The Simulation Training in Coronary Angiography and Its Impact on Real Life Conduct in the Catheterization Laboratory.

Our study aimed to evaluate the effectiveness of mentored simulation training (ST) in coronary angiography and to assess the transferability of acquired skills from virtual reality to the real world. Twenty cardiology residents were randomized to ST or control before performing real-life cases in the catheterization laboratory. The control group underwent secondary ST and reperformed real-life cases in the catheterization laboratory. Skill metrics were compared between the ST and the control group, and within the control group between before and after ST. In real-life cases, the procedure time was shorter (p = 0.002), the radiation dose lower (p = 0.001), and the global procedure skill score was higher (p = 0.0001) in the ST group as compared with the control (before ST) group. During virtual ST procedural time (p <0.001), fluoroscopic time (p <0.001), training contrast amount (p <0.001), and global training score (p <0.001) significantly decreased. In the control group, all monitoring procedure parameters were significantly improved after ST, as well as, the global procedure flow score (p <0.0001). In conclusion, simulator-based training in coronary angiography improved operator skills compared with traditional in catheterization laboratory mentor-based training. ST should be incorporated in the curriculum of the interventionalist to improve learning in coronary angiography.

Myocardial reperfusion for acute myocardial infarction under an optimized antithrombotic medication: What can you expect in daily practice?

AIMS: To assess both epicardiac macrovascular as well as microvascular and tissue reperfusion following different intravenous preadmission antithrombotic strategies prior primary PCI in STEMI patients. METHODS AND RESULTS: Consecutive STEMI patients (n = 488) undergoing pPCI received prehospitally either bivalirudin (n = 179), bivalirudin and periprocedural GPIIb/IIIa inhibitors (GPI) (n = 109), heparin (n = 99) or heparin and periprocedural GPI (n = 101). Epicardial perfusion and microvascular perfusion were assessed by angiography (TIMI flow rate and corrected TIMI frame count [cTFC]) and by ECG (ST resolution [STR]). TIMI 3 flow was restored at the end of the procedure in 85.2% of the cases; cTFC of ≤23 was obtained in 37.2% of cases and STR >70% in 42.5% of the cases. The rates of STR >70% and cTFC ≤23 were not different between the three groups. Multivariate analysis did not identify a predictive antithrombotic treatment to obtain either post-procedural TIMI 3 flow rate or a STR rate >70%. TIMI 3 flow before procedure and delay first symptoms-balloon <6 h represented a positive predictive value of STR rate >70% and the LAD as infarct related artery a negative predictive value of STR rate of >70%. CONCLUSION: The process of myocardial reperfusion by pPCI continues to be improved with earlier reperfusion but an optimal tissular reperfusion was present in only half of the cases.

Coronary Embolism Among ST-Segment-Elevation Myocardial Infarction Patients: Mechanisms and Management.

BACKGROUND: Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of ST-segment-elevation myocardial infarction. The objective was to describe clinical characteristics and long-term outcomes and to identify risks factors of CE in a large consecutive series of ST-segment-elevation myocardial infarction patients. METHODS AND RESULTS: We studied 1232 consecutive patients who presented with de novo ST-segment-elevation myocardial infarction. CE was diagnosed based on criteria encompassing clinical, angiographic, and diagnostic imaging findings. A total of 53 patients were identified in the CE group including 12 (22.6%) patients with multisites CE and 9 patients with other extracoronary localization. Compared with the non-CE group, age and coronary risks factors were not significantly different in the CE group except for smoking (P=0.03) and body mass index (P<0.001). Interventional coronary procedures were characterized by a higher use of glycoprotein IIb/IIIa inhibitors (P<0.001) and lower use of angioplasty (P<0.001) in the CE group. The most frequent underlying cardiac diseases were atrial fibrillation (n=15, 28.3%) followed by dilated cardiomyopathy (n=5), endocarditis (n=4), and intracardiac tumor (n=3), whereas among systemic diseases, malignancy (n=8) and systemic autoimmune disease or antiphospholipid syndrome (n=4) were present. No etiopathological mechanisms could be identified in 14 patients (26.4%). Coronary embolism was associated with a higher risk of death (crude hazard ratio, 4.87; 95% confidence interval, 2.52-9.39; P<0.0001). CONCLUSIONS: Etiopathogenesis of ST-segment-elevation myocardial infarction secondary to CE is diverse ranging from cardiac to systemic disease, and patient long-term survival is worse than expected according to the baseline cardiovascular risk.