[Overall and therapy specific mortality of patients hospitalized for acute myocardial infarction in Zagreb University Hospital Centre]. / Razlike u mortalitetu bolesnika hospitaliziranih zbog akutnog infarkta miokarda u KBC-u Zagreb ovisno o nacinu lijecenja.

In Coronary Care Unit and Intensive Care Unit, Zagreb University Hospital Centre, 403 patients were hospitalized for acute myocardial infarction (AMI) in the year 2005. Majority (288) patients presented with ST-segment elevation myocardial infarction (STEMI) and 115 patients with acute myocardial infarction without ST-segment elevation (NSTEMI). In-hospital mortality of STEMI patients was 13.9% vs. 9.6% of NSTEMI group of patients. In STEMI group 202 patients underwent urgent percutaneous coronary intervention (PCI), and 86 patients in STEMI group received conservative therapy. In-hospital mortality of patients treated with primary PCI was 5.9% vs. 29.1% in the group treated conservatively. The main reason for conservative therapy was late presentation to the hospital (> 12 hours from the beginning of symptoms). Only 11 high-risk patients in NSTEMI group underwent primary PCI and 99 NSTEMI patients received conservative therapy (in-hospital mortality 10.1%). We performed totally 218 urgent PCI interventions in both groups with low in-hospital mortality of 6.1% in comparison with high mortality in conservatively treated groups of patients. The mortality in PCI group was strongly connected with unsuccessful intervention and late reperfusion. Total ischemic time (6 hours and 5 minutes), and time from hospital presentation to reperfusion -"door to balloon time" (1 hour and 25 minutes) are longer that in similar patients series, and need to be improved. Transportation time (1 hour and 40 minutes) is acceptable. In conclusion, high percentage (70.1%) of STEMI and NSTEMI patients underwent primary PCI in our institution with low perioperative mortality. This group of patients had superior in-hospital mortality when compared with conservatively treated group of patients. There is still unacceptably high percentage of patients with AMI, who came into the hospital too late for any reperfusion therapy.

[Acute results and 6 month follow up in patients with direct stenting during primary angioplasty in acute myocardial infarction with ST elevation in KBC Zagreb]. / Primarni uspjeh i 6-mjesecni ishod bolesnika s akutnim infarktom miokarda sa ST-elevacijom u KBC-u Zagreb kod kojih je primijenjena metoda direktnog stentinga.

We perform primary angioplasty in all acute myocardial infarction patients with ST elevation in the first 6 hours, with good results. In 30 selected patients (36.2% of all primary angioplasty patients in this period) we used the method od direct stenting with 100% primary success. In all patients we achieved TIMI 2-3 flow, and complete or partial ST elevation resolution. The early mortality rate was 3.3%, and no other complications arose. Direct stenting in primary coronary angioplasty is a safe and effective procedure, with high primary result in selected cases, and low complication rate during procedure and incidence of MACE (Mayor Adverse Cardiac Events) during hospital stay and after 6 month follow up. The results are comparable with standard interventional procedure in acute myocardial infarction, with the advantage of shorter procedure, lower radiation exposure and less material use.

Frequency of radial artery anatomic variations in patients undergoing transradial heart catheterization.

Over the last ten years, transradial cardiac catheterization has been increasingly applied, primarily because of its lower incidence of complications compared to the femoral approach. However, one of the greatest flaws of the transradial approach is a relatively high incidence of catheterization failure (1%-5%). Anatomic variations of radial artery are ranked second among the reasons for this. Previous studies have not provided unambiguous data on the frequency of these anomalies. It was therefore the aim of this study to determine the frequency of anatomic variations using routine angiographies of radial artery during left heart catheterization. This was a retrospective study involving examination of 602 images of routine angiographies of radial artery performed during cardiac catheterization. The frequency of anatomic variations of radial artery was 8.8%, exclusive of tortuosities with a frequency of 12.7%. The most frequent anatomic variation was the high origin of radial artery, found in 31 (5.1%) subjects. Radioulnar loops, being one of the potential contraindications for the procedure, were reported in 2% of cases. Regression analysis revealed that age (p < 0.001), female sex (p = 0.015) and high origin (p = 0.034) considerably contributed to the development of tortuosity. The results indicated the incidence of tortuosity to increase linearly with age. Although it is not a contraindication for continuing with the procedure, we recommend that elderly patients have angiography of radial artery performed at the beginning of the procedure due to the higher frequency of tortuosity.

Five-year angiographic and clinical follow-up of patients with drug-eluting stent implantation for symptomatic myocardial bridging in absence of coronary atherosclerotic disease.

OBJECTIVES: The objective of this study was to determine the long-term efficacy and dynamics of systolic and diastolic luminal changes within the bridged segments of coronary arteries after intracoronary stenting with drug-eluting stent (DES) in patients (pts) with symptomatic myocardial bridging (SMB) in the absence of coronary atherosclerosis. BACKGROUND: Although myocardial bridging (MB) represents a benign disease in the majority of pts, in its severest forms it is clinically manifested as typical or atypical angina, myocardial ischemia, myocardial infarction, left ventricular dysfunction, atrioventricular conduction disturbance, exercise-induced ventricular tachycardia, or sudden death. The only existing prospective study of 11 pts with SMB treated with bare-metal stent (BMS) reported a 36% in-stent restenosis (ISR) rate at 7 weeks repeated quantitative coronary angiography (QCA). METHODS: The study consisted of 15 consecutive patients (13 men and 2 women) with SMB of the mid-portion of the left anterior descending (LAD) coronary artery (and in 1 patient, concomitant MB of the left circumflex [LCX] coronary artery) and luminal diameter systolic narrowing of the tunneled segment of ≥50%, underwent percutaneous coronary intervention with DES. Clinical and non-invasive assessments of myocardial ischemia were determined every 6 months over 5 years and QCA was performed 12 and 24 months post procedure if not urged differently by deterioration of clinical symptoms and/or presence of positive ischemia tests. The minimal systolic and diastolic luminal diameters of the bridged/stented segments were measured before, immediately after, and 12 and 24 months post procedure by two independent observers blinded to each other's readings, using QCA commercial software. The endpoints of the study were ISR, target lesion revascularization (TLR) rate, in-stent diameter late luminal loss (LLL), and permanent disappearance or significant improvement of clinical symptoms. RESULTS: After 12 months, ISR and TLR in 16 treated vessels was 18.7%, LLL was 0.2 ± 0.6 mm and permanent disappearance or significant improvement of symptoms was achieved in all 15 pts. In 3 pts, clinically-driven repeat revascularization was necessary within the first 6 months. In 1 patient, coronary perforation complicated stent deployment and was immediately resolved by stent-graft implantation, followed by completely uneventful recovery. CONCLUSIONS: DES implantation in pts with SMB resistant to medical treatment results in prompt and long-term increase of systolic and diastolic luminal diameters, and long-lasting relief of clinical symptoms. Compared to BMS, stenting of SMB with DES resulted in significantly lower ISR and TLR rate.

The impact of successful manual thrombus aspiration on in-stent restenosis after primary PCI: angiographic and clinical follow-up.

OBJECTIVES: This study sought to investigate the impact of successful manual thrombus aspiration on angiographic in-stent restenosis and clinical outcome in patients treated by bare metal stent implantation for ST-segment elevation acute myocardial infarction. BACKGROUND: There are very limited data on the impact of manual thrombus aspiration on the occurrence of in-stent restenosis after bare metal stent implantation. METHODS: This was a prospective, randomized, single-center study. Patients (N=60) presenting within 12 h of ST-segment elevation acute myocardial infarction symptom onset were randomized to primary percutaneous coronary intervention (PCI) with (N=30) or without (N=30) upfront manual thrombus aspiration using the Export aspiration catheter. All patients underwent control coronary angiography after 6 months. RESULTS: Baseline, clinical, and angiographic preprocedural findings did not differ between the two groups. Patients who underwent successful manual thrombus aspiration had significantly higher minimal lumen diameter after 6 months (2.25±0.90 vs. 1.63±0.76, P=0.005), significantly lower percentage diameter stenosis (28.81 vs. 45.03%, P=0.017), and significantly lower late lumen loss (0.73±0.84 vs. 1.18±0.79, P=0.035). There was a trend for lower rate of major adverse cardiocerebrovascular events such as death, myocardial reinfarction, stroke, and target lesion revascularization in the same group of patients (16.67 vs. 26.67%, P=0.347). CONCLUSION: Successful upfront manual thrombus aspiration during primary PCI showed beneficial effects on the reduction of in-stent restenosis after bare metal stent implantation compared with standard PCI.

Apical ballooning syndrome and myocardial bridging in the patient presenting with pulmonary edema.

The apical ballooning syndrome is a relatively rare and underrecognized transient cardiomyopathy precipitated by emotional or physical stress. The role of myocardial bridging in its cause is unknown and extremely rarely reported. We present a case of a 68-year-old woman with apical ballooning syndrome and transient myocardial bridging of the left anterior descending coronary artery, clinically manifested as pulmonary edema. Ischemic ECG changes and mild elevation of cardiac biomarkers were present. She recovered well on medical treatment, and follow-up echocardiography revealed complete recovery of the left ventricular systolic function, whereas repeated coronary angiography after 1 year showed no signs of myocardial bridging. To the best of our knowledge, this is the first report of transient myocardial bridging in a patient with Takotsubo cardiomyopathy with documented normalization of the left ventriculogram and disappearance of left anterior descending coronary artery myocardial bridging.

Early detection of left ventricular diastolic dysfunction in hypertensive heart disease by color Doppler myocardial imaging.

AIM: To determine if Color Doppler myocardial imaging could provide evidence of diastolic dysfunction in patients with hypertension whose pulse-wave Doppler parameters were normal. METHOD: The study included 33 patients (mean age 48+/-7.3 years) and a control group of 13 sex- and age-matched healthy individuals. Patients were divided into two groups according to mean blood pressure (BP) values during 24-hour blood pressure monitoring while under antihypertensive therapy: those with uncontrolled hypertension (n=22) and those with controlled hypertension (n=11). All study participants underwent complete standard echocardiography (2D, M-mode, pulsed and continuous Doppler) and a Color Doppler myocardial imaging study. RESULTS: Conventional Doppler parameters indicated relaxation disturbances in patients with uncontrolled hypertension, but were within a normal range in patients with controlled hypertension at baseline and follow-up. Parameters of global diastolic function measured by Color Doppler myocardial imaging revealed that E'/A', the ratio between E'-wave (early filling phase) and A'-wave (late diastolic wave due to atrial contraction), was <1 in 57% of segments at baseline in patients with uncontrolled hypertension, and did not significantly change at follow-up. In patients with controlled hypertension, E'/A'<1 was noted in 4.7% of segments at baseline and in 28.6% of segments at follow-up. CONCLUSION: Regional diastolic dysfunction measured by Color Doppler myocardial imaging was the first sign of myocardial dysfunction due to arterial hypertension, while the parameters of global diastolic dysfunction measured by conventional Doppler and Color Doppler myocardial imaging were still normal. Furthermore, in patients with uncontrolled hypertension with manifested global diastolic dysfunction, there was a change in late diastolic parameters. Our results point to a potentially important role of Color Doppler myocardial imaging in diagnosing hypertensive heart disease as well as in follow-up of treatment.