Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction, Resuscitated Cardiac Arrest, and Cardiogenic Shock The Role of Primary Multivessel Revascularization

ObjectivesThis study sought to assess the impact of multivessel (MV) primary percutaneous coronary intervention (PCI) on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) and resuscitated cardiac arrest (CA).BackgroundThe safety and efficacy of MV primary PCI in patients with STEMI and refractory CS is unknown.MethodsWe conducted a multicenter prospective observational study of consecutive STEMI patients presenting to 5 French centers. Patients were classified as having single-vessel (SVD) or multivessel (MVD) coronary disease, and underwent culprit-only or MV primary PCI. Baseline characteristics and 6-month survival were compared.ResultsAmong 11,530 STEMI patients, 266 had resuscitated CA and CS. Patients with SVD (36.5%) had increased 6-month survival compared to those with MVD (29.6% vs. 42.3%, p = 0.032). Baseline characteristics were similar in those with MVD undergoing culprit-only (60.9%) or MV (39.1%) primary PCI. However, 6-month survival was significantly greater in patients who underwent MV PCI (43.9% vs. 20.4%, p = 0.0017). This survival advantage was mediated by a reduction in the composite of recurrent CA and death due to shock (p = 0.024) in MV PCI patients. In those with MVD, culprit artery PCI success (hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.41 to 0.96, p = 0.030) and MV primary PCI (HR: 0.57; 95% CI: 0.38 to 0.84, p = 0.005) were associated with increased 6-month survival.ConclusionsThe results of this study suggest that in STEMI patients with MVD presenting with CS and CA, MV primary PCI may improve clinical outcome. Randomized trials are required to verify these results

Device-Related Thrombus After Left Atrial Appendage Closure

Although left atrial appendage closure (LAAC) has proved non-inferior to oral anticoagulants in patients with AF, there has been recent concern about the occurrence of late complications, especially device-related thrombus (DRT), which was associated with increased risk of stroke. In this article, the incidence, risk factors and time course of DRT after LAAC are discussed, as well as the potential benefits of dedicated strategies in the management of DRT, which remain speculative, especially in patients with a contraindication to oral anticoagulants. In these patients, decision-making should be based on a multidisciplinary evaluation of the ischaemic/bleeding balance on an individual basis

157 Percutaneous femoral implantation of aortic valve prosthesis without surgical cutdown. A single center experience

PurposeFemoral transcatheter aortic valve implantation (TAVI) is usually done by surgical cut down under general anesthesia. Complete percutaneous approach has become widely accepted in endovascular management of aortic disease, and we have decided to apply this technique for TAVI. We aimed to evaluate the impact of the sheath size on safety and efficacy of this technique.MethodThe study cohort included 64 consecutive patients who underwent femoral approach using Prostar XL device at our institution between Mar 2008 and Feb 2010. The cohort was divided into two groups: group 1, 18 or 19 Fr sheath (1 Prostar XL device) and group 2, 22 or 24Fr (2 Prostar XL). The iliac and femoral angiogram was obtained before insertion and after removal of the sheath using contralateral approach. Device success was defined as immediate hemostasis without surgery or death related to access site during hospital stay.ResultsClinical characteristics were similar in both groups (83.6±5.7 years, male gender 50% and logistic Euroscore 25.3±11.0%) besides higher rate of hypertension (81.0% vs 56.1%; p=0.03) in group 1.In group 1, Corevalve was used in 14 cases and Edwards valve in 9 cases. In group 2, 22 Fr sheath was used in 22 cases and 24Fr in 19.The angiogram showed smaller femoral artery diameter in group 1 (7.7±1.2 vs 9.0±0.9mm; p=0.001 and common iliac artery 9.4±1.4 vs 11.5±1.8mm; p=0.001), a lower calcium score (0.6±0.8 vs 1.1±0.7; p=0.034) and tortuosity score (0.6±0.7 vs 1.2±0.7; p=0.001). Device success was achieved in 100% in group 1 and 95.1% in group 2 (p=ns).The rate of iliac artery perforation or rupture was lower in group 1 (0% vs 9.8%; p=0.044). Death due to access site complication was observed only in 1 case in group 2 (p=ns).ConclusionThanks to the development of lower profile devices, percutaneous approach for femoral arterial access is emerging as a promising method for TAVI and will decrease the need for general anesthesia in this high risk patients

072 Five-year outcome of patients with bifurcation lesions treated with provisional side branch T-stenting using drug-eluting stents

BackgroundCoronary bifurcation lesions remain a challenge, as lower success rates and higher reintervention rates persist in this lesion subset. The ideal strategy to treat such lesions is still debated and data regarding long-term efficacy and safety of drug-eluting stents in this setting are sparse.ObjectivesWe sought to determine the long-term efficacy and safety of a provisional side branch T-stenting (PTS) strategy for bifurcation lesions in an unselected population.Methods477 consecutive Pts were treated for bifurcation lesions with DES (Paclitaxel or Sirolimus-eluting stents) between 2003 and 2005. Data were entered prospectively into a single-center registry. The PTS strategy was employed in 92%, with a side-branch stent in 28% and final kissing balloon inflation in 95%. Five-year follow-up, at a median of 61 months, is available for 93.5% of patients.ResultsAngiographic success was achieved in 99%, with 2.5% in-hospital major adverse cardiac events (MACE, defined as any cardiac death, early reintervention, Q – or non-Q-wave MI or target vessel revascularisation). The cumulative rate of MACE was 10.7% at 1 year, 13.6% at 2 years and 19.7% at 5 years, including target vessel revascularisation rates of 6.9%, 8.9% and 13%, and cardiac death rates of 3%, 3.7% and 6.7%, respectively. Ischaemia-driven target lesion revascularisation at 5 years is 7.3%. The cumulative rate of definite or probable stent thrombosis at long-term is 3.1%, most cases occurring within the first year (2.5%). The need for reintervention in the long-term was not predicted by any procedural variable, and not significantly related to the use of 1 or 2 stents or to the type of stent deployed.ConclusionsA PTS strategy with first generation drug-eluting stents, was applicable to over 90% of real-world patients with bifurcation lesions with a target lesion revascularisation < 10% at 5 years. The rate of very-late stent thrombosis in this complex lesion subset remains low

Revisiting Sex Equality With Transcatheter Aortic Valve Replacement Outcomes A Collaborative, Patient-Level Meta-Analysis of 11,310 Patients

AbstractBackgroundThere has been conflicting clinical evidence as to the influence of female sex on outcomes after transcatheter aortic valve replacement.ObjectivesThe aim of this study was to evaluate the impact of sex on early and late mortality and safety end points after transcatheter aortic valve replacement using a collaborative meta-analysis of patient-level data.MethodsFrom the MEDLINE, Embase, and the Cochrane Library databases, data were obtained from 5 studies, and a database containing individual patient-level time-to-event data was generated from the registry of each selected study. The primary outcome of interest was all-cause mortality. The safety end point was the combined 30-day safety end points of major vascular complications, bleeding events, and stroke, as defined by the Valve Academic Research Consortium when available.ResultsFive studies and their ongoing registry data, comprising 11,310 patients, were included. Women constituted 48.6% of the cohort and had fewer comorbidities than men. Women had a higher rate of major vascular complications (6.3% vs. 3.4%; p < 0.001), major bleeding events (10.5% vs. 8.5%; p = 0.003), and stroke (4.4% vs. 3.6%; p = 0.029) but a lower rate of significant aortic incompetence (grade ≥2; 19.4% vs. 24.5%; p < 0.001). There were no differences in procedural and 30-day mortality between women and men (2.6 % vs. 2.2% [p = 0.24] and 6.5% vs. 6.5% [p = 0.93], respectively), but female sex was independently associated with improved survival at median follow-up of 387 days (interquartile range: 192 to 730 days) from the index procedure (adjusted hazard ratio: 0.79; 95% confidence interval: 0.73 to 0.86; p = 0.001).ConclusionsAlthough women experience more bleeding events, as well as vascular and stroke complications, female sex is an independent predictor of late survival after transcatheter aortic valve replacement. This should be taken into account during patient selection for this procedure