In-Hospital Outcomes after Rescue Percutaneous Coronary Intervention in Patients with ST Segment Elevation Myocardial Infarction.

Objective: To investigate the outcomes of patients who underwent rescue percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) after failed thrombolytic therapy. Material and Method: This observational cohort study was conducted between June 1, 2008 and May 31, 2013. Consecutive STEMI patients who underwent either emergency rescue PCI or primary PCI were included. Rescue PCI patients were compared with primary PCI patients. Clinical data including baseline characteristics, angiographic results, periprocedural details, and in-hospital adverse events were reviewed. Results: Three hundred sixteen patients were enrolled, of which 72.5% were male. Mean age of participants was 59.5 years. Rescue PCI and primary PCI was performed in 24 and 292 patients, respectively. Median time from symptom onset to emergency room (ER) arrival was 175 minutes and not statistically different between groups. Thirteen percent of patients were critically ill and in cardiogenic shock upon arrival. Radial artery access was significantly more frequently used in the rescue PCI group. The rescue PCI group had a significantly higher proportion of initial TIMI grade 3 flow than the primary PCI group (rescue PCI 33.3% vs. primary PCI 13.4%, p = 0.042). No significant differences were observed in final TIMI grade 3 between the two groups (rescue PCI 87.5% vs. primary PCI 89.7%, p = 0.77). Rate of platelet glycoprotein IIb/IIIa receptor blocker use was significantly higher in the primary PCI group (41.4% vs. 4.2%, p<0.001). Left ventricular ejection fraction was significantly higher in the rescue PCI group (rescue PCI 57.7% vs. primary PCI 50%, p = 0.013). There were no significant differences between groups for angiographic success rate (rescue PCI 83.3% vs. primary PCI 88.7%, p = 0.229) or procedural success rate (rescue PCI 79.2% vs. primary PCI 85.6%, p = 0.164). Forty-one patients (14%) in primary PCI group and two patients (8.3%) in rescue PCI group died during hospitalization (p = 0.75). Stroke and reinfarction were rare events in this study. Hemorrhagic stroke occurred in one patient in each group. There were no significant differences in major bleeding or major vascular complications between groups. Conclusion: The angiographic outcome and procedural success rates in patients who underwent rescue PCI were not significantly different from rates in patients who underwent primary PCI. Rescue PCI in STEMI can be performed with favorable success rates and in-hospital outcomes and should be considered in patients that experience failure after thrombolytic therapy.

Differentiation of Takotsubo Cardiomyopathy from ST Elevation Myocardial Infarction in Patients Activated for Fast-Track Coronary Angiography.

Objective: To compare clinical and electrocardiographic (ECG) features between Takotsubo cardiomyopathy (TC) and ST-elevation myocardial infarction (STEMI). Material and Method: We retrospectively reviewed clinical, electrocardiographic, and laboratory features of 20 consecutive TC patients and 155 consecutive STEMI patients who were activated for fast-track coronary angiography and were ultimately diagnosed with either TC or STEMI and compared these data between the two groups. Results: Patients with TC were older (p = 0.001), more often female (p = 0.001), had more often been triggered by intense emotional or physical stress (p = 0.001) or illness (p = 0.001), and had a lower rate of smoking (p = 0.005) than STEMI patients. Compared with patients who presented with anterior wall STEMI, those with TC less commonly had Q waves (30.0% vs. 62.9%, p = 0.007) and reciprocal change (0.0% vs. 37.1%, p = 0.001), and had a lower rate of ST-segment elevation in lead V1 (5.0% vs. 59.8%, p = 0.001). ST-segment depression was also more common in TC in lead aVR (20.0% vs. 2.1%, p = 0.008). Previously proposed ECG criteria had low sensitivity, but high specificity in our patients. Our proposed point scoring model includes the use of both clinical and ECG findings. According to our proposed model, a score ≥4 had 90% sensitivity and 98% specificity in differentiating TC from acute anterior STEMI (AUC = 0.976, p<0.001). Conclusion: In patients activated for fast-track coronary angiography because of acute coronary ST-segment elevation syndrome, a number of clinical and ECG features differ between TC patients and patients with true STEMI. Our proposed point scoring model that uses clinical and ECG findings demonstrated improved diagnostic accuracy in differentiating TC from acute anterior STEMI.

One-year clinical outcomes of ST segment elevation myocardial infarction patients treated with emergent percutaneous coronary intervention: the impact of thrombus burden.

OBJECTIVE: To investigate the impact of thrombus burden on 1-year clinical outcomes in patients who underwent emergent percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). MATERIAL AND METHOD: Angiographic evidence of intracoronary thrombus adversely affects the outcome of PCI in STEMI. Large thrombus burden (> or = 2 times vessel diameter) has been shown to be a significant predictor of major adverse cardiac events (MACE). The impact of thrombus burden in Asian patients who undergo PCI in STEMI has not been described. This is an observational cohort of patients with STEMI from June 1, 2008 through May 31, 2011, who underwent emergent PCI (primary or rescue). The patients were categorized into two groups according to the angiographic thrombus burden, large thrombus burden (> or = 2X vessel diameter size, LTB) and small thrombus burden (< 2X vessel diameter size, STB). MACE was defined as the composite of death, repeat myocardial infarction, target vessel revascularization and stent thrombosis. RESULTS: 202 patients were enrolled, 72% were male and the mean age was 60 years old. 134 patients (66%) presented with an occluded infarct related artery. Primary PCI was performed in 90.6% of the patients and the remainder underwent rescue PCI. One hundred eleven (55%) patients were categorized into the STB group and 91 patients (45%) into the LTB group. The use of aspiration thrombectomy was significant higher in the LTB group (LTB 80.2% vs. STB 60.44%, p = 0.002). A higher proportion of patients in the STB group underwent direct stenting strategy (STB 32.4% vs. LTB 18.7%, p = 0.027). There were no significant differences in final TIMI grade 3 flows and procedural success between the groups. Overall, in hospital, mortality was 13.4% and there were no significant differences among the groups. At 1-year follow-up, there was no significant difference in cumulative MACE-free survival in the LTB vs. STB group (82.4% vs. 79.3%, 95% confidence interval for the difference: -8.0% to 13.8%, p = 0.59). CONCLUSION: In the current study, large thrombus burden is not an independent predictor of 1-year cumulative MACE in STEMI patients who were treated with emergent PCI.

Predictors of in-hospital adverse events after PCI for NSTEMI in the National Percutaneous Coronary Intervention (PCI) Registry.

OBJECTIVE: Evaluate the in-hospital major adverse cardiovascular events (MACE) and clinical predictors of non-ST-T Mt that undergoing percutaneous coronary interventions (PCI) in Thailand. MATERIAL AND METHOD: Thailand National PCI Registry enrolled 4156 patients that underwent PCI in Thailand between May 1 and October 31, 2006. Four hundred eighty three patients underwent PCI with indication of non-ST-T MI. Baseline demographic and angiographic characteristic were recorded. MACE included CV death, M, and stroke. RESULTS: In-hospital MACE occurred in 27 patients (5.6%), included CV death in 15 patients (3.1%), MI in 14 patients (2.9%), and stroke in 2 patients (0.4%). In-hospital MACE were higher in patients with previous history of CABG (19.2% versus 4.8%, p = 0.01), cardiogenic shock at presentation (29.3% versus 3.4%, p<0.001), significant left main disease (19.4% versus 4.6%, p = 0.005), baseline ejection fraction <30% (25% versus 4.4%, p = 0.003), and used of intra-aortic balloon counter pulsation (IABP) during PCI (26.3% versus 3.8%, p<0.001). After multiple logistic regression analysis, prior history of CABG (OR = 6.1, 95% CI: 1.1-32.4, p = 0.03), baseline ejection fraction <30% (OR = 6.5, 95% CI: 1.7-24.4, p = 0.005), and used of lABP during PCI (OR = 4.7, 95% CI: 1.3-16.8, p = 0.01) are the strongest predictors of in-hospital MACE. CONCLUSION: In the National Thai PCI Registry, patients with non-ST-T MI undergoing PCI had in-hospital major adverse events rate at 5.6%. Prior CABG, low EF <30%, unstable hemodynamic required used of lABP during PCI and procedure scheduled as an urgent or emergent were predictors of in-hospital MACE.

First medical contact to device time in the Thailand percutaneous coronary intervention (PCI) registry.

OBJECTIVE: The aim of this study is to evaluate the first medical contact (FMC) to device time in the Thai national PCI registry 2006, and its effect on the clinical outcome. MATERIAL AND METHOD: Thailand national PCI registry enrolled 4,156 patients who underwent PCI from the all catheterization laboratories in Thailand between May 1st and October 31st, 2006. RESULTS: 581 patients with acute myocardial infarction (AMI), 352 patients underwent primary angioplasty, 229 patients underwent rescue angioplasty/facilitated PCI or after successful thrombolytic. Median FMC.to device time in primary angioplasty group was 115 minutes (range 24-1335 minutes); only 29.8% of patients who able to achieve FMC to device time ≤ 90 minutes. Cardiogenic shock was significant lower if FMC to device time ≤ 90 minutes (2.1% (1/48) versus 12.4% (14/113) if FMC to device time > 90, p = 0.040). In-hospital mortality occurred for 4.8% (2/48) ifFMC to device time ≤ 90 minutes and was 8.8% (10/113) if FMC to device time > 90 minutes, p = 0.510). Death occurred in 4.2% (2/48) if FMC to device time ≤ 90 minutes, 6.3% (5/79) if FMC to device time between 91-180 minutes, 6.7% (1/15) if FMC to device time between 181-270 minutes, 42.9% (3/7) if FMC to device time between 271-360 minutes and 8.3% (1/12) if FMC to device time > 360 minutes, (p = 0.040). CONCLUSION: FMC to device time is strongly associated with the risk ofcardiogenic shock and mortality. In Thailand national PCI registry in 2006, the majority of the patients did not receive primary PCI in timely fashion.

N-terminal pro-brain natriuretic peptide as a biomarker for a significant renal artery stenosis in medically refractory hypertensive patients.

BACKGROUND: Although RAS is a relatively uncommon cause of hypertension, it is the most common form of correctable hypertension. There are clinical clues to be gained in identifying the small subset of individuals in whom directed evaluation for RAS may be useful. But its diagnostic accuracy is still poor. OBJECTIVE: The aim of the present study is to determine the usefulness of N-terminal pro-brain natriuretic peptide (NT-pro BNP) levels in helping improved diagnostic accuracy of a significant renal artery stenosis (RAS) in medically refractory hypertensive patients. MATERIAL AND METHOD: The present study included 40 patients with medical refractory hypertension in whom RAS was suspected and who were undergoing magnetic resonance angiogram (MRA) of renal artery and/or renal angiogram. Twenty consecutive patients with a significant RAS by MRA or renal angiogram (RAS group) compared with 20 consecutive patients in whom RAS was suspected but whose MRA/renal angiogram was normal or non-significant (normal group). Baseline clinical characteristics, number of antihypertensive medications before the procedure and NT-pro BNP were obtained from both groups. RESULTS: Age, gender glomerular filtration rate (GFR) and LV function did not differ significantly between the two groups. NT-pro BNP level was significantly higher in RAS group (1,243 ng/ml, range 156-10,628 ng/ml) compared to normal group (129 ng/ml, range 61-3,457 ng/ml), p = 0.009. NT-proBNP level > or = 600 ng/ml has sensitivity and specificity of 80% and 95%, respectively, in diagnosis of significantRAS. CONCLUSION: In medical refractory hypertensive patients, NT-pro BNP level increased in patients with significant RAS and was an aid in separating a significant RAS from non-significant/normal renal artery.

High on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention.

OBJECTIVE: To determine the prevalence, clinical profile, and risk factors of high on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients undergoing coronary angiography and planned for elective percutaneous coronary intervention (PCI). Ten ml of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin and platelet count. Platelet aggregation test was performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 5 microM adenosine diphosphate (ADP). Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. High on-clopidogrel treatment platelet reactivity was defined as post treatment maximal platelet aggregation > 46% with 5 micromol/l ADP used as agonist. RESULTS: The present study consecutively enrolled two hundred four patients diagnosed with chronic stable angina planned for PCI. Seventy-nine patients demonstrated the high on-clopidogrel treatment platelet reactivity (38.7%). Among these patients, 48% were men with a mean age of 66 years. Diabetes mellitus and chronic kidney disease were detected in 34.2%. Original clopidogrel (Plavix) was prescribed in 72% of the patients and 28% received generic clopidogrel (Apolets). The prevalence of high on-clopidogrel treatment platelet reactivity increased in the older patients, patients with CKD and patients receiving angiotensin receptor blockers (ARB). However from multivariate analysis, none of the risk factors, including age, BMl, diabetes mellitus, smoking, CKD, ARB use, and type of clopidogrel (Plavix versus Apolets) had a statistically significant association with the high on-clopidogrel treatment platelet reactivity. CONCLUSION: The prevalence of high on-clopidogrel treatment platelet reactivity in the present study was 38.7%. No significant association was demonstrated between age, BMI, diabetes mellitus, smoking, CKD, ARB use, type of clopidogrel, and high on-clopidogrel treatment platelet reactivity.

Aspirin resistance in Thai patients with chronic stable angina.

OBJECTIVE: To determine the prevalence, clinical profile and risk factors of aspirin resistance in Thai patients with chronic stable angina. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients diagnosed chronic stable angina at Siriraj Hospital during March 2011 to February 2012. Ten milliliter of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin, platelet count and platelet aggregation test performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 0.5 mg/ml of arachidonic acid and 10 mM adenosine diphosphate. Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. Aspirin resistance was defined as the mean platelet aggregation of > or = 70% with 10 mM ADP and the mean platelet aggregation of > or = 20% with 0.5 mg/ml of arachidonic acid. RESULTS: One-hundred and fifty seven patients diagnosed chronic stable angina were enrolled in the present study. There were 34 patients (21.6%) demonstrating aspirin resistance. The clinical characteristic of these patients included male 58.8% with mean age of 66 years, body mass index 27.5 kg/m2, diabetes mellitus 52.9%, smoking 8.8%, hypercholesterolemia 70.6% and proton pump inhibitor use 23.5%. Multivariate analysis demonstrated none of the risk factors including age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking and proton pump inhibitor (PPI) use had a statistically significant association with aspirin resistance. CONCLUSION: Our study demonstrated that the prevalence of aspirin resistance in Thai patients with chronic stable angina was 21.6%. No significant association was demonstrated between age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking, proton pump inhibitor (PPI) use and aspirin resistance.

The incidence of clinically significant ECG abnormalities detected by routine everyday ECG: the first analysis from CCU/ICCU patients in Siriraj Hospital.

BACKGROUND: Electrocardiography (ECG) has been routinely performed in all patients in CCU and ICCU in Siriraj Hospital everyday in the morning until discharge for screening the abnormalities, such as ischemic changes and arrhythmia. Nevertheless, the occurrence of ECG changes from everyday recording is not common and the real incidence has not been studied. There is uncertainty regarding the benefit derived, when weighted with the cost and the time wasted from the routine everyday ECG. OBJECTIVE: The purpose of the present study was to demonstrate the incidence of ECG abnormalities that can be detected and have the effects on treatment from the routine everyday ECG in the patients admitted in CCU and ICCU. MATERIAL AND METHOD: One hundred and ten patients, admitted in CCU/ICCU in Siriraj Hospital were consecutively enrolled in the present study. Routine everyday 12 leads ECG was performed in the morning in all patients. ECG was interpreted by 2 cardiologists for the incidence and detail of ECG changes as compared to prior ECG. Furthermore, the incidence of those changes that affected management was recorded. Disease spectra and onset of ECG changes were reported. RESULTS: ECG changes from routine everyday ECG was 52.7%, however 25.9% of these changes could be detected by telemetry recorded in every CCU/ICCU patients. ECG changes which affected treatment were 20%, whereas 36.4% of them could be detected by telemetry. Incidence was more pronounced in patients with acute coronary syndrome (ACS), heart failure (HF) and arrhythmias, and found mostly within the first 4 days of hospitalization. CONCLUSION: While ECG changes from routine everyday ECG occurred in half of the CCU/ICCU patients, one-fourth could be detected by the telemetry recorded. ECG changes that affected treatment were much lower and found merely in one-fifth. This incidence could lead to the limitation of every routine ECG to only high-risk patients during the high-risk period.

Clinical Outcomes of Rotational Atherectomy in Heavily Calcified Lesions: Evidence From the Largest Cardiac Center in Thailand.

Background: Evidence regarding the clinical outcomes of rotational atherectomy (RA) in middle-income countries is limited. We analyzed the clinical outcomes of patients with heavily calcified coronary lesions who underwent RA-assisted percutaneous coronary intervention (PCI) and explored the risks for developing major adverse cardiovascular and cerebrovascular events (MACCE). Methods: This is a single-center, retrospective cohort analysis that enrolled consecutive patients who underwent RA-assisted PCI at the largest tertiary hospital in Thailand. The primary endpoint is the incidence of MACCE during the first-year follow-up. MACCE consists of cardiac death, ischemic stroke, definite stent thrombosis, target lesion revascularization, and target vessel revascularization. Results: From January 2015 to December 2018, 616 patients (663 lesions) were enrolled. The mean age was 72.8 ± 9.7 years, 292 (47.4%) patients were female and 523 (84.9%) completed one-year follow-up. Drug-eluting stents were deployed in 606 (91.4%) lesions. The RA success rate - defined as when the operator successfully passed the burr across the target lesion - was 99.4% and the angiographic success rate was 94.8%. 130 (21.4%) procedures developed periprocedural complications. The cumulative MACCE rate at 30-days was 1.5% and at 1-year was 6.3%. The in-hospital mortality rate was 1.1% and the cardiac death rate was 1.6%. Independent risk factors for developing MACCE included the use of an intra-aortic balloon pump (hazard ratio [HR] 3.96, 95% confidence interval [CI] 1.54-10.21; P = 0.004), a history coronary artery bypass graft (HR 2.30, 95% CI 1.01-5.25; P = 0.048), and increased serum creatinine (HR 1.16, 95% CI 1.04-1.30; P = 0.008). Conclusions: RA is an effective revascularization technique for heavily calcified lesions. This study demonstrates a high success rate and good short- to intermediate-term results of RA-assisted PCI in middle-income countries which are similar to high-income countries. Nevertheless, the rate of periprocedural complications remains high.

Intravascular Imaging Guidance Reduce 1-Year MACE in Patients Undergoing Rotablator Atherectomy-Assisted Drug-Eluting Stent Implantation.

Objectives: This study aimed to investigate the incidence of 1-year major adverse cardiac events (MACE) compared between intravascular imaging guidance and angiographic guidance in patients undergoing rotablator atherectomy (RA)-assisted percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Methods: This retrospective analysis included 265 consecutive patients with heavy calcified lesion who underwent RA-assisted PCI with DES implantation at our institution during the January 2016-December 2018 study period. This study was approved by the Siriraj Institutional Review Board. Patients were divided into either the angiographic guidance PCI group or the imaging guidance PCI group, which was defined as intravascular ultrasound or optical coherence tomography. The primary endpoint was 1-year MACE. Results: Two hundred and sixty-five patients were enrolled, including 188 patients in the intravascular imaging guidance group, and 77 patients in the angiographic guidance group. One-year MACE was significantly lower in the imaging guidance group compared to the angiographic guidance group (4.3 vs. 28.9%, respectively; odds ratio (OR): 9.06, 95% CI: 3.82-21.52; p < 0.001). The 1-year rates of all-cause death (OR: 8.19, 95% CI: 2.15-31.18; p = 0.002), myocardial infarction (MI) (OR: 6.13, 95% CI: 2.05-18.3; p = 0.001), and target vessel revascularization (TVR) (OR: 3.67, 95% CI: 1.13-11.96; p = 0.031) were also significantly lower in the imaging guidance group compared with the angiographic guidance group. The rate of stroke was non-significantly different between groups. Conclusion: In patients with heavy calcified lesion undergoing RA-assisted DES implantation, the intravascular imaging guidance significantly reduced the incidence of 1-year MACE, all-cause death, MI, and TVR compared to the angiographic guidance.

Evaluation of the firebird sirololimus eluting stent in all comers with coronary artery stenosis.

OBJECTIVE: Percutaneous coronary intervention (PCI) has been widely used to treat obstructive coronary artery disease. With the advent of drug-eluting stent (DES) in real world registry was proved as promising therapy. The limitation of the use of DES is the limited health care expenditure. We propose the use of Chinese made DES among Thai patients and that this will solve the cost issue. The clinical result of this DES has not been well known. METHODS: Prospective study from November 2005 to March 2007 using the structured registry form to evaluate the safety and efficacy of new Chinese made Firebird sirolimus eluting stent (Firebird SES) on clinical parameters from in-hospital, 30 days and 12 months or longer term follow-up. End point is major adverse cardiac event (MACE) including death, MI, TLR and CABG at 30 day and cumulative MACE at 12 month follow-up. RESULTS: Ninety consecutive patients who were treated with Firebird stent implantation (107 target lesions) were analyzed. Angiographic success (defined as < 30% diameter stenosis) was 85%. Procedure success was 77.8%. MACE at 30 day was 16.6%, cumulative MACE at 12 months was 18.8%. There were total 9 deaths during the study period, two deaths occurred at before 30 days, 3 deaths occurred before 12 months and other 4 deaths occurred after 12 months to 1305 days. Eighty patients (88.9%) had either office visit or telephone call follow-up after 12 months, 38 patients (42.2%) underwent clinical driven coronary arteriography, binary restenosis was 26.3%. Shock and smoking history was the analyzed predictor of MACE at follow-up. CONCLUSION: The implantation of Firebird DES in unselected patients (all comers) is safe, effective and could be an alternative choice of stent for Thai patients.

Early and intermediate outcomes of left main coronary intervention.

OBJECTIVE: We examined the immediate and long-term outcomes after stenting of all comers for left main coronary artery (LMCA) stenoses. BACKGROUND: Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area. MATERIAL AND METHOD: Eighty-one consecutive patients with LMCA stenoses were treated with stents. The post-stent antithrombotic regimens were aspirin and clopidogrel. The major adverse cardiac events (MACE) including death, Q-wave myocardial infarction, or repeat target lesion revascularization were followed. Patients were followed very closely and all attended office visit at 12 months. RESULTS: The procedural success rate was 86.4%, with no episodes of acute thrombosis. Follow-up angiography was performed in 30 of 65 eligible patients (46.2%). Angiographic restenosis occurred in eight patients (9.9%). Cumulative death occurred in 16 patients (19.7%). MACE at 30 day and 12-month was 12.3% and 33.3% respectively. From multivariate analysis, dialysis (HR =3.22, p = 0.048), urgent PCI (HR =2.39, p = 0.036), post-procedure TIMI flow < 3 (HR =25.99, p = 0.001) and final kissing balloon inflation (HR = 0.30, p = 0.04) were independent predictors of MACE at 12-month. There was one definite late stent thrombosis (1.2%). CONCLUSION: Stenting of LMCA stenosis may be a safe and effective alternative to CABG in carefully selected patients. Further studies in larger patient populations are needed to assess late outcome.

One-year outcome of cardioversion of atrial fibrillation in patients with mitral stenosis after percutaneous balloon mitral valvuloplasty.

Our objectives were to study the success rate of electrical cardioversion after percutaneous balloon mitral valvuloplasty (PBMV) in patients with symptomatic moderate-to-severe mitral stenosis and atrial fibrillation (AF) and the maintenance rate of sinus rhythm for < or =1 year. We studied patients with mitral stenosis and AF who were scheduled for PBMV. Electrical cardioversion was performed 1 month after PBMV. Amiodarone 200 mg/day was started the day after PBMV. The primary outcomes studied were the rate of successful cardioversion and the maintenance rate of sinus rhythm at 12 months. Of 272 patients scheduled for PBMV, 70 were enrolled. The average age was 45 +/- 10 years. The average mitral valve area was 0.82 +/- 0.22 cm(2). Cardioversion was successful in 50 patients (71%). Logistic regression analysis revealed that left atrial size and associated aortic valvular disease were predictors of successful cardioversion. Of the 50 patients with successful cardioversion, AF recurred in 24 (48%). An increased left atrial diameter was the only factor associated with AF recurrence at 12 months. In conclusion, good candidates for cardioversion after PBMV were those with a left atrial diameter of <60 mm and no associated aortic valvular disease -- approximately 43% of patients with AF scheduled for PBMV. In this group, about 2/3 were in sinus rhythm at 12 months after cardioversion.

Changes in hematologic markers in patients with mitral stenosis after successful percutaneous balloon mitral valvuloplasty.

Systemic embolism is a major complication of mitral stenosis which is usually related to a presence of left atrial thrombus. Percutaneous balloon mitral valvuloplasty (PBMV) was previously reported to reduce the incidence of this complication. However, the mechanisms of this beneficial procedure was under investigated. The aim of this study was to investigate the changes in coagulation activity, platelet activity and endocardial function in 29 patients with mitral stenosis after successful PBMV. All subjects had good left ventricular systolic function and 48.3% had atrial fibrillation. There was a significant reduction in thrombin-antithrombin complex (TAT) after a successful procedure and the level of thrombomodulin was also significantly higher one month after successful procedure. However, the level of platelet factor 4 (PF4) and beta-thromboglobulin (beta-TG) were increased after this procedure but not achieved the statistical significance. In conclusion, successful PBMV can reduce the prethrombotic state in patients with mitral stenosis. In addition, it may improve endocardial function of the left atrium in those without atrial fibrillation.

Stent placement compared with balloon angioplasty for obstructed coronary artery disease in Thai elderly patients: initial result and 6 months follow-up.

UNLABELLED: Percutaneous Old Balloon Angioplasty (POBA) is accepted worldwide for the treatment of obstructive coronary artery disease because this technique is safe, and quick and the patient may return to work earlier than with bypass surgery (particularly elderly patients). But the major problem with POBA is restenosis which occurs between 20-40 per cent. Stent placement has been reported to reduce the restenosis rate to 10-20 per cent. OBJECTIVE: The purpose of this study was to compare the effects of stent placement with those of balloon angioplasty on clinical and angiographic outcomes in elderly Thai patients with obstructive coronary artery disease. METHOD: The study was a randomized controlled trial. The sample size was 45 lesions in 42 patients who were assigned into 2 groups; 23 in the balloon angioplasty group and 22 in the stent placement group (Crown Stent). Clinical information and coronary angiography were recorded and performed at the time of the index procedure and six months later. RESULTS: There was 100 per cent procedural success in 22 lesions treated in the stent group and 82.6 per cent in the 23 lesions treated in the balloon angioplasty group. Patients in the stent group had a lesser degree of stenosis immediately after the procedure (8.78 +/- 8.63 vs 30.92 +/- 9.01%, p < 0.001) and a greater minimal luminal diameter (MLD) (3.04 +/- 0.44 vs 2.15 +/- 0.33 mm, p < 0.001). There were no major complications in either group during the procedure or during their hospital stay. These were not maintained at the six months follow-up. (26.88 +/- 16.23 vs 33.82 +/- 14.63 mm, p = 0.19, 2.28 +/- 0.67 vs 2.01 +/- 0.51 mm, p = 0.17) for the degree of stenosis and the MLD respectively. The restenosis rate, which was the primary endpoint of the study, was 4.5 per cent in the stent group and 21 per cent in the balloon angioplasty group (p = 0.10). CONCLUSIONS: Stenting in Thai elderly ischemic patients has a higher procedural success rate when compared with balloon angioplasty. The restenosis rate of stenting is also lower than that of balloon angioplasty but did not reach statistical significance. However, both techniques had no major complications either during the procedure or in-hospital.

Efficacy and safety of percutaneous metallic mitral valvuloplasty in rheumatic mitral stenosis at Siriraj Hospital.

Mitral stenosis is an important problem that leads to heart failure and stroke in Thailand. The options of treatment at present are either surgical or balloon mitral commissurotomy. However, the cost of balloon is very expensive. To reduce the expense of the procedure, the authors prospectively did a study using a new device called the metallic valvulotome in symptomatic severe mitral stenosis to assess the safety, feasibility and immediate outcomes. Fifty-seven patients were included in the study. The successful outcome achieved by the metallic valvulotome was 96.2 per cent in patients in whom the procedure was actually performed. The mean transmitral gradient, left atrial pressure and pulmonary artery pressure were significantly decreased and the mitral valve area was also significantly increased. Three cases failed the procedure due to inappropriate position of the septal puncture. No death occurred in the study and complications of the procedure included only two cases of hemopericardium. In the future, it is believed that this new innovative device will provide improvement and reduce the cost of the procedure in patients with severe mitral stenosis.

An abnormal systemic and regional hypercoagulable state in patients with mitral stenosis.

Mitral stenosis still remains a major problem in Southeast Asia including Thailand. It contributes to the morbidity and mortality related to thromboembolism which was associated with the left atrial thrombus. However, the pathogenesis of left atrial thrombus in these patients is not completely understood. Therefore, the objective of this study was to investigate the coagulation and platelet activity including the function of the endocardium in the left atrium and peripheral circulation in patients with mitral stenosis who were free of left atrial thrombus and to compare those hematologic markers activity in the peripheral venous blood between the patients with mitral stenosis and the control. Thirty-six patients with moderate to severe mitral stenosis were included in the study. Most of the patients were in functional class II and 50 per cent had atrial fibrillation. Blood was obtained from the femoral vein, femoral artery, pulmonary artery and left atrium of these patients before heparin was administered to determine the value of various hematologic markers. In the control group, blood for determining the hematologic markers was collected only from the antecubital vein. The results of this study demonstrated that the levels of prothrombin activation fragment 1+2 (F1+2), thrombin-antithrombin III complex (TAT) and Beta-thromboglobulin (beta-TG) in the left atrium of the patients with mitral stenosis were significantly higher than those in the femoral vein and femoral artery, whereas the level of thrombomodulin was significantly lower in the left atrium compared with the femoral artery and vein. When comparing with the control group, the levels of TAT, plasminogen activator inhibitors-1 (PAI-1) from the peripheral vein were significantly higher and the level of thrombomodulin was also significantly lower in the patients with mitral stenosis. In conclusion, the present study demonstrated an abnormal hypercoagulable state of the left atrium and systemic circulation related to the abnormalities of coagulation, platelets and the endocardium which may cause the formation of left atrial thrombus in patients with mitral stenosis.