Effectiveness of the transradial approach to reduce bleedings in patients undergoing urgent coronary angioplasty with GPIIb/IIIa inhibitors for acute coronary syndromes.

OBJECTIVES: To analyze the effectiveness of the transradial approach in reducing bleeding rates following urgent percutaneous coronary intervention (PCI) in patients with acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors (GPIs). BACKGROUND: PCI and use of GPIs are recommended in acute coronary syndromes, but are strong predictors of severe hemorrhagic complications, which, in turn, are associated with reduced survival. The transradial approach represents a simple and effective solution to reduce vascular access site bleedings, particularly with GPIs. METHODS: All consecutive patients undergoing urgent transradial PCI under GPI treatment were enrolled in the registry. No patients were excluded. In addition, we performed a case-matched comparison of the transradial versus transfemoral approach using propensity analysis to adjust for known risk factors for bleeding. The primary end point was the rate of bleedings, graded according to the Thrombolysis in Myocardial Infarction (TIMI) classification. RESULTS: Five hundred thirty-one consecutive patients were prospectively enrolled in the registry. TIMI major, minor, and minimal bleedings were 0.2%, 1.7%, and 6.4%, respectively. Transfusion rate was 0.8%. After propensity-matched analysis, the transradial approach was associated with significantly lower rates of all types of bleedings, while the transfemoral approach was the strongest predictor of TIMI major/minor bleedings (odds ratio 6.67; 95% confidence interval 1.72-25; P = 0.006). CONCLUSIONS: The transradial approach dramatically reduces access site bleedings, including TIMI major and minor bleedings, and transfusion rate, while preserving procedural success and clinical outcome. The transradial approach is an attractive solution to reduce bleeding complications in patients treated with GPIs.

Emergency coronary artery bypass grafting in patients with acute myocardial infarction treated with glycoprotein IIb/IIIa receptor inhibitors.

Glycoprotein (GP) IIb/IIIa receptor inhibitors before primary angioplasty in patients with ST-elevation acute myocardial infarction (STEMI) are recommended by current guidelines. Thus, an increasing number of patients receive these drugs before coronary angiography, particularly if a between-hospital transfer is needed. However, when coronary anatomy is unsuitable for angioplasty, emergency coronary artery bypass grafting (CABG) under GP IIb/IIIa inhibitor treatment may be needed, with a potential increase in bleeding risk. Abciximab has a long duration of action, because of its high-affinity binding to GP IIb/IIIa receptors. Initial retrospective studies reported a higher incidence of major bleeding during emergency CABG after abciximab administration, leading to the recommendation of delaying surgery >12 h. However, data from the prospective trials on abciximab do not confirm the increase in bleeding risk, and current evidence shows that emergency surgery can be performed safely soon after abciximab cessation. Monitoring of activated clotting time during surgery and platelet transfusion in case of postoperative relevant bleeding are the only measures needed. No data are available on emergency surgery in patients with STEMI treated with eptifibatide or tirofiban. However, their short-lasting effects and the results of trials on non-ST-elevation acute coronary syndromes suggest that they could even reduce postoperative bleeding by preventing platelet consumption during cardiopulmonary bypass. In conclusion, the early administration of GP IIb/IIIa inhibitors, in particular of abciximab, in patients with STEMI in whom primary angioplasty is planned should not be discouraged because of the potential bleeding risk in case of emergency CABG.

An arrhythmic storm: a potential complication on opening the umbrella for percutaneous closure of interatrial communications.

Interatrial communications (ICs) have been linked to paradoxic embolism, which may be prevented using both surgical and percutaneous interventions. The case of a 61-year-old woman with a history of transient cerebral ischemic attack who developed repetitive ventricular arrhythmias and an intermittent left branch bundle block immediately after percutaneous closure of an IC is described. Transthoracic echocardiography showed that the device had migrated into the left ventricular outflow tract, and the patient consequently underwent emergency cardiac surgery to retrieve the device and repair the IC. In conclusion, percutaneous transcatheter closure of ICs is more rapid and less invasive compared with surgery, but nevertheless may be associated with significant short-term morbidity.

Randomized comparison of sirolimus and paclitaxel drug-eluting stents for long lesions in the left anterior descending artery: an intravascular ultrasound study.

OBJECTIVES: The goal of this work was to verify whether the superiority of the sirolimus-eluting stent (SES) in inhibiting neointimal hyperplasia could be demonstrated in complex coronary lesions. BACKGROUND: Both the SES (Cypher, Cordis, Miami Lakes, Florida) and the paclitaxel-eluting stent (PES) (Taxus, Boston Scientific, Natick, Massachusetts) have shown a marked reduction in neointimal hyperplasia compared with bare-metal stents. Intravascular ultrasound (IVUS) is the best method to assess arterial response to stent deployment, but few IVUS data are available comparing complex lesions treated with SES or PES. METHODS: We prospectively randomized patients with complex lesions to SES or PES implantation. Intravascular ultrasound and quantitative angiography were performed post-procedure and at 9 months. Mean neointimal hyperplasia area (NIHA), percent of NIHA (NIHA%), mean peristent plaque area (PSPA), and percent of PSPA (PSPA%) were calculated. The primary end point was NIHA% at follow-up. Secondary end points included change in PSPA% and angiographic late luminal loss at follow-up. RESULTS: Of the 100 patients enrolled, 42 receiving the SES and 43 receiving the PES had adequate IVUS assessment. Vessel, plaque, and lumen areas were comparable at follow-up, but NIHA% was significantly lower with SES than PES (7.4 +/- 4.2% vs. 15.4 +/- 8.1%; p < 0.001). A significant reduction in PSPA% was observed with SES (-4 +/- 10% vs. 0 +/- 8%; p = 0.01). Late loss was significantly lower with SES (0.16 +/- 0.19 mm vs. 0.32 +/- 0.33 mm; p = 0.003). CONCLUSIONS: The SES shows a significantly higher inhibition of neointimal hyperplasia compared with PES in complex lesions. However, both stents have excellent IVUS and angiographic results at 9 months. A significant reduction in peri-stent plaque is observed only with SES.

Left ventricular remodeling after primary coronary angioplasty in patients treated with abciximab or intracoronary adenosine.

BACKGROUND: Primary angioplasty is the best treatment of acute myocardial infarction but fails to achieve adequate myocardial reperfusion in 25% to 30% of patients, despite TIMI grade 3 flow. Drug treatment aimed at reducing the no-reflow phenomenon may improve myocardial salvage, thus preventing left ventricular remodeling. Our aim was to evaluate the impact of abciximab and adenosine on immediate angiographic results and on 6-month left ventricular remodeling. METHODS: Ninety consecutive patients undergoing primary angioplasty with coronary stenting were randomized in a sequential alternating fashion to standard abciximab treatment (ABCX) group, intracoronary adenosine distal to the occlusion (ADO) group, or neither (CTRL) group. All patients underwent a clinical and echocardiographic follow-up at 1 and 6 months. The primary end point was the prevalence of 6-month left ventricular remodeling. RESULTS: Baseline clinical, echocardiographic, and angiographic characteristics were similar. Mean final corrected TIMI frame count was 17 +/- 9, 16 +/- 12, and 23 +/- 11 frames in ABCX, ADO, and CTRL patients, respectively (P = .002). Angiographic no-reflow was observed in 7%, 13%, and 17% of ABCX, ADO, and CTRL patients, respectively (P > .20). At 6 months, left ventricular remodeling occurred in 7%, 30%, and 30% of ABCX, ADO, and CTRL patients, respectively (P = .045), with a percent increase in end-diastolic volume of 5% +/- 13%, 15% +/- 15%, and 12% +/- 18% (P = .04). CONCLUSIONS: During primary angioplasty, abciximab enhances myocardial reperfusion, translating into a reduced incidence of 6-month left ventricular remodeling. In contrast, adenosine administration improves angiographic results but does not prevent left ventricular remodeling.

Simvastatin does not inhibit intimal hyperplasia and restenosis but promotes plaque regression in normocholesterolemic patients undergoing coronary stenting: a randomized study with intravascular ultrasound.

BACKGROUND: Restenosis after coronary stenting is mainly caused by intimal hyperplasia. Both experimental and clinical studies suggest that statins may be able to inhibit intimal hyperplasia and, therefore, in-stent restenosis (ISR), by mechanisms beyond lipid lowering. METHODS: In a 12-month study, we randomized 71 normocholesterolemic patients to 20 mg simvastatin or no treatment, 2 weeks before elective coronary stenting. Patients were evaluated by quantitative coronary angiography and intravascular ultrasound, immediately after the index procedure and at the 12-month catheterization. RESULTS: Binary ISR was present in 15% and in 18% of simvastatin-treated patients and controls, respectively (P = NS). Intimal hyperplasia did not differ significantly between the 2 groups (3.6 +/- 1.8 vs 3.8 +/- 2.3 mm3/mm, 34% +/- 15% vs 35% +/- 23% for simvastatin vs controls, P = NS). However, persistent plaque decreased with simvastatin but increased in controls (-4.0 +/- 4.0 vs +1.6 +/- 3.8 mm3/mm, -14% +/- 10% vs +6% +/- 12%, P < .05). The same behavior was shown by intermediate plaques at nonstented sites (-2.5 +/- 3.0 vs +1.0 +/- 3.0 mm3/mm, -10% +/- 8% vs +9% +/- 9%, P < .05). Major adverse events at 12 months were present in 11% and 24% of simvastatin-treated patients and controls, respectively (P = .20). CONCLUSIONS: In normocholesterolemic patients undergoing coronary stenting, simvastatin does not prevent intimal hyperplasia or ISR, but it promotes atherosclerotic regression both at stented and at nonstented sites.

Primary angioplasty for acute myocardial infarction in a patient with a solitary coronary ostium and a "superdominant" right coronary artery.

Coronary artery anomalies (CAAs) are a rare angiographic finding, sometimes associated with acute coronary events. We report on a case of primary angioplasty for inferior acute myocardial infarction (AMI) in a 66-year-old woman with a solitary coronary ostium in the right sinus of Valsalva and a "superdominant" right coronary artery. We also discuss two potential pitfalls of primary angioplasty: correct interpretation of coronary anatomy and approach to challenging lesions.

Role of platelet glycoprotein IIb/IIIa inhibitors in rescue percutaneous coronary interventions.

In the setting of acute myocardial infarction, thrombolytic therapy fails to restore an adequate epicardial flow in a large number of patients. Although an increasing number of patients undergoes a percutaneous coronary intervention (PCI) after failed thrombolysis, this treatment has been poorly investigated. This review focuses particularly on the safety and prognostic impact of glycoprotein (GP) IIb/IIIa receptor inhibitors after failed thrombolysis. GPIIb/IIIa inhibitors have been demonstrated to improve the clinical outcome in patients undergoing primary PCI. However, the increased risk of bleeding with the administration of potent antiplatelet drugs after full-dose thrombolytics has limited the widespread use of GPIIb/IIIa inhibitors during rescue PCI. We recently reported that abciximab treatment during rescue PCI has a beneficial effect on the short-term prognosis, without excess bleeding complications. This result can be achieved by using the radial approach, a low-dose weight-adjusted heparin regimen, and by limiting the use of aortic counterpulsation. In conclusion, in case of thrombolysis failure, patients should be referred to tertiary hospitals where rescue PCI can be performed with expertise.

Safety, feasibility, and six-month outcomes of a systematic strategy of direct coronary stenting by a transradial approach in patients with single-vessel disease.

BACKGROUND: Strategies for percutaneous coronary intervention are continuously evolving, in order to reduce complications and to warrant better immediate and long-term outcomes. We sought to evaluate the safety, feasibility, and long-term outcomes of a systematic strategy of coronary stenting without predilation (direct stenting) via a transradial approach for single-vessel procedures. METHODS: Stenting was performed with Snapper stent and wide inner-lumen, preformed, guiding catheters; 118 minimally-selected patients (59% of all single-vessel procedures performed at our center during the study period) were enrolled: among them 39% presented for acute coronary syndromes, 28% were under glycoprotein IIb/IIIa inhibitor treatment, and 10% had a poor left ventricular function; 130 lesions were treated (1.1 stents/lesion): 53% were type B2/C, 8% longer than 20 mm, and 16% on bifurcations. RESULTS: The transradial approach was successful in 96% of cases; 7% required predilation. The immediate angiographic and clinical success rates were 100 and 98% respectively. No bleeding complications occurred when the transradial approach was successful. At 6 months, the mortality, major adverse events, recurrent ischemia, and target lesion revascularization rates were 0, 14, 15, and 10% respectively. CONCLUSIONS: A systematic strategy of direct stenting via a transradial approach for single-vessel procedures seems safe, feasible, and efficacious both immediately, and at 6 months of follow-up, even when treating complex lesions and/or high-risk patients.

Percutaneous ulnar artery approach for primary coronary angioplasty: safety and feasibility.

Transradial approach in primary and rescue angioplasty may be advantageous with respect to the femoral access due to the lower incidence of vascular complications. Ulnar cannulation has been proposed for elective procedures in patients not suitable for transradial approach. We here report on 13 patients undergoing primary angioplasty performed using the transulnar approach. Ulnar access was finally obtained in 10 patients, sheath insertion time ranged from 2 to 5 min, time from arterial puncture to vessel recanalization ranged from 21 to 36 min. Primary angioplasty was successful in all patients. At 30-day echo color Doppler, all ulnar arteries were patent and with a physiologic pattern of flow. Subcutaneous hemorrhage of the forearm was observed in two patients, whereas hematoma, pseudoaneurysm, thrombus, and arterovenous fistula were not observed. In conclusion, transulnar access may represent an additional option in patients undergoing primary angioplasty when the radial artery access site is not available.

[Acute mitral insufficiency secondary to dehiscence of a Carpentier-Edwards Physio ring: diagnosis with transthoracic echocardiography]. / Insufficienza mitralica acuta secondaria a distacco di anello di Carpentier-Edwards Physio: diagnosi con ecocardiografia transtoracica.

We describe a case of a 63-year-old patient admitted to our hospital because of cardiogenic shock. Past medical records showed anterior myocardial necrosis, myocardial surgery revascularization with apical aneurysmectomy and, 3 weeks before, another coronary artery bypass operation due to malfunction of the previous grafts and mitral annuloplasty with placement of a Carpentier-Edwards Physio no. 28 prosthetic ring. Transthoracic echocardiography revealed, in the middle of the mitral orifice, the presence of an echogenic structure with hypermobility and severe peri-ring mitral regurgitation due to dehiscence of the posterior side of the prosthetic ring. The diagnosis was finally confirmed by surgery and then mitral valve replacement was performed.