One-year Outcomes in Patients with ST-segment Elevation Myocardial Infarction Caused by Unprotected Left Main Coronary Artery Occlusion Treated by Primary Percutaneous Coronary Intervention.

BACKGROUND: Very few data have been reported for ST-segment elevation myocardial infarction (STEMI) caused by unprotected left main coronary artery (ULMCA) occlusion, and very little is known about the results of this subgroup of patients who underwent primary percutaneous coronary intervention (PCI). The aim of this study was to determine the clinical features and outcomes of patients with STEMI who underwent primary PCI for acute ULMCA occlusion. METHODS: From January 2000 to February 2014, 372 patients with STEMI caused by ULMCA acute occlusion (ULMCA-STEMI) who underwent primary PCI at one of two centers were enrolled. The 230 patients with non-ST-segment elevation MI (NSTEMI) caused by ULMCA lesion (ULMCA-NSTEMI) who underwent emergency PCI were designated the control group. The main indexes were the major adverse cardiac events (MACEs) in-hospital, at 1 month, and at 1 year. RESULTS: Compared to the NSTEMI patients, the patients with STEMI had significantly higher rates of Killip class≥III (21.2% vs. 3.5%, χ2 = 36.253, P < 0.001) and cardiac arrest (8.3% vs. 3.5%, χ2 = 5.529, P = 0.019). For both groups, the proportions of one-year cardiac death in the patients with a post-procedure thrombolysis in myocardial infarction (TIMI) flow grade<3 were significantly higher than those in the patients with a TIMI flow grade of 3 (STEMI group: 51.7% [15/29] vs. 4.1% [14/343], P < 0.001; NSTEMI group: 33.3% [3/9] vs. 13.6% [3/221], P = 0.001; respectively]. Landmark analysis showed that the patients in STEMI group were associated with higher risks of MACE (16.7% vs. 9.1%, P = 0.009) and cardiac death (5.4% vs. 1.3%, P = 0.011) compared with NSTEMI patients at 1 month. Meanwhile, in patients with ULMCA, the landmark analysis for incidences of MACE and cardiac death was similar between the STEMI and NSTEMI (all P = 0.72) in the intervals of 1-12 months. However, patients who were diagnosed with STEMI or NSTEMI had no significant difference in reinfarction (all P > 0.05) and TVR (all P > 0.05) in the intervals of 0-1 month as well as 1 month to 1 year. The results of Cox regression analysis showed that the differences in the independent predictors for MACE included the variables of Killip class ≥ III and intra-aortic balloon pump support for the STEMI patients and the variables of previous MI, ULMCA distal bifurcation, and 2-stent for distal ULMCA lesions for the NSTEMI patients. CONCLUSIONS: Compared to the NSTEMI patients, the patients with STEMI and ULMCA lesions still remain at a much higher risk for adverse events at 1 year, especially on 1 month. If a successful PCI procedure is performed, the 1-year outcomes in those patients might improve.

A Multicenter, Randomized, Double-Blind, and Placebo-Controlled Study of the Effects of Tongxinluo Capsules in Acute Coronary Syndrome Patients with High On-Treatment Platelet Reactivity.

BACKGROUND: High platelet reactivity (HPR) during clopidogrel treatment predicts postpercutaneous coronary intervention (PCI) ischemic events strongly and independently. Tongxinluo capsules (TCs) are a traditional Chinese medicine formulation used as antiplatelet treatment. However, its efficacy against HPR is not known. The aim of the present study was to evaluate the effects of TCs in acute coronary syndrome (ACS) patients with HPR. METHODS: This multicenter, randomized, double-blind, placebo-controlled study prospectively analyzed 136 ACS patients with HPR who underwent PCI. The patients were enrolled from November 2013 to May 2014 and randomized to receive placebo or TCs in addition to standard dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. The primary end points were the prevalence of HPR at 30 days and the mean change in P2Y12reaction units (PRUs) between baseline and 30 days. Survival curves were constructed with Kaplan-Meier estimates and compared by log-rank tests between the two groups. RESULTS: Both groups had a significantly reduced prevalence of HPR at 30 days versus baseline, but the TC group, compared with the placebo group, had greater reduction (15.8% vs. 24.8%, P = 0.013), especially among patients with one cytochrome P450 2C19 loss of function (LOF) allele (χ2 = 2.931, P = 0.047). The TC group also had a lower prevalence of HPR (33.3% vs. 54.2%, t = 5.284, P = 0.022) and superior performance in light transmittance aggregometry and higher levels of high-sensitivity C-reactive protein (hsCRP), but the composite prevalence of ischemic events did not differ significantly (χ2 = 1.587, P = 0.208). CONCLUSIONS: In addition to standard DAPT with aspirin and clopidogrel, TCs further reduce PRU and hsCRP levels, especially in patients carrying only one LOF allele. The data suggest that TCs could be used in combination therapy for ACS patients with HPR undergoing PCI.

Cost-Utility Analysis of Cataract Surgery in Advanced Glaucoma Patients.

PURPOSE: To assess the cost-effectiveness of cataract surgery in advanced glaucoma (AG) patients. MATERIALS AND METHODS: A total of 93 patients with AG who underwent cataract surgeries were collected prospectively from June 2010 through June 2013 in Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, and were followed up for at least 3 months. A standard phacoemulsification technique was used to remove cataract(s). No complications occurred intraoperatively or postoperatively. Costs associated with surgery were recorded. Utility values of cataract surgery were obtained by using time trade-off method. Quality-adjusted life-years (QALYs) were calculated using the patients' life expectancy at a 3% discounted rate. Incremental cost-utility analysis was performed (compared with no treatment) by calculating the incremental cost-effectiveness ratio (ICER), that is, the mean incremental cost for each QALY. The bootstrap method was used for statistical analysis, and sensitivity analyses were performed to test robustness of the results. RESULTS: The mean incremental cost of cataract surgery was 9876 Chinese yuan (CNY) [1593 US dollar (USD)] [95% confidence interval (CI), 9144-10,570 CNY (1475-1705 USD)].The mean additional QALYs gained were 2.20 (95% CI, 1.85-2.54), and the incremental cost for each additional QALY was 4508 CNY (727 USD) [95% CI, 3890-5234 CNY (627-844 USD)], far lower than the per capita annual disposable income in Shanghai, 40,188 CNY (6482 USD). CONCLUSION: For AG patients, cataract surgery does help obtain more QALYs and was highly cost effective.

Vision-related Quality of Life Outcomes of Cataract Surgery in Advanced Glaucoma Patients.

PURPOSE: To demonstrate longitudinal postoperative vision-related quality of life and visual acuity changes after cataract surgery in advanced glaucoma patients. MATERIALS AND METHODS: In total, 93 patients who underwent cataract surgeries were collected from June 2010 through June 2013 in Shanghai First People's Hospital, Shanghai Jiao Tong University, and were followed up for at least 3 months. Patients with advanced glaucoma, here defined as near total cupping of the optic nerve with severe visual field loss within 10 degrees of fixation, were enrolled. A standard phacoemulsification technique with the insertion of an intraocular lens was used. No complications occurred intraoperatively or postoperatively. Preoperative and 3-month postoperative vision-related quality of life were assessed in face-to-face interviews. The Chinese-version of the Low Vision Quality of Life Questionnaire (CLVQOL) was used. Wilcoxon signed-rank test was used to compare the differences in the best-corrected visual acuity (BCVA), weighted average LogMAR (WMAR), and CLVQOL scores. A binary logistic regression analysis was conducted to explore the potential factors associated with the change in CLVQOL scores. RESULTS: The overall changes in the CLVQOL composite scores ranged between 4 and 42 (median=19). Statistically significant increases occurred in the composite scores of all of the subscales, the total CLVQOL, the BCVA in the surgery eye, and the WMAR (all P<0.001). Greater increases in the CLVQOL composite scores was associated with superior preoperative WMAR (odds ratio: 9.920, P<0.05), and age below 60 years (odds ratio: 9.905, P<0.05). CONCLUSIONS: Cataract surgery should be recommended for advanced glaucoma patients with stable intraocular pressure.

Comparison of the efficacy of drug-eluting stents versus bare-metal stents for the treatment of left main coronary artery disease.

BACKGROUND: Recent studies reported that percutaneous coronary intervention with stent implantation was safe and feasible for the treatment of left main coronary artery (LMCA) disease in select patients. However, it is unclear whether drug-eluting stents (DESs) have better outcomes in patients with LMCA disease compared with bare-metal stent (BMS) during long-term follow-up in Chinese populations. METHODS: From a perspective multicenter registry, 1136 consecutive patients, who underwent BMS or DES implantation for unprotected LMCA stenosis, were divided into two groups: 1007 underwent DES implantation, and 129 underwent BMS implantation. The primary outcome was the rate of major adverse cardiac events (MACEs), including cardiovascular (CV) death, myocardial infarction (MI), and target lesion revascularization (TLR) at 5 years postimplantation. RESULTS: Patients in the DES group were older and more likely to have hyperlipidemia and bifurcation lesions. They had smaller vessels and longer lesions than patients in the BMS group. In the adjusted cohort of patients, the DES group had significantly lower 5 years rates of MACE (19.4% vs. 31.8%, P = 0.022), CV death (7.0% vs. 14.7%, P = 0.045), and MI (5.4% vs. 12.4%, P = 0.049) than the BMS group. There were no significant differences in the rate of TLR (10.9% vs. 17.8%, P = 0.110) and stent thrombosis (4.7% vs. 3.9%, P = 0.758). The rates of MACE (80.6% vs. 68.2%, P = 0.023), CV death (93.0% vs. 85.3%, P = 0.045), TLR (84.5% vs. 72.1%, P = 0.014), and MI (89.9% vs. 80.6%, P = 0.029) free survival were significantly higher in the DES group than in the BMS group. When the propensity score was included as a covariate in the Cox model, the adjusted hazard ratios for the risk of CV death and MI were 0.41 (95% confidence interval [CI]: 0.21-0.63, P = 0.029) and 0.29 (95% CI: 0.08-0.92, P = 0.037), respectively. CONCLUSIONS: DES implantation was associated with more favorable clinical outcomes than BMS implantation for the treatment of LMCA disease even though there was no significant difference in the rate of TLR between the two groups.

Short-term rosuvastatin treatment for the prevention of contrast-induced acute kidney injury in patients receiving moderate or high volumes of contrast media: a sub-analysis of the TRACK-D study.

BACKGROUND: Current randomized trials have demonstrated the effects of short-term rosuvastatin therapy in preventing contrast-induced acute kidney injury (CIAKI). However, the consistency of these effects on patients administered different volumes of contrast media is unknown. METHODS: In the TRACK-D trial, 2998 patients with type 2 diabetes and concomitant chronic kidney disease (CKD) who underwent coronary/peripheral arterial angiography with or without percutaneous intervention were randomized to short-term (2 days before and 3 days after procedure) rosuvastatin therapy or standard-of-care. This prespecified analysis compared the effects of rosuvastatin versus standard therapy in patients exposed to (moderate contrast volume [MCV], 200-300 ml, n = 712) or (high contrast volume [HCV], ≥ 300 ml, n = 220). The primary outcome was the incidence of CIAKI. The secondary outcome was a composite of death, dialysis/hemofiltration or worsened heart failure at 30 days. RESULTS: Rosuvastatin treatment was associated with a significant reduction in CIAKI compared with the controls (2.1% vs. 4.4%, P = 0.050) in the overall cohort and in patients with MCV (1.7% vs. 4.5%, P = 0.029), whereas no benefit was observed in patients with HCV (3.4% vs. 3.9%, P = 0.834). The incidence of secondary outcomes was significantly lower in the rosuvastatin group compared with control group (2.7% vs. 5.3%, P = 0.049) in the overall cohort, but it was similar between the patients with MCV (2.0% vs. 4.2%, P = 0.081) or HCV (5.1% vs. 8.8%, P = 0.273). CONCLUSIONS: Periprocedural short-term rosuvastatin treatment is effective in reducing CIAKI and adverse clinical events for patients with diabetes and CKD after their exposure to a moderate volume of contrast medium.

Long-term follow-up study of elderly patients with covered stent implantation after coronary perforation.

OBJECTIVE: To evaluate the long-term efficacy of covered stent implantation in the treatment of elderly patients with coronary perforation while undergoing percutaneous coronary intervention (PCI). METHODS: From June 2004 to June 2012, our center has followed ten elderly patients (age ≥ 60 years) who sustained coronary perforation during PCI. The major adverse cardiac events (MACE) were observed as well. The patients were advised to take 75 mg/day Clopidogrel for two years, and indefinite use of 100 mg/day enteric-coated aspirin. RESULTS: Six out of the 10 patients aged from 60 to 76 years old (mean 68.6 ± 5.2 years) were male, four were female. The average diameter of the implanted stents was 3.3 ± 0.3 mm, and the average length was 22.1 ± 3.7 mm. All the ruptures were successfully sealed without intra-procedural death. The follow-up duration ranged from 0.6 to 67 months (mean 31.7 ± 24.5 months). One patient died of multiple organ failure due to lung infection in 19 days after PCI; one died of cardiac sudden death in 13 months after PCI; one had angina pectoris in 53 months after PCI; one underwent multi-slice CT examination in six months after PCI, and no in-stent restenosis was found. The other four patients received angiography follow-up, and the results showed that three patients had no intra-stent restenosis, while one had left anterior descending (LAD) restenosis in the covered stent in 67 months after PCI. The in-hospital mortality was 10% (1/10). The MACE rate in 12 months after PCI was 10% (1/10). During the entire followed-up period, the restenosis rate in target vessels was 20% (1/5), mortality was 20% (2/10), and the MACE rate was 40% (4/10). CONCLUSION: Treatment of coronary perforation by using covered stents can achieve favorable long-term results; a two-year dual antiplatelet therapy (DAPT) after PCI can effectively prevent intra-stent thrombosis.

Dual antiplatelet therapy over 6 months increases the risk of bleeding after biodegradable polymer-coated sirolimus eluting stents implantation: insights from the CREATE study.

BACKGROUND: The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation remains controversial. The primary aim of our study was to evaluate the impact of optimal DAPT duration on bleeding events between 6 and 12 months after biodegradable polymer-coated DES implantation. The secondary aim is to determine the predictors and prognostic implications of bleeding. METHODS: This study is a post hoc analysis of the Multi-Center Registry of EXCEL Biodegradable Polymer Drug Eluting Stents (CREATE) study population. A total of 2,040 patients surviving at 6 months were studied, including 1,639 (80.3%) who had received 6-month DAPT and 401 (19.7%) who had received DAPT greater than 6 months. Bleeding events were defined according to the bleeding academic research consortium (BARC) definitions as described previously and were classified as major/minor (BARC 2-5) and minimal (BARC 1). A left censored method with a landmark at 6 months was used to determine the incidence, predictors, and impact of bleeding on clinical prognosis between 6 and 12 months. RESULTS: At 1-year follow-up, patients who received prolonged DAPT longer than 6 months had a significantly higher incidence of overall (3.0% vs. 5.5%, P = 0.021) and major/minor bleeding (1.1% vs. 2.5%, P = 0.050) compared to the patients who received 6-month DAPT. Multivariate analysis showed that being elderly (OR = 1.882, 95% CI: 1.109-3.193, P = 0.019), having diabetes (OR = 1.735, 95% CI: 1.020-2.952, P = 0.042), having a history of coronary artery disease (OR = 2.163, 95% CI: 1.097-4.266, P = 0.026), and duration of DAPT longer than 6 months (OR = 1.814, 95% CI: 1.064-3.091, P = 0.029) were independent predictors of bleeding. Patients with bleeding events had a significantly higher incidence of cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis. CONCLUSIONS: Prolonged DAPT (greater than 6 months) after biodegradable polymer-coated DES increases the risk of bleeding, and is associated with adverse cardiac events at 1-year follow-up. (J Interven Cardiol 2014;27:119-126).

The efficacy and safety of pharmacoinvasive therapy with prourokinase for acute ST-segment elevation myocardial infarction patients with expected long percutaneous coronary intervention-related delay.

OBJECTIVES: To elucidate the efficacy and safety of pharmacoinvasive therapy by using prourokinase (prouk) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Patients with STEMI often have long percutaneous coronary intervention (PCI)-related delays due to various reasons, which are associated with poor outcomes. METHODS: A randomized study which enrolled patients from four centers in China was conducted. Patients were randomly assigned to accept routine primary PCI or prouk-PCI. The primary end points were the angiographic parameters, including thrombolysis in myocardial infarction (TIMI) flow grade, TIMI frame count, and myocardial blush grade. Secondary endpoints were incidence of major adverse cardiac events (MACE, defined as death from all causes, reinfarction, revascularization, or rehospitalization due to new or worsening congestive heart failure) at 30 days and 1 year. RESULTS: One hundred and ninety-seven eligible patients were enrolled, of whom 100 were randomized to the prouk-PCI group. Significantly more patients in the prouk-PCI group than in the PCI group had an opened infarct-related artery on arrival in the catheterization laboratory (48% vs. 21%, P = 0.0002) and better TIMI frame count after PCI (33 ± 6 vs. 40 ± 10, P < 0.001). At 1-year follow-up, there was a trend that patients in the prouk-PCI group had less chances to have MACE (7.0% vs. 12.6%, P = 0.235) or be readmitted to hospital due to new or worsening congestive heart failure (1.0% vs. 4.1%, P = 0.209). CONCLUSION: A strategy of emergent PCI preceded by fibrinolysis with prouk results in a better myocardial perfusion in infarct-related artery compared with primary PCI alone in patients with STEMI and long PCI-related delay.

Clinical presentations, antiplatelet strategies and prognosis of patients with stent thrombosis: an observational study of 140 patients.

BACKGROUND: Until now there has been scarce evidence regarding an optimal antiplatelet strategy and clinical outcomes for patients who had suffered from stent thrombosis (ST). METHODS AND RESULTS: 140 patients who suffered from stent thrombosis were prospectively registered. Patients received dual (aspirin and 150 mg clopidogrel, N = 66) or triple (additional cilostazol, N = 74) antiplatelet therapy at the physician's discretion. Thereafter platelet reactivity and one year clinical outcomes were analyzed. The primary outcome included the composite of cardiac death, non-fatal myocardial infarction (MI) or stroke at one year,which developed in 41 (29.3%) patients, consisting of 31 (22.1%) cardiac death, 9 (6.4%) non-fatal MI and 1 (1.4%) stroke. Recurrent definite and probable ST according to ARC definition was observed in 8 (5.7%) and 14 (10.0%) patients, respectively. Triple therapy was associated with significantly lower platelet reactivities (50.2 ± 17.8, % vs. 59.6 ± 17.2, %, P = 0.002) compared to high dose dual antiplatelet therapy. However, the incidence of primary events (24.3% vs. 34.8%, P = 0.172) did not differ between triple and dual antiplatelet therapies. High on-treatment platelet reactivity (HR: 8.35, 95% CI: 2.234∼30.867, P = 0.002) and diabetes (HR: 3.732, 95% CI: 1.353∼10.298, P = 0.011) were independent predictors of primary events. CONCLUSIONS: Patients who suffered from stent thrombosis have a poor prognosis even after revascularization with intensive antiplatelet therapy. Triple antiplatelet therapy was more effective in reducing on-treatment platelet reactivity, compared to high dose dual antiplatelet therapy.

Value of a new post-procedural intravascular ultrasound score in predicting target vessel revascularization after coronary drug-eluting stents implantation.

OBJECTIVE: There is no simple or feasible post-procedural intravascular ultrasound (IVUS) score to predict major adverse cardiac events (MACE) in patients undergoing drug-eluting stents (DES) implantation. The aim of this study is to validate a new IVUS score for predicting MACE. METHODS: A total of 295 patients (with 322 lesions) were enrolled. IVUS score was calculated in each lesion based on five IVUS morphological characteristics: inflow/outflow disease, malapposition, underexpansion, tissue protrusion, and edge dissection (iMUTE score). We assigned two points to an underexpansion and one point for each presence of other factors. Patients were divided into low score (iMUTE score<2, n=137) and high score (iMUTE score≥2, n=158) groups. RESULTS: At one year follow-up, a trend was seen in favor of the low iMUTE score group in MACE (3.65% vs. 10.10%; P=0.052), and there was more target vessel revascularization (TVR) in the high iMUTE score group compared with low score group (6.96% vs. 1.46%; P=0.044). Low iMUTE score was an independent predictor of freedom from TVR at one year (adjusted hazard ratio (HR) 0.5, 95% confidence interval (CI) 0.1-0.8; P=0.02). CONCLUSIONS: Post-procedural IVUS iMUTE scoring was simple and feasible in clinical practice, and can provide independent prognostic value for TVR in patients undergoing DES implantation.

Incidence and predictors of definite stent thrombosis after coronary stent implantation.

BACKGROUND: Coronary stents are widely used in percutaneous coronary intervention (PCI) procedures. We aimed to explore the incidence, predictors and characteristics of stent thrombosis (ST) after coronary stent implantation in routine clinical practice. METHODS: From data of 18 063 consecutive patients who underwent successful stent implantation in Shenyang Northern Hospital from 2004 to 2010, we identified patients with definite ST (n = 140) and control patients (n = 280) matched on age, diagnosis, sex, current antiplatelet medication and stent type. The incidence, predictors and characteristics of ST after coronary stent implantation were investigated. RESULTS: The incidence of angiographically confirmed ST was 0.78% (140/18 063). The time distribution of ST was acute in 43 (30.7%), subacute in 50 (35.7%), and late in 47 (33.6%) patients. Binary Logistic regression analysis identied the angiotensin-converting enzyme inhibitor (ACEI) (odds ratio (OR) = 0.472, 95%CI: 0.276 - 0.807, P = 0.006) and heparin (OR = 0.477, 95%CI: 0.278 - 0.819, P = 0.007) were associated with an reduced risk of cumulative ST. Stent length (OR = 1.042, 95%CI: 1.026 - 1.058, P < 0.001), serum creatinine total (OR = 1.020, 95%CI: 1.004 - 1.035, P = 0.04), cholesterol (OR = 1.267, 95%CI: 1.021 - 1.573, P = 0.032), glucose (OR = 1.086, 95%CI: 1.002 - 1.176, P = 0.044), and platelet aggregation (OR = 1.113, 95%CI: 1.075 - 1.154, P < 0.001) were associated with an increased risk of cumulative ST. CONCLUSION: ST is associated with longer stent length and higher level of total cholesterol, glucose and platelet aggregation.

[Effects of intensive antiplatelet therapy for patients with high on-treatment platelet reactivity after coronary stent implantation].

OBJECTIVE: To explore the effects of intensive antiplatelet therapy for patients with high on-treatment platelet reactivity (HPR) after coronary stent implantation. METHODS: Between March 2009 and February 2011, a total of 3316 consecutive acute coronary syndrome patients undergoing drug-eluting stent implanting from 3 hospitals were enrolled. Among them, 840 patients (25.3%) were identified as HPR (defined as 20 µmol/L adenosine diphosphate induced platelet aggregation of ≥ 55% at 24 hours after administration of 300 mg clopidogrel loading dose and 300 mg aspirin). The HPR patients were randomly assigned to receive standard (aspirin 300 mg/d and clopidogrel 75 mg/d, n = 280) or intensified (n = 560) antiplatelet therapy by the ratio of 1:2. Patients in the intensive group were initially treated with a double maintenance dose of clopidogrel (150 mg/d) and aspirin (300 mg/d). After 3 days, patients with unsolved HPR received additional cilostazol treatment (50 - 100 mg, bid). The reversion rate of HPR and clinical events were observed. RESULTS: In the intensive group, HPR reversed in 304 out of 560 patients (54.3%) at 3 days post therapy and the remaining 256 patients with HPR were treated with additional cilostazol regimen for another 3 days and the total reversion rate of HPR was 81.1% (454/560). The reversion rate of HPR at 30 days in the intensified group was significantly higher than that of the standard group (69.9% vs. 55.7%, P = 0.000). At 30 days after percutaneous coronary intervention, 1 patient suffered from subacute stent thrombosis (0.2%) in intensified group and no stent thrombosis was observed in standard group (P = 1.000). There were no death, major or minor bleeding in both two groups. Minimal bleeding was also similar in the two groups (intensive: 4.28% vs. standard: 2.14%, P = 0.166). CONCLUSIONS: The intensified antiplatelet therapy regimens could significantly increase the reversion rate of HPR in acute coronary syndrome patients undergoing coronary stenting without increasing the risk of bleeding. The clinic impact of this strategy needs to be elucidated by long term follow-up outcome studies.

[Clinical efficacy of intra-aortic balloon pumping in treating patients with acute myocardial infarction with left main coronary artery disease].

OBJECTIVE: To evaluate the efficacy and safety of intra-aortic balloon pump (IABP) counter pulsation in the treatment of ST-segment elevation myocardial infarction (STEMI) with concurrent left main coronary artery (LMCA) disease. METHODS: A retrospective analysis was performed on 305 patients with confirmed STEMI due to LMCA occlusion (≥ 50%) by coronary angiography. They were divided into IABP and non-IABP groups according to the application of IABP or not. Two groups were further divided into 2 subgroups according to the treatment with percutaneous coronary intervention (PCI) or drug alone. Short and long-term clinical efficacies and the incidence of complications caused by the application of IABP were analyzed in all groups and subgroups. RESULTS: (1) PCI procedure: Successful rate of immediate post-procedure was 100%. No death, major cardiovascular event and cerebrovascular accident occurred during the procedure. The average number of stents per patient was 2.1 ± 0.7 and the average diameter and length of stent were (3.9 ± 0.6) and (24.2 ± 7.1) mm respectively. (2) SAFETY: No significant difference existed between the IABP and non-IABP groups in in-hospital massive bleeding rate (0.94% vs 1.00%, P > 0.05). However, the IABP group had a higher prevalence of mild in-hospital bleeding than the non-IABP group. (3) In-hospital and long-term major adverse cardiac event (MACE) rate: (1) IABP group had a lower MACE rate (25.3% (24/95) vs 38.5% (57/148), P < 0.05). (2) In spite of IABP implantation, the PCI subgroup had significantly a lower mortality rate than the drug subgroup (7.2% (6/83) vs 25.0% (6/24), P < 0.05). (3) The combined use of PCI and IABP was superior to other regimens with regards to decreasing short and long-term mortality (11.2% (12/107) and 25.3% (50/198), P < 0.01). CONCLUSION: PCI is feasible and safe for the STEMI patients with LMCA and better short and long-term efficacies may be achieved. The use of IABP in the treatment of LMCA-related STEMI reduces MACE rate and improves survival rate.

Comparison of drug-eluting stents with bare metal stents implantation for the treatment of acute ST-elevation myocardial infarction: 2-year clinical outcomes from single-center registry.

BACKGROUND: Some larger scale, randomized studies have demonstrated the superiority of drug-eluting stents (DES) over bare metal stents (BMS) for the treatment of acute myocardial infarction (AMI). This study aimed to investigate the impact of DES, in comparison with BMS, on the 2-year clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). METHODS: From January 2002 to December 2008, a total of 1301 consecutive STEMI patients treated with coronary stenting in Shenyang Northern Hospital were prospectively registered. Patients received BMS (n = 868) or DES (n = 435) implantation in the infarction related artery according to physician's discretion. A propensity score analysis was performed and two well matched subgroups were selected (BMS, n = 288; DES, n = 288) to evaluate the 2-year clinical outcomes. The primary outcome was the occurrence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, myocardial infarction (MI), or target vessel revascularization (TVR). RESULTS: Survival salvage analysis showed that 2-year cumulative hazards were not significantly different between the two groups with respect to TVR (2.8% vs. 3.1%, log-rank P = 0.780), stent thrombosis (1.7% vs. 4.2%, log-rank P = 0.079) and MACE (8% vs. 10.8%, log-rank P = 0.236). Multivariate analysis showed that DES was an independent protective factor of MI (HR: 0.211, 95%CI: 0.049 to 0.908) and stent thrombosis (HR: 0.327, 95%CI: 0.107 to 0.994). CONCLUSION: DES was associated with similar 2-year clinical outcomes to those of BMS for the treatment of STEMI in daily practice.

Coronary collateral circulation: Effects on outcomes of acute anterior myocardial infarction after primary percutaneous coronary intervention.

BACKGROUND: To investigate the effects of collateral coronary circulation on the outcome of the patients with anterior myocardial infarction (MI) with left anterior desending artery occlusion abruptly. METHODS: Data of 189 patients with acute anterior MI who had a primary percutaneous coronary intervention (PCI) in the first 12 h from the onset of symptoms between January 2004 and December 2008 were retrospective analyzed. Left anterior descending arteries (LAD) of all patients were occluded. LADs were reopened with primary PCI. According to the collateral circulation, all patients were classified to two groups: no collateral group (n = 111), patients without angiographic collateral filling of LAD or side branches (collateral index 0) and collateral group (n = 78), and patients with angiographic collateral filling of LAD or side branches (collateral index 1, 2 or 3). At one year's follow-up, the occurrence of death, reinfarction, stent thrombosis (ST), target vessel revascularization and readmission because of heart failure were observed. RESULTS: At one year, the mortality was lower in patients with collateral circulation compared with those without collateral circulation (1% vs. 8%, P = 0.049), whereas there were no differences in the occurrence of reinfarction, ST, target vessel revascularization and readmission because of heart failure. The occurrence of composite of endpoint was lower in patients with collateral circulation compared with those without collateral circulation (12% vs. 26%; P = 0.014). CONCLUSIONS: Pre-exist collateral circulation may prefigure the satisfactory prognosis to the patients with acute anterior MI after primary PCI in the first 12 h of MI onset.

[Therapeutic effect and safety of drug eluting stent for patients with acute ST-elevation anterior wall myocardial infarction by left anterior descending artery occluded abruptly].

OBJECTIVE: To assess the therapeutic effect and safety of drug eluting stent for the patients with anterior wall myocardial infarction by left anterior descending artery occluded abruptly. METHODS: From January 2004 to December 2008, 302 patients with anterior wall myocardial infarction in 12 hours from chest pain to treatment were treated. But only 189 patients were recruited and randomly divided into drug eluting stent group (n = 95) and bare metal stent group (n = 94). The occurrence of cardiac death, stent thrombosis, reinfarction, target vessel revascularization and re-hospitalization because of heart function failure was compared. RESULTS: There was no difference in cardiac death [3/95 (3%) vs 7/94 (7%), P = 0.206], reinfarction [1/95 (1%) vs 5/94 (5%), P = 0.112] and re-hospitalization because of heart function failure [8 (8%) vs 5 (5%), P = 0.434]. Compared with those in bare metal stent group, the patients in drug eluting stent group has a lower rate of target vessel revascularization [2 (2%) vs 13 (14%), P = 0.009] and composite therapeutic effect endpoints [12 (13%) vs 25 (27%), P = 0.011]. There was no difference in safety endpoint or stent thrombosis [1 (1%) vs 4 (4%), P = 0.204]. CONCLUSION: In patients with anterior wall myocardial infarction by left anterior descending artery occluded abruptly, drug eluting stent decreases the rate of target vessel revascularization. But it has no increased stent thrombosis.

Long-term efficacy and safety of drug-eluting stent implantation for patients with multiple coronary chronic total occlusions.

BACKGROUND: Data on the efficacy and safety of drug-eluting stent (DES) for treatment of multiple coronary chronic total occlusion (CTO) lesions are scanty. The aim of the present study was to compare the long-term outcomes of DES versus bare metal stent (BMS) implantation for multiple coronary CTO lesions. METHODS: We analyzed 188 patients who underwent coronary stenting for at least two de novo CTO lesions in our center from November 2000 to November 2006. Among them, 118 patients (62.8%) received DES and 70 patients (37.2%) received BMS implantation after the recanalization for CTO lesions. All patients were followed up for up to 5 years for the occurrence of major adverse cardiac events (MACE). Long-term survival rates were estimated with the Kaplan-Meier method. RESULTS: There were no significant differences in baseline clinical characteristics and procedural success rate between DES group and BMS group. Compared with the BMS group, the DES group showed a significantly higher rate of long CTO (> or = 15 mm) (62.0% vs. 50.6%, P = 0.023). The number of stents per lesion (1.39 +/- 0.71 vs. 1.17 +/- 0.66, P = 0.007) and the mean length of stents in the DES group were also higher than those in the BMS group ((40.8 +/- 11.4) mm vs. (23.4 +/- 8.7) mm, P < 0.001). But the mean diameter of stents in the DES group was smaller than that in the BMS group ((3.1 +/- 0.2) mm vs. (3.3 +/- 0.5) mm, P < 0.001). Average follow-up time was 4.8 +/- 0.7 (1.5 - 5.0) years in the BMS group and 4.3 +/- 0.5 (1.3 - 5.0) years in the DES group. Both the 5-year cumulative survival rates and the target vessel revascularization (TVR)-free survival rates of the DES group were significantly higher than those in the BMS group (83.1% vs. 72.9%, Log-rank P = 0.044; 77.1% vs. 62.9%, Log-rank P = 0.009). The cumulative MACE-free survival rates in the DES group were significantly higher than those in the BMS group (71.2% vs. 51.4%, Log-rank P = 0.001). Multivariable Cox regression analysis demonstrated that DES implantation for multiple CTO lesions could significantly reduce the long-term MACE risk after percutaneous coronary intervention (PCI) (HR: 0.436; 95%CI 0.327 - 0.665, P < 0.001). Age over 65 years (HR: 2.018; 95%CI 1.491 - 3.127, P < 0.001) and left ventricular ejection fraction < 50% (HR: 1.494; 95%CI 1.125 - 2.376, P < 0.001) were identified as the independent predictors of long-term MACE. CONCLUSION: This study demonstrates the long-term (up to 5 years) efficacy and safety of DES for treatment of multiple coronary CTO lesions, and its superiority compared to BMS in reducing the rates of TVR and MACE.

Elective percutaneous intervention for unprotected left main coronary artery stenosis complicated with left anterior descending artery chronic total occlusive lesions.

BACKGROUND: The patients with unprotected left main coronary artery (ULMCA) stenosis and chronic total occlusion (CTO) lesions at the left anterior descending (LAD) artery are often recommended for bypass surgery. However, some of these patients are deemed inoperable or are at high risk for surgery. In this study, we explored strategies and evaluated the efficacy of percutaneous coronary intervention for the treatment of ULMCA stenosis complicated by LAD CTO. METHODS: From November 2001 to July 2009, 78 patients with ULMCA stenosis and LAD CTO lesions were selectively treated with stenting. Six patients (7.7%) refused surgery due to their young age (< or = 40 years), and the other 72 patients (92.3%) were unsuitable for surgery. Reasons for poor surgical candidacy included advanced age (> 80 years), chronic obstructive pulmonary, unsuitable distal target vessels for bypass, EuroSCORE > or = 6, and so on. Four different strategies were applied based on the degree of left main stenosis and the ostial diameter and involvement of the left circumflex. RESULTS: Total procedural success was achieved in 94.9%, there were no deaths or thromboses. Five patients (6.4%) experienced non-Q-wave myocardial infarction in hospital. At long-term follow-up ((52 +/- 28) months), there were 3 cardiac deaths (3.8%) and 4 (5.1%) nonfatal myocardial infarctions. Angiographic follow-up was performed in 50 patients (64.1%), and target vessel revascularizations were required in 10 patients (12.8%), among which 4 nonfatal myocardial infarction patients included. The rate of major adverse cardiac events was 16.7% (13/78). CONCLUSIONS: This study indicates that percutaneous intervention can be performed safely in high risk surgical patients with ULMCA and LAD CTO lesions based on individual therapeutic strategies. It may be feasible to apply this technique in selected patients mentioned above.

Efficacy and safety of intra-aortic balloon pump-assisted interventional therapy in different age groups of patients with acute coronary syndrome.

BACKGROUND: Currently intra-aortic balloon pump (IABP) has been widely used in patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI). However, few studies have been done with regard to the clinical outcome and safety of IABP in assisting PCI in aged patients with ACS. The purpose of the present study was to evaluate the safety of IABP in different age groups of patients with ACS. METHODS: Data on 292 ACS patients who received IABP-assisted PCI in Shenyang General Hospital of People's Liberation Army were retrospectively analyzed. More specifically, the successful rate, mortality and complications associated with the treatment were compared between the senior (>/= 60 years old) and the non-senior (< 60 years old) groups of patients. RESULTS: The attack rate of non-ST segment elevation ACS was significantly higher in the senior group than in the non-senior group (38.8% vs 21.1%, P < 0.01). The incidence of the IABP-associated complications was not significantly different between both groups (P > 0.05). CONCLUSION: The clinical outcome and safety of IABP-assisted PCI in the elderly patients were comparable to that for the non-elderly patients.