Major improvement of percutaneous cardiovascular procedure outcomes with radial artery catheterisation: results from the PREVAIL study.

OBJECTIVE: To obtain a "snapshot" view of access-specific percutaneous cardiovascular procedures outcomes in the real world. DESIGN: Multicentre, prospective study performed over a 30-day period. SETTING: Nine hospitals with invasive cardiology facilities, reflecting the contemporary state of healthcare. PATIENTS: Unselected consecutive sample of patients undergoing any percutaneous cardiovascular procedure requiring an arterial access. INTERVENTIONS: Percutaneous cardiovascular procedures by radial or femoral access MAIN OUTCOME MEASURES: The primary outcome was the combined incidence of in-hospital (a) major and minor haemorrhages; (b) peri-procedural stroke; and (c) entry-site vascular complications. The secondary outcome was the combined incidence of in-hospital death and myocardial infarction/reinfarction. For analysis purposes, outcomes were allocated to arterial access-determined study arms on an intention-to treat basis. Multivariable analysis adjusted using propensity score was performed to correct for selection bias related to arterial site. RESULTS: A total of 1052 patients were enrolled: 509 underwent radial access and 543 femoral access. In both groups, 40% underwent a coronary angioplasty. Relative to femoral access, radial access was associated with a lower incidence both of primary (4.2% vs 1.96%, p = 0.03, respectively) and secondary endpoints (3.1% vs 0.6%, p = 0.005, respectively). Multivariate analysis, adjusted for procedural and clinical confounders, confirmed that intention-to-access via the radial route was significantly and independently associated with a decreased risk both of primary (OR 0.37, 95% CI 0.16 to 0.84) and secondary endpoints (OR 0.14, 95% CI 0.03 to 0.62). CONCLUSIONS: Our study indicates strikingly better outcomes of percutaneous cardiovascular procedures with radial access versus femoral access in contemporary, real-world clinical settings.

Direct coronary stenting: effect on coronary blood flow, immediate and late clinical results.

Direct stenting (DS) was attempted in 99 coronary lesions in 94 patients while standard stenting (SS) was attempted in 113 lesions in 103 patients matched for clinical characteristics, stenosis type, and location and stent type. The angiographic result was also evaluated according to TIMI frame count method (TFC) before and after procedure. A clinical follow-up was performed 1 year after the procedure. Before the procedure, TIMI grade 3 flow was detected in 42 cases (42.4%), grade 2 in 40 cases (40.4%), grade 1 in 5 cases (5.1%), and grade 0 in 12 cases (12.1%) in the DS group; these data were similar in SS group. After the procedure, TIMI grade flow was 3 in 90 cases (92.8%) in DS group and in 87 (77.0%) in SS group (P < 0.005); grade 2 was observed in 7 case (7.2%) in DS group and in 25 (22.1%) in SS group (P < 0.005). Major adverse cardiac events during hospitalization and at follow-up were similar in two groups. Radiation exposure time and procedure costs per lesion were significantly reduced in DS group compared to SS group (10.1 +/- 8 min vs. 13.9 +/- 4.7 min, P < 0.001; and 1901 +/- 687 Euro vs. 2352 +/- 743 Euro, P < 0.001, respectively). This study confirms that, in selected patients, direct stenting is a safe and successful procedure, allowing a significant reduction in radiation exposure time and procedural costs compared to standard stenting technique. The angiographic success is confirmed by the improvement in TFC in all cases.

[Emergency coronary surgery after failed angioplasty: 11 years of experience (1987-1997)]. / Chirurgia coronarica d'emergenza dopo angioplastica fallita: undici anni d'esperienza (1987-1997).

METHODS: From January 1987 to December 1997, thirty patients underwent emergent or urgent coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Dissection/occlusion of the target artery was the commonest complication, but we also had two cases of stent dislocation and one case of coronary artery wall perforation. Two-thirds of the patients experienced extreme preoperatory hemodynamic instability (i.e., cardiac arrest or cardiogenic shock) and half had to be intubated in the Catheterization Laboratory. An average of 1.73 grafts/patient was performed. Complete coronary revascularization was achieved in 93% of the cases; the internal mammary artery could be employed in one-third only. RESULTS: In-hospital mortality was 10%, and perioperatory myocardial infarction or persistent ischemia could be detected in half of the patients. The need for aortic counterpulsation, and the use of inotropic and antiarrhythmic drugs were higher than average in this group of patients; while intensive care unit and hospital stay were longer. Patients with deteriorated preoperative hemodynamics fared significantly worse. Late results were encouraging: seventy-five per cent of all patients (and 84% of hospital survivors) were still alive an average of 52 months after surgery. Two-thirds of all patients (and 72% of hospital survivors) were alive and angina-free. CONCLUSIONS: Even in the current era, revascularization surgery after failed coronary angioplasty still carries an increased risk for postoperative complications and death, especially for patients with deteriorated preoperative hemodynamic conditions. On the other hand, postoperative middle- and long-term results are encouraging, as hospital survivors were similar to elective bypass patients regarding survival and freedom from return of angina.

[Clocking diagnostic and therapeutic procedures in coronary care unit patients: analysis of clinical performance times]. / Le prestazioni diagnostiche e terapeutiche nel paziente di unità coronarcia: valutazione dei tempi di effettuazione e dei fattori correlati.

BACKGROUND: An optimal use and exploitation of professional personnel is of paramount importance for health management organizations, as human resources are both their greatest asset and heaviest financial burden. To better understand the amount of medic and paramedic work and time required for the typical diagnostic and therapeutic procedures in a coronary-care unit setting, we measured their average times and analyzed their inherent co-factors. METHODS: This study was conducted on 206 consecutive coronary-care unit patients. These patients were divided into subgroups according to their admission diagnosis: acute myocardial infarction, unstable angina, acute cardiac failure, pulmonary embolism or other pathologies. Each subgroup was then subdivided even further according to the severity of their clinical status. Diagnostic and therapeutic procedures ("macroactivities") have been identified and each one was subdivided into sub-procedures ("microactivities"). All microactivities were carefully clocked in every patient in order to calculate the average execution time for every macroactivity. RESULTS: Our data show that myocardial infarction patients and, in general, a more severe clinical status required a longer stay in the coronary-care unit. Again, longer overall clinical performance times were necessary in myocardial infarction patients as compared to the unstable angina subgroup. There were no statistically significant differences among other subgroups. More severely ill patients required longer clinical performance times because of both a longer coronary-care unit stay and longer clinical performance time per day. More than half of the total clinical performance time for each patient was spent during the first two days. Paramedics supplied more than 80% of the total performance time. CONCLUSIONS: The authors undertook a study of typical coronary-care unit clinical activities by clocking the performance times of the usual diagnostic and therapeutic procedures. The data thus obtained come from direct measurements and describe the clinical performance of both medics and paramedics in a real-life setting. This could thus be used as a yardstick to verify current workload standards. It is hoped that a deeper understanding of these activities will optimize the full exploitation of available human resources.

Magnetic resonance imaging for assessment of apical hypertrophy in hypertrophic cardiomyopathy.

The purpose of the study was to evaluate the value of magnetic resonance imaging as compared with two-dimensional echocardiography for a reliable assessment of the degree and distribution of apical hypertrophy in hypertrophic cardiomyopathy (HCM). The study includes 10 HCM patients (8 males and 2 females, mean age: 42 +/- 7 years). Two-dimensional echocardiography was not definitive in assessing the abnormal thickening of the apical myocardium in two patients. Two other patients had inadequate echocardiographic visualization of the lower left ventricle due to technical reasons. At magnetic resonance imaging, 3 patients showed localized hypertrophy at the left ventricular apex only. Three other patients had evidence of hypertrophy at the apex as well as at the left ventricular free wall. In four patients, the hypertrophy was detected at either the apex or the lower interventricular septum. It is concluded that magnetic resonance imaging might provide an accurate assessment of myocardial hypertrophy in HCM patients. This technique appears to be of major value in those with wall thickening localized to (or predominant in) the apical portion of the ventricle.

Comparison of left ventricular ejection fraction by magnetic resonance imaging and radionuclide ventriculography in idiopathic dilated cardiomyopathy.

To assess the validity of gated magnetic resonance imaging (MRI) in determining left ventricular (LV) ejection fraction (EF), MRI (Spin Echo, multislice-multiphase technique on the short-axis plane) was compared with equilibrium radionuclide ventriculography in 32 patients with idiopathic dilated cardiomyopathy. All patients underwent MRI and radionuclide ventriculography, performed consecutively on the same day (mean time interval between the 2 examinations: 40 minutes). Comparison with LVEF showed a high correlation (y = 0.79 X +3.51, r = 0.91; p less than 0.001). Mean difference between radionuclide ventriculography and MRI data was 1.7, with the 95% confidence interval 0.71 to 2.68: MRI slightly underestimated LVEF. MRI interobserver and intrapatient variability (assessed in 15 of 32 patients) showed a high correlation (r = 0.91, r = 0.98). In conclusion, data suggest that MRI, using the short-axis approach and the multislice-multiphase technique, is an accurate, noninvasive, highly reproducible method of evaluating LVEF in patients with idiopathic dilated cardiomyopathy.

Amiodarone-induced concomitant first and second degree sinoatrial block.

The occurrence of concomitant first and second degree sinoatrial block due to chronic amiodarone treatment in 1 patient with moderate mitral valve stenosis is described. Discontinuation of amiodarone resulted in the disappearance of such a sinoatrial conduction disturbance.