Restoration of microvascular function in the infarct-related artery by intracoronary transplantation of bone marrow progenitor cells in patients with acute myocardial infarction: the Doppler Substudy of the Reinfusion of Enriched Progenitor Cells and Infarct Remodeling in Acute Myocardial Infarction (REPAIR-AMI) trial.

BACKGROUND: The Doppler Substudy of the randomized, double-blind, placebo-controlled Reinfusion of Enriched Progenitor Cells and Infarct Remodeling in Acute Myocardial Infarction (REPAIR-AMI) trial aimed to investigate the effects of intracoronary infusion of bone marrow-derived progenitor cells (BMCs) on coronary blood flow regulation in patients with reperfused acute myocardial infarction. METHODS AND RESULTS: In a total of 58 patients (BMC group, n=30; placebo group, n=28), coronary flow reserve (CFR) in the infarct artery and a reference vessel was assessed by intracoronary Doppler at the time of study therapy (4.2+/-0.1 days after acute myocardial infarction) and at the 4-month follow-up. Initial CFR was reduced in the infarct artery compared with the reference vessel in both groups (BMC: 2.0+/-0.1 versus 2.9+/-0.2, P<0.05; placebo: 1.9+/-0.1 versus 2.8+/-0.2; P<0.05). At the 4-month follow-up, CFR in the infarct artery had slightly improved in the placebo group (+0.88+/-0.18; P<0.001 versus initial) but was markedly increased by 90% (+1.80+/-0.25; P=0.005 versus placebo) in BMC-treated patients, resulting in a normalization of CFR (3.8+/-0.2; P<0.001 versus initial and placebo at 4 months). In the infarct vessel, adenosine-induced minimal vascular resistance index declined slightly in the placebo group (from 1.77+/-0.12 to 1.52+/-0.15 mm Hg x s/cm; P<0.05) but considerably decreased by -29+/-6% in the BMC group (from 1.86+/-0.19 to 1.20+/-0.12 mm Hg x s/cm; P<0.05 versus initial and placebo at 4 months). CONCLUSIONS: Intracoronary BMC therapy after acute myocardial infarction restores microvascular function of the infarct-related artery, which is associated with a significant improvement in maximal vascular conductance capacity. These data provide clinical proof of concept that progenitor cell transplantation promotes vascular repair.

Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery.

BACKGROUND: Minimally invasive bypass surgery and coronary-artery stenting are both accepted treatments for isolated stenosis of the proximal left anterior descending coronary artery. We compared the clinical outcomes after these two procedures. METHODS: A total of 220 symptomatic patients with high-grade lesions in the proximal left anterior descending coronary artery were randomly assigned to treatment--110 to surgery and 110 to stenting. The combined clinical end point was freedom from major adverse cardiac events, such as death from cardiac causes, myocardial infarction, and the need for repeated revascularization of the target lesion within six months. RESULTS: A major adverse cardiac event occurred in 31 percent of patients after stenting, as compared with 15 percent in the surgery group (P=0.02). The difference was predominantly due to a higher rate of repeated revascularization of the target vessel for restenosis after stenting (29 percent vs. 8 percent, P=0.003). The combined rates of death and myocardial infarction did not differ significantly between groups (3 percent in the stenting group and 6 percent in the surgery group, P=0.50). Adverse events occurred more frequently after surgery. The percentage of patients free from angina after six months was 79 percent in the surgery group, as compared with 62 percent in the stenting group (P=0.03). CONCLUSIONS: In patients with isolated high-grade lesions of the proximal left anterior descending artery, both minimally invasive bypass surgery and stenting are effective. Stenting yields excellent short-term results with fewer periprocedural adverse events, but surgery is superior with regard to the need for repeated intervention in the target vessel and freedom from angina at six months of follow-up.

Transplantation of blood-derived progenitor cells after recanalization of chronic coronary artery occlusion: first randomized and placebo-controlled study.

Transplantation of blood-derived circulating progenitor cells (CPC) has been shown to improve myocardial regeneration after myocardial infarction. It remains unclear whether CPC transplantation exerts beneficial effects also in patients with chronic myocardial ischemia. We initiated a randomized, double-blind, placebo-controlled study evaluating the impact of intracoronary infusion of CPCs on coronary vasomotion and left ventricular (LV) function in patients after recanalization of chronic coronary total occlusion (CTO). After recanalization of CTO, 26 patients (age, 63+/-2 years; LV ejection fraction, 53+/-2%) were randomly assigned to the treatment (intracoronary transplantation of CPCs) or control group. Coronary flow reserve in response to adenosine (2.4 mg/min) was measured in the target vessel at the beginning of the study and after 3 months. LV function and infarct size were assessed by MRI and metabolism by 18F deoxyglucose positron emission tomography. CPC application resulted in an increase in coronary flow reserve by 43% from 2.3+/-0.3 to 3.3+/-0.5 (P<0.05 versus beginning and control). At 3 months, the number of hibernating segments in the target region (from 2.9+/-0.6 to 2.0+/-0.6 segments, P<0.05 versus beginning and control) had declined in the treatment group, whereas no significant changes were observed in the control group. MRI revealed a reduction in infarct size by 16% and an increase in LV ejection fraction by 14% in the treatment group (from 51.7+/-3.7 to 58.9+/-3.2%; P<0.05 versus beginning and control) because of an augmented wall motion in the target region. Hence, intracoronary transplantation of CPCs after recanalization of CTO results in an improvement of macro- and microvascular function and contributes to the recruitment of hibernating myocardium.

Effect of two different neuroprotection systems on microembolization during carotid artery stenting.

OBJECTIVES: This study sought to compare the efficacy of two different cerebral protection systems for the prevention of embolization during carotid artery stenting (CAS) using a transcranial Doppler (TCD) monitoring with the detection of microembolic signals (MES). BACKGROUND: Despite the introduction of cerebral protection systems, neurologic complications during CAS cannot completely be prevented. Transcranial Doppler and detection of MES may aid in assessing the efficacy of different neuroprotection systems. METHODS: A total of 42 patients with internal carotid artery stenoses were treated by CAS using either a filter (E.P.I. FilterWire, Boston Scientific Corp., Santa Clara, California) (n = 21) or a proximal endovascular clamping device (MO.MA system, Invatec s.r.l., Roncadelle, Italy) (n = 21). Microembolic signal counts were compared during five phases: placement of the protection device, passage of the stenosis, stent deployment, balloon dilation, and retrieval of the protection device. RESULTS: There were no significant differences in clinical or angiographic outcomes between the two groups. Compared to the filter device, the MO.MA system significantly reduced MES counts during the procedural phases of wire passage of the stenosis, stent deployment, balloon dilation, and in total (MES counts for the filter device were 25 +/- 22, 73 +/- 49, 70 +/- 31, and 196 +/- 84 during the three phases and in total, MES counts for the MO.MA system were 1.8 +/- 3.2, 11 +/- 19, 12 +/- 21, and 57 +/- 41, respectively; p < 0.0001). CONCLUSIONS: In comparison to a filter device the MO.MA system led to significantly lower MES counts during CAS. The detection of MES by TCD may facilitate the evaluation and comparison of different neuroprotection systems.

Effect of carotid artery stenting on the release of S-100B and neurone-specific enolase.

Serum levels of S-100B and neurone-specific enolase (NSE) reflect cerebral injury in a variety of neurological conditions such as stroke, traumatic brain injury, and cardiac arrest. There are limited data on the release of S-100B and NSE following carotid artery stenting (CAS). In 22 patients undergoing CAS, serial blood samples for S-100B and NSE were collected before and 2, 4, and 6 to 8 hours after the procedure. A group of 20 patients with significant CAS undergoing purely diagnostic angiography served as controls. A significant increase in S-100B levels was observed 2 hours after the procedure in patients with CAS (P = .001) with a gradual decline over the next hours. In contrast, patients who underwent purely diagnostic angiography did not show significant changes in S-100B levels up to 8 hours after the procedure. Neither patients with CAS nor those undergoing diagnostic angiography displayed any significant changes in serial NSE levels.

Impact of high-dose N-acetylcysteine versus placebo on contrast-induced nephropathy and myocardial reperfusion injury in unselected patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. The LIPSIA-N-ACC (Prospective, Single-Blind, Placebo-Controlled, Randomized Leipzig Immediate PercutaneouS Coronary Intervention Acute Myocardial Infarction N-ACC) Trial.

OBJECTIVES: The aim of this randomized, single-blind, controlled trial was to assess N-acetylcysteine effects on contrast-induced nephropathy and reperfusion injury in ST-segment elevation myocardial infarction patients undergoing primary angioplasty with moderate contrast volumes. BACKGROUND: High-dose N-acetylcysteine reduced the incidence of contrast-induced nephropathy in patients with high contrast volumes and reduced reperfusion injury in animal trials. METHODS: Patients undergoing primary angioplasty were randomized to either high-dose N-acetylcysteine (2 x 1,200 mg/day for 48 h; n = 126) or placebo plus optimal hydration (n = 125). The 2 primary end points were: 1) the occurrence of >25% increase in serum creatinine level <72 h after randomization; and 2) a reduction in reperfusion injury measured as myocardial salvage index by magnetic resonance imaging. RESULTS: The median volume of an iso-osmolar contrast agent during angiography was 180 ml (interquartile range [IQR] 140 to 230 ml) in the N-acetylcysteine and 160 ml (IQR 120 to 220 ml) in the placebo group (p = 0.20). The primary end point contrast-induced nephropathy occurred in 14% of the N-acetylcysteine group and in 20% of the placebo group (p = 0.28). The myocardial salvage index was also not different between both treatment groups (43.5; IQR 25.4 to 71.9 vs. 51.5; IQR 29.5 to 75.3; p = 0.36). Activated oxygen protein products and oxidized low-density lipoprotein as markers for oxidative stress were reduced by as much as 20% in the N-acetylcysteine group (p < 0.05), whereas no change was evident in the placebo group. CONCLUSIONS: High-dose intravenous N-acetylcysteine reduces oxidative stress. However, it does not provide an additional clinical benefit to placebo with respect to CIN and myocardial reperfusion injury in nonselected patients undergoing angioplasty with moderate doses of contrast medium and optimal hydration. (Myocardial Salvage and Contrast Dye Induced Nephropathy Reduction by N-Acetylcysteine [LIPSIA-N-ACC]; NCT00463749).

Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock.

AIMS: Mortality in cardiogenic shock (CS) following acute myocardial infarction (AMI) remains unacceptably high despite percutaneous coronary intervention (PCI) of the infarcted artery and use of intra-aortic balloon pump (IABP) counterpulsation. A newly developed percutaneous left ventricular assist device (VAD) (Tandem Heart, Cardiac Assist, Pittsburgh, PA, USA) with active circulatory support might have positive haemodynamic effects and decrease mortality. METHODS AND RESULTS: Patients in CS after AMI, with intended PCI of the infarcted artery, were randomized to either IABP (n=20) or percutaneous VAD support (n=21). The primary outcome measure cardiac power index, as well as other haemodynamic and metabolic variables, could be improved more effectively by VAD support from 0.22 [interquartile range (IQR) 0.19-0.30] to 0.37 W/m2 (IQR 0.30-0.47, P<0.001) when compared with IABP from 0.22 (IQR 0.18-0.30) to 0.28 W/m2 (IQR 0.24-0.36, P=0.02; P=0.004 for intergroup comparison). However, complications like severe bleeding (n=19 vs. n=8, P=0.002) or limb ischaemia (n=7 vs. n=0, P=0.009) were encountered more frequently after VAD support, whereas 30 day mortality was similar (IABP 45% vs. VAD 43%, log-rank, P=0.86). CONCLUSION: Haemodynamic and metabolic parameters can be reversed more effectively by VAD than by standard treatment with IABP. However, more complications were encountered by the highly invasive procedure and by the extracorporeal support.

Proximal endovascular flow blockage for cerebral protection during carotid artery stenting: results from a prospective multicenter registry.

PURPOSE: To evaluate the feasibility of cerebral protection during carotid artery stenting (CAS) using the Mo.Ma device, which prevents cerebral embolization by proximal endovascular blockage of blood flow in the internal and external carotid arteries. METHODS: In 14 European centers, 157 patients (121 men; mean age 68.0+/-8.3 years) were enrolled in a prospective registry between March 2002 and March 2003. Eligible patients had a symptomatic (>50%) or asymptomatic (>70%) stenosis of the internal carotid artery suitable for carotid stenting. Protected carotid stenting was performed with the Mo.Ma system, which occludes both the common and external carotid arteries via 2 independently inflatable compliant low-pressure balloons before any device is advanced across the lesion. Blood is aspirated through the catheter intermittently or at the end of the procedure. RESULTS: The device was successfully positioned and stents were implanted in all cases. Diameter stenosis was reduced from 84.1%+/-7.8% to 6.7%+/-5.1%. The mean duration of flow blockage was 7.6+/-5.9 minutes. In 12 (7.6%) patients, transient intolerance to flow blockade was observed, but the procedures were completed successfully. In 124 (79.6%) cases, there was macroscopic evidence of debris after filtering the aspirated blood. In-hospital complications included 4 (2.5%) minor strokes, 8 (5.1%) transient ischemic attacks, no deaths, and no major strokes, resulting in a 2.5% death/stroke rate at discharge. At 30-day follow-up, there was 1 cardiac death, 1 major stroke, and 3 minor strokes, for an overall 5.7% 30-day death/stroke rate and a 30-day major stroke and death rate of 1.3%. CONCLUSIONS: Cerebral protection with proximal endovascular blood flow blockage during CAS is feasible, with a high procedural success rate.