Arterial access and door-to-balloon times for primary percutaneous coronary intervention in patients presenting with acute ST-elevation myocardial infarction.

OBJECTIVES: This study compares the transradial versus the transfemoral approach for time to intervention for patients presenting with ST elevation myocardial infarction (STEMI). BACKGROUND: Survival following STEMI is associated with reperfusion times (door-to-balloon; D2B). For patients undergoing primary PCI for acute STEMI, potential effects of transradial approach (r-PCI) as compared with the femoral artery approach (f-PCI) on D2B times have not been extensively studied. METHODS: Consecutive patients presenting with STEMI at a tertiary care medical center were enrolled in a comprehensive-Heart Alert program (HA) and included in this analysis. Time parameters measured included: door-to-ECG, ECG-to-HA activation, HA activation-to-cath lab team arrival, patient arrival in cath lab to arterial access, and arterial access-to-balloon inflation. RESULTS: Of 240 total patients, 205 underwent successful PCI (n = 124 r-PCI; n = 116 f-PCI). No significant difference was observed in the pre-cath lab times. Mean case start times for r-PCI took significantly longer (12.5 +/- 5.4 min vs. 10.5 +/- 5.7 min, P = 0.005) due to patient preparation. Once arterial access was obtained, balloon inflation occurred faster in the r-PCI group (18.3 vs. 24.1 min; P < 0.001). Total time from patient arrival to the cardiac cath lab to PCI was reduced in the r-PCI as compared to the f-PCI group (28.4 vs. 32.7 min, P = 0.01). There was a small but statistical difference in D2B time (r-PCI 76.4 min vs. f-PCI 86.5 min P = 0.008). CONCLUSIONS: Patients presenting with STEMI can undergo successful PCI via radial artery approach without compromise in D2B times as compared to femoral artery approach.

Coronary artery occlusion after arterial switch operation in an asymptomatic 15-year-old boy.

A 15-year-old boy with transposition of the great arteries (TGA) and neonatal arterial switch operation (ASO) presented with complete occlusion of the left main coronary artery (LMCA). Intra-operatively, an intramural left coronary artery was identified. Therefore, since age 7 years he had a series of screening exercise stress tests. At 13 years old, he had 3 to 4 mm ST segment depression in the infero-lateral leads without symptoms. This progressed to 4.2 mm inferior ST segment depression at 15 years old with normal stress echocardiogram. Sestamibi myocardial perfusion scan and cardiac magnetic resonance imaging was inconclusive. Therefore, a coronary angiogram was obtained which showed complete occlusion of the LMCA with ample collateralization from the right coronary artery system. This was later confirmed on a computed tomogram (CT) angiogram, obtained in preparation of coronary artery bypass grafting. The case illustrates the difficulty of detecting coronary artery stenosis and occlusion in young patients with rich collateralization. Coronary CT angiogram and conventional angiography were the best imaging modalities to detect coronary anomalies in this adolescent with surgically corrected TGA. Screening CT angiography may be warranted for TGA patients, particularly for those with known coronary anomalies.

Usefulness of temporary left ventricular pacing through the coronary sinus as an adjunct to transfemoral percutaneous coronary intervention.

In 10 patients who underwent percutaneous coronary intervention involving the right coronary artery, a new procedure for adjunctive temporary transfemoral pacing of the left ventricle through the coronary sinus was tested. The procedure was successful in 8 of 10 patients and could be performed in <5 minutes by experienced operators and supervised cardiology fellows.