros , Insuficiencia Renal Crónica/epidemiología , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversosRESUMEN
BACKGROUND: Very elderly patients (age ≥ 85 years) are a rapidly increasing segment of the population. As a group, they experience high rates of in-hospital mortality and bleeding complications following percutaneous coronary intervention (PCI). However, the relationship between bleeding and mortality in the very elderly is unknown. METHODS: Retrospective review was performed on 17,378 consecutive PCI procedures from 2000 to 2015 at Dartmouth-Hitchcock Medical Center. Incidence of bleeding during the index PCI admission (bleeding requiring transfusion, access site hematoma > 5 cm, pseudoaneurysm, and retroperitoneal bleed) and in-hospital mortality were reported for four age groups (< 65 years, 65-74 years, 75-84 years, and ≥ 85 years). The mortality of patients who suffered bleeding complications and those who did not was calculated and multivariate analysis was performed for in-hospital mortality. Lastly, known predictors of bleeding were compared between patients age < 85 years and age ≥ 85 years. RESULTS: Of 17,378 patients studied, 1019 (5.9%) experienced bleeding and 369 (2.1%) died in-hospital following PCI. Incidence of bleeding and in-hospital mortality increased monotonically with increasing age (mortality: 0.94%, 2.27%, 4.24% and 4.58%; bleeding: 3.96%, 6.62%, 10.68% and 13.99% for ages < 65, 65-74, 75-84 and ≥ 85 years, respectively). On multivariate analysis, bleeding was associated with increased mortality for all age groups except patients age ≥ 85 years [odds ratio (95% CI): age < 65 years, 3.65 (1.99-6.74); age 65-74 years, 2.83 (1.62-4.94); age 75-84 years, 3.86 (2.56-5.82), age ≥ 85 years: 1.39 (0.49-3.95)]. CONCLUSIONS: Bleeding and mortality following PCI increase with increasing age. For the very elderly, despite high rates of bleeding, bleeding is no longer predictive of in-hospital mortality following PCI.
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OBJECTIVE: The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited. METHODS: We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching. RESULTS: 8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases. CONCLUSION: Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.
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Anticoagulantes/administración & dosificación , Antitrombinas/administración & dosificación , Enfermedad de la Arteria Coronaria/cirugía , Heparina/administración & dosificación , Hirudinas/administración & dosificación , Infarto del Miocardio/cirugía , Fragmentos de Péptidos/administración & dosificación , Intervención Coronaria Percutánea , Anciano , Anticoagulantes/efectos adversos , Antitrombinas/efectos adversos , Causas de Muerte , Toma de Decisiones Clínicas , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Bases de Datos Factuales , Femenino , Hemorragia/inducido químicamente , Hemorragia/mortalidad , Heparina/efectos adversos , Hirudinas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , New Hampshire , Fragmentos de Péptidos/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
The HS3ST1 gene controls endothelial cell production of HSAT+ - a form of heparan sulfate containing a specific pentasaccharide motif that binds the anticoagulant protein antithrombin (AT). HSAT+ has long been thought to act as an endogenous anticoagulant; however, coagulation was normal in Hs3st1-/- mice that have greatly reduced HSAT+ (HajMohammadi et al., 2003). This finding indicates that HSAT+ is not essential for AT's anticoagulant activity. To determine if HSAT+ is involved in AT's poorly understood inflammomodulatory activities, Hs3st1-/- and Hs3st1+/+ mice were subjected to a model of acute septic shock. Compared with Hs3st1+/+ mice, Hs3st1-/- mice were more susceptible to LPS-induced death due to an increased sensitivity to TNF. For Hs3st1+/+ mice, AT treatment reduced LPS-lethality, reduced leukocyte firm adhesion to endothelial cells, and dilated isolated coronary arterioles. Conversely, for Hs3st1-/- mice, AT induced the opposite effects. Thus, in the context of acute inflammation, HSAT+ selectively mediates AT's anti-inflammatory activity; in the absence of HSAT+, AT's pro-inflammatory effects predominate. To explore if the anti-inflammatory action of HSAT+ also protects against a chronic vascular-inflammatory disease, atherosclerosis, we conducted a human candidate-gene association study on >2000 coronary catheterization patients. Bioinformatic analysis of the HS3ST1 gene identified an intronic SNP, rs16881446, in a putative transcriptional regulatory region. The rs16881446G/G genotype independently associated with the severity of coronary artery disease and atherosclerotic cardiovascular events. In primary endothelial cells, the rs16881446G allele associated with reduced HS3ST1 expression. Together with the mouse data, this leads us to conclude that the HS3ST1 gene is required for AT's anti-inflammatory activity that appears to protect against acute and chronic inflammatory disorders.
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Antitrombinas/fisiología , Aterosclerosis/genética , Enfermedades de las Arterias Carótidas/genética , Sulfotransferasas/genética , Animales , Antitrombinas/farmacología , Aterosclerosis/enzimología , Aterosclerosis/inmunología , Enfermedades de las Arterias Carótidas/enzimología , Enfermedades de las Arterias Carótidas/inmunología , Femenino , Estudios de Asociación Genética , Genotipo , Humanos , Inmunomodulación , Desequilibrio de Ligamiento , Lipopolisacáridos/farmacología , Masculino , Ratones de la Cepa 129 , Ratones Endogámicos C57BL , Ratones Noqueados , Polimorfismo de Nucleótido Simple , Factor de Necrosis Tumoral alfa/fisiología , VasodilataciónRESUMEN
OBJECTIVES: To assess the benefit of vitamin K antagonist (VKA) therapy for prevention of ischemic stroke following anterior ST-elevation myocardial infarction (STEMI) in patients with reduced ejection fraction. METHODS: A prospective institutional-based registry was used to identify survivors of anterior STEMI with a post-STEMI ejection fraction of 40% or less over a 10-year period. Clinical and procedural characteristics were collected from medical records and vital status from the Social Security Death Index. Outcomes were compared on the basis of VKA use. The primary outcome was a composite of ischemic stroke, death, and clinically relevant bleeding. A secondary analysis examined the effects of low-molecular-weight heparin bridging therapy. RESULTS: The primary outcome occurred in 24.7% (40/162) of VKA patients and 20.5% (22/107) of non-VKA patients [adjusted hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.71-2.31]. Ischemic stroke occurred in 2.5 and 0.9% of VKA patients and non-VKA patients, respectively (adjusted HR, 2.81; 95% CI, 0.31-25.1). There was no significant difference in the rate of bleeding or death between groups. The addition of a low-molecular-weight heparin bridge to VKA therapy was associated with increased bleeding events (adjusted HR, 2.55; 95% CI, 1.04-6.24). CONCLUSION: Ischemic stroke was infrequent in the 6 months following anterior STEMI irrespective of VKA treatment status. The routine use of anticoagulation for prevention of stroke following anterior STEMI may not be warranted.
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Anticoagulantes/uso terapéutico , Isquemia Encefálica/prevención & control , Infarto del Miocardio/tratamiento farmacológico , Accidente Cerebrovascular/prevención & control , Trombosis/prevención & control , Warfarina/uso terapéutico , Anciano , Anticoagulantes/efectos adversos , Isquemia Encefálica/etiología , Isquemia Encefálica/mortalidad , Femenino , Hemorragia/inducido químicamente , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , New Hampshire , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Volumen Sistólico , Trombosis/etiología , Trombosis/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda , Warfarina/efectos adversosRESUMEN
BACKGROUND: The aim of this study was to summarize our single-center real-world experience with percutaneous coronary intervention (PCI) stenting of unprotected left main coronary artery (ULMCA). PCI-stenting of the ULMCA, while controversial, is emerging as an alternative to coronary artery bypass graft (CABG) surgery in select patients and clinical situations. METHODS: Between January 2005 and December 2008, PCI-stenting was performed on 125 patients with ULMCA lesions at our institution. Clinical and procedural data were recorded at the time of procedure, and patients were followed prospectively (mean 1.7 years; range 1 day-4.1 years) for outcomes, including death, myocardial infarction (MI), and target vessel revascularization (TVR). RESULTS: The majority of cases were urgent or emergent (82.5%), 50.4% of patients were non-surgical candidates, and 63.2% had 3 vessel disease. Many emergent patients presented in shock (62.1%), were not surgical candidates (89.7%), and had high mortality (20.7% in-hospital, 44.8% long-term). Mortality in the elective group was 6.3%. Cumulative death and TVR rates were 28.8% and 13.6%, respectively. Independent predictors of mortality were ejection fraction (EF) ≤ 35% (HR 2.4, CI 1.1 - 5.4) and left main bifurcation (HR 2.7, CI 1.2 - 5.7). CONCLUSIONS: PCI-stenting is a viable option in patients with LMCA disease and extends options to patients who are poor candidates for CABG. Elective PCI in low-risk CABG patients results in good long-term survival. Cumulative TVR is 13.6%. EF ≤ 35% and left main bifurcation are independently associated with increased mortality.
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Central needle embolization is a rare complication of intravenous drug abuse which has only been reported on a handful of occasions. Previously reported cases of needle embolization to the heart have been managed conservatively (observation alone) or by surgical intervention. We report a case of purulent pericarditis without evidence of valvular vegetations resulting from an embolized, infected needle fragment. In the present case, the needle was successfully removed from the right ventricle percutaneously. This case illustrates the unique finding of purulent pericarditis due to a persistent foreign body in the right ventricle, and the nontraditional intervention performed for needle fragment removal which resulted in full clinical recovery of the patient.
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Migración de Cuerpo Extraño/etiología , Agujas , Pericarditis/etiología , Infecciones Estafilocócicas/etiología , Abuso de Sustancias por Vía Intravenosa/complicaciones , Antibacterianos/uso terapéutico , Cateterismo Cardíaco , Remoción de Dispositivos , Electrocardiografía , Migración de Cuerpo Extraño/diagnóstico , Migración de Cuerpo Extraño/terapia , Humanos , Masculino , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Agujas/microbiología , Pericarditis/diagnóstico , Pericarditis/microbiología , Pericarditis/terapia , Radiografía Intervencional , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/terapia , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: The purpose of the study was to compare creatinine clearance (CrCl), estimated glomerular filtration rate (eGFR) and serum creatinine (SCr) in predicting contrast-induced acute kidney injury (CI-AKI), dialysis and death following percutaneous coronary intervention (PCI). METHODS AND MATERIALS: Data were prospectively collected on 7759 consecutive patients within the Dartmouth Dynamic Registry undergoing PCI between January 1, 2000, and December 31, 2006. Renal function was measured at baseline and within 48 h after PCI using three methods: CrCl using the Cockcroft-Gault equation, eGFR using the abbreviated Modification of Diet in Renal Disease equation and SCr. We compared CrCl, eGFR and SCr in predicting CI-AKI, post-PCI dialysis-dependent renal failure and in-hospital mortality. Areas under the receiver operating characteristic curve (ROC) were calculated using logistic regression and tested for equality. RESULTS: On univariable analysis, CrCl [ROC: 0.69; 95% confidence interval (CI): 0.67-0.72] predicted CI-AKI better than eGFR (ROC: 0.67; 95% CI: 0.64-0.70) (P=.013) and SCr (ROC: 0.64; 95% CI: 0.61-0.67) (P<.001). Creatinine clearance (ROC: 0.73; 95% CI: 0.69-0.77) and eGFR (ROC: 0.70; 95% CI: 0.65-0.74) outperformed SCr for predicting in-hospital mortality. On multivariable analysis, CrCl (ROC: 0.77; 95% CI: 0.75-0.80), SCr (ROC: 0.78; 95% CI: 0.76-0.80) and eGFR (ROC: 0.77; 95% CI: 0.75-0.80) predicted CI-AKI well. Creatinine clearance (ROC: 0.88; 95% CI: 0.85-0.90) and eGFR (ROC: 0.87; 95% CI: 0.85-0.90) were strong independent predictors of in-hospital mortality. CONCLUSIONS: Creatinine clearance, eGFR and SCr predict CI-AKI equally well. Creatinine clearance and eGFR are strong independent predictors of in-hospital mortality.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Angioplastia , Medios de Contraste/efectos adversos , Creatinina/metabolismo , Tasa de Filtración Glomerular/fisiología , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/mortalidad , Anciano , Angioplastia/efectos adversos , Femenino , Mortalidad Hospitalaria , Humanos , Pruebas de Función Renal , Modelos Logísticos , Masculino , Tasa de Depuración Metabólica , Análisis Multivariante , Estudios Prospectivos , Curva ROCRESUMEN
OBJECTIVES: We sought to determine if differences existed in in-hospital outcomes, long-term rates of target vessel revascularization (TVR), and/or long-term mortality trends between patients with diabetes mellitus undergoing percutaneous coronary intervention (PCI) with either a drug-eluting stent(s) (DES) or a bare metal stent(s) (BMS). BACKGROUND: Short- and long-term clinical outcomes of patients with diabetes mellitus undergoing PCI with DES versus BMS remain inconsistent between randomized-controlled trials (RCTs) and observational studies. METHODS: Data were collected prospectively on diabetics undergoing PCI with either DES or BMS from January 2000 to June 2008. Demographic information, medical histories, in-hospital outcomes, and long-term TVR and mortality trends were obtained for all patients. RESULTS: A total of 1,319 patients were included in the study. Diabetics receiving DES had a significant reduction in index admission MACE compared to diabetics receiving BMS. Using multivariable adjustment, after a mean follow-up of 2.5 years (maximum 5 years), diabetics who received DES had a 38% decreased risk of TVR compared to diabetics with BMS [HR 0.62 (95% CI: 0.43-0.90)]; diabetics with DES had an insignificant adjusted improvement in long-term survival compared to diabetics with BMS [HR 0.72 (95% CI: 0.52-1.00)]. These long-term survival and TVR rates were confirmed using propensity scoring. CONCLUSIONS: The use of DES when compared with BMS among diabetics undergoing PCI is associated with significant improvement in long-term TVR, with an insignificant similar trend in all-cause mortality. The long-term results of this observational study are consistent with prior RCTs after adjusting for confounding variables.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Stents Liberadores de Fármacos , Cardiopatías/terapia , Metales , Stents , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/mortalidad , Diabetes Mellitus Tipo 1/mortalidad , Diabetes Mellitus Tipo 2/mortalidad , Femenino , Cardiopatías/complicaciones , Cardiopatías/mortalidad , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , New England , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Diseño de Prótesis , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
We compare real-world, extended target vessel revascularization (TVR)-free survival following percutaneous coronary intervention (PCI) for patients receiving either sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) following an index drug-eluting stent (DES) supported procedure. We analyzed 2,363 consecutive patients having first DES-supported PCI at receiving PES (n = 1,012) or SES (n = 1,332) from April 2004 to July 2006. Baseline clinical and procedural characteristics and in-hospital outcomes were recorded during the time of the index procedure and extended clinical outcomes data were obtained thereafter. TVR and all cause mortality were identified during the study period. Adjusted Kaplan-Meier and Cox's proportional hazard survival methods were performed. TVR-free survival at 2.3 years was 91.3% for SES compared with 88.9% for PES (P = 0.06). Kaplan-Meier survival curves did not significantly differ (adjusted hazard ratio -1.39 [95% CI 0.99-1.97]) between the SES and PES patient cohorts. TVR was similar between the stent platforms at one (96.6% for SES [95% CI 95.3-97.6] vs. 95.7% for PES [95% CI 94.1-96.9]) and two (95.0%[95% CI 93.0-96.4] for SES vs. 93.7% for PES [95% CI 91.6-95.3]) years. Overall survival at 2 years was 96.2% for SES (95% CI 94.7-97.3) and 95.3% for PES (95% CI 93.7-96.5). SES and PES drug-eluting stent platforms have good and similar extended outcomes in this real world registry of unselected patients having PCI.