Lijevi lateralni pogled tijekom perkutane koronarne intervencije kod akutnog infarkta donje stijenke miokarda s podizanjem ST spojnice i dekstrokardijom

Rapid recognition of ST-segment elevation myocardial infarction and electrocardiogram interpretation in patients with dextrocardia could be a challenging situation. This case report discusses presentation in a patient with dextrocardia and situs inversus who was found to have acute inferior myocardial infarction. Percutaneous coronary intervention in cases of dextrocardia can be technically challenging considering coronary origin and orientation, and difficulty in appropriate catheter selection.Pravodobno prepoznavanje infarkta miokarda s elevacijom ST segmenta i interpretacija elektrokardiograma u bolesnika s dekstrokardijom predstavlja klinički izazov. Ovim prikazom slučaja opisujemo bolesnika s dekstrokardijom i situs inversusom za kojeg je utvrđeno da ima akutni infarkt miokarda s podizanjem ST segmenta. Perkutana koronarna intervencija u slučajevima dekstrokardije može biti tehnički izazovna s obzirom na poziciju ušća koronarnih arterija te poteškoće u odgovarajućem odabiru i manipulaciji intervencijskim kateterima

Gender Differences in In-hospital Mortality and Angiographic Findings of Patients with Acute ST-segment Elevation Myocardial Infarction (STEMI) Undergoing Percutaneous Coronary Intervention (PCI)

There are conflicting reports in the literature regarding the role of sex on the in-hospital mortality of patients with acute myocardial infarction. The objective of this study is to determine whether there are gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We conducted a prospective study of all patients admitted to University Hospital Center Split, Croatia with STEMI from 2004 to 2008 who underwent PCI. From March 2004 throughout September 2008, 488 patients with STEMI underwent PCI (364 men, 74.6%; 124 women, 25.4%). Compared with men, women were significantly older (mean age, 67.3 vs. 60.3 years; p<0.001). Men had a significantly higher proportion of circumflex artery occlusion (19.5% vs. 10.5%, p=0.022). A higher proportion of men had a multivessel disease than women (56.8% vs. 41.9%; p=0.004). In-hospital mortality was significantly higher among women (11.3% vs. 4.6%; p=0.002) but after adjustment for the baseline difference in age, the female sex was not an independent predictor of in-hospital mortality (adjusted OR 1.15; 95% CI 0.82–1.84). In men, occlusions of left anterior descending artery showed higher mortality rate than occlusions of other coronary arteries (LM 0%, LAD 7.3%, Cx 2.8%, RCA 0.7%, p=0.03). According to our results female gender is not an independent predictor of in-hospital mortality after percutaneous coronary intervention. In men, occlusions of left anterior descending arteries are associated with higher mortality rate comparing to occlusions of other coronary arteries

Right Atrial Pacemaker Lead Thrombosis Incidentally Detected by Transesophageal Echocardiography

In a 62-year-old man with permanent atrial fibrillation and recurrent stroke, a large right atrial thrombus attached to a permanent pacemaker lead was incidentally identified by transesophageal echocardiography. Surgical treatment, recommended because of the large dimensions of the mass, was refused by the patient, and thrombus was successfully dissolved by anticoagulant treatment. Pathogenesis of pacemaker lead thrombosis, clinical implications, diagnostic and therapeutic options are discussed

PRIMARY PERCUTANEOUS CORONARY INTERVENTION (PPCI) IN HOSPITAL WITHOUT REGIONAL CARDIAC SURGERY SUPPORT, DATA FROM SPLIT REGION

Svrha rada: Cilj je istraživanja istražiti izvedivost programa PCI u bolnici bez kardiokirurške potpore, i usporediti naše rezultate sa smjernicama i skupinom konzervativno liječenih bolesnika u razdoblju prije uvođenja primarne perkutane koronarne intervencije (pPCI). Metode: Podatci o svim bolesnicima s akutnim infarktom miokarda sa ST elevacijom (STEMI) liječenim pPCI prospektivno su bilježeni. Rezultati: Od početka programa pPCI od siječnja 2005. do listopada 2007. godine kada je u našoj ustanovi započeo s radom Odjel kardiokirurgije liječeno je 366 bolesnika. Unutarbolnička smrtnost iznosila je 6,3%, u usporedbi s 15% (87/583) u skupini konzervativno liječenih bolesnika u trogodišnjem razdoblju prije uvođenja pPCI. Prosječno vrijeme od početka boli do postavljanja balona iznosilo je 315 minuta, vrijeme od boli do prvoga medicinskog kontakta 102 minute, vrijeme od prvoga medicinskog kontakta do vrata bolnice 94 minute, vrijeme od vrata bolnice do laboratorija 84 minute, vrijeme od laboratorija do otvaranja krvne žile 45 minuta, a vrijeme od vrata do postavljanja balona 129 minuta. Zaključak: Analiza rezultata pokazuje da je uvođenje programa primarne PCI u bolnici bez kardiokirurške potpore u regiji sigurno i da pruža značajnu redukciju mortaliteta u bolesnika sa STEMI. U organizaciji službe za zbrinjavanje akutnog infarkta miokarda treba naglasiti agresivno rješavanje vremenskog zastoja u primjeni pPCI unutar bolnice.Objectives: The aim of our study was to investigate the feasibility of pPCI in hospital without cardiac surgery, and to compare our »real-world« results to current guidelines and historical controls. Methods: Data of all STEMI patients treated by PCI were prospectively recorded. Results: From January 2005 through October 2007, 366 consecutive patients with STEMI were enrolled. In-hospital mortality was 6.3%, as compared to 15% (87/543) in historical records of a three year period before pPCI program was developed. Pain to balloon time was 315 minutes, pain to first medical contact was 102 minutes, first medical contact to door was 94 minutes, door to cathlab time was 84 minutes, cathlab to balloon time was 45 minutes, and door to balloon time was 129 minutes. Conclusions: Our preliminary experience indicates that implementation of pPCI in a hospital without regional cardiac surgical back-up is feasible and offers significant mortality reduction in STEMI patients. Intrahospital time delays should be managed aggressively

Percutaneous Coronary Interventions with Drug-eluting Balloons: Croatian Experience

Uvod: Lijekom obloženi baloni (DEB) predstavljaju novu tehnološku platformu u području perkutane koronarne intervencije. Jedina prihvaćena indikacija za njihovu uporabu je liječenje in-stent stenoze, a za sve ostale indikacije nema jasnog konsenzusa. Cilj: Evaluirati upotrebu DEB-a u rutinskoj kliničkoj praksi u Republici Hrvatskoj. Metode: Restrospektivni nerandomizirani multicentrični registar svih liječenih bolesnika u sedam hrvatskih centara između veljače 2011. i siječnja 2014. godine. Podatci su sakupljeni uvidom u dostupnu medicinsku dokumentaciju. Nije bilo kliničkih niti angiografskih isključnih kriterija, niti pisanog zajedničkog protokola za indikacije niti praćenje bolesnika. Praćena su velika nepovoljna događanja (MACE) definirana kao kombinacija srčane smrti, infarkta miokarda na tretiranoj krvnoj žili (MI) ili klinički indicirane reintervencije na tretiranoj krvnoj žili TLR za sve bolesnike tijekom iste hospitalizacije, nakon 6 mjeseci kliničkog praćenja te dostupni angiografski podatci. Rezultati: Kod 248 bolesnika tretirane su 284 lezije. Najčešća indikacija bila je in-stent restenoza u 31,4% bolesnika, u 21,4% bolesnika DEB je implantiran u žilama manjim od 2,75 mm, a ostale indikacije su bile: lezije veće od 2,8 mm, bifurkacije, ostijalne lezije, kronične totalne okluzije (redom: 11,3%; 11,3%; 7,3%; 1,6% ). U 39 bolesnika (15,6%) nakon prethodne implantacije običnih metalnih stentova (BMS) rađena je postdilatacija DEB-om. MACE su se tijekom hospitalizacije javili u 1,6% bolesnika: 1 smrt (0,4%), 3 akutne tromboze (1,2%), 1 MI (0,4%). Nakon 6 mjeseci praćenja dostupni su podatci za 83 bolesnika (33%). U 6% bolesnika je rađena TLR, a nije bilo registriranih smrti niti akutnih infarkta miokarda. Angiografska kontrola nakon 6 mjeseci učinjena je u 55 bolesnika (22%). U 69% bolesnika nalaz je opisivan kao potpuno uredan, nesignifikantna stenoza opisana je u 20% bolesnika, a u 11% bolesnika je opisana stenoza u rasponu od >50% do potpune okluzije. Zaključak: Naše kliničko iskustvo u svakodnevoj kliničkoj praksi pokazuje da se DEB u Hrvatskoj koristi u najvećem slučaju u prihvaćenim indikacijama in-stent restenoze, ali i u velikom postotku i za indikacije za koje ne postoji jasni konsenzus u literaturi. Akutni angiografski rezultati i rani klinički ishodi su odlični, a uporaba DEB-a je izrazito sigurna.Introduction: Drug-eluting balloons (DEB) represent a new technological platform in the area of percutaneous coronary interventions. The only accepted indication for their use is the treatment of in-stent stenosis, with no clear consensus for all other indications. Aim: To evaluate the use of DEB in routine clinical practice in Croatia. Methods: Retrospective nonrandomized multicentric register of all treated patients in seven Croatian centers in the time frame from February 2011 to January 2014. The data were collected from available medical documents. There were no clinical or angiographic exclusion criteria, nor was there any written common protocol for indications or for for the clinical follow up of patients. Major adverse cardiac events (MACE) were monitored. MACE were defined as the combination of cardiac death, development of myocardial infarction (MI) on treated vessel, and/or target lesion revascularization (TLR) for all patients during the same hospitalization, following a 6-month clinical observation and through available angiographic data. Results: 248 patients were treated for 284 lesions. The most common indication was the in-stent restenosis present in 31.4% of the patients, for 21.4% of the patients DEB was implanted in vessels smaller than 2.75 mm, and other indications were: lesions larger than 2.8 mm, bifurcations, ostial lesion, chronic total occlusions (11.3%; 11.3%; 7.3%; 1.6% respectively). On 39 patients (15.6%) following the previous implantation of bare metal stents (BMS), postdilatation with DEB was conducted. MACE during hospitalization appeared in 1.6% of the patients: 1 death (0.4%), 3 acute thromboses (1.3%), 1 MI (0.4%). Following the 6 month long observation, data is available for 83 patients (33%). TLR was performed on 6% of the patients, and there were no registered deaths or acute myocardial infarctions. Angiographic follow-up was performed on 55 patients (22%) after 6 months. In 69% of the patients the findings were described as completely clean, insignificant stenosis was described for 20% of the patients, and for 11% of the patients a stenosis to the amount of >50% of full occlusion was described. Conclusion: Our clinical experience in everyday clinical practice shows that in Croatia DEB is mostly used in cases of accepted indications of in-stent re-stenosis, but also to a great percentage for indications for which no clear consensus exists in literature. Acute angiographic results and early clinical results are excellent, and the use of DEB is highly safe

Značenje vremena od dolaska u prvu zdravstvenu ustanovu do postizanja reperfuzije i ukupnog trajanja ishemije u bolesnika s akutnim infarktom miokarda s ST-elevacijom liječenih primarnom perkutanom koronarnom intervencijom

The aim of the study was to evaluate the influence of door-to-balloon time and symptom onset-to-balloon time on the prognosis of patients with acute ST-elevation myocardial infarction (STEMI ) treated with primary percutaneous coronary intervention (PCI) in the Croatian Primary PCI Network. A total of 1190 acute STEMI patients treated with primary PCI were prospectively investigated in eight centers across Croatia (677 non-transferred, 513 transferred). All patients were divided according to door-to-balloon time in three subgroups (180 minutes) and according to symptom onset-to-balloon time in three subgroups (360 minutes). The postprocedural Thrombolysis in Myocardial Infarction flow, in-hospital mortality, and major adverse cardiovascular events (mortality, pectoral angina, restenosis, reinfarction, coronary artery by-pass graft and cerebrovascular accident rate) in six-month follow-up were compared between the subgroups. The Croatian Primary PCI Network ensures results of treatment of acute STEMI comparable with randomized studies and registries abroad. None of the result differences among the door-to-balloon time subgroups was statistically significant. Considering the symptom onset-to-balloon time subgroups, a statistically significant difference at multivariate level was highest for in-hospital mortality in the subgroup of patients with longest onset-to-balloon time (4.5 vs.2.6 vs. 5.7%; p=0.04). Door-to-balloon time is one of the metrics of organization quality of primary PCI network and targets for quality improvement, but without an impact on early and sixmonth follow-up results of treatment for acute STEMI . Symptom onset-to-balloon time is more accurate for this purpose; unfortunately, reduction of the symptom onset-to-balloon time is more complex than reduction of the former.Cilj studije bio je procijeniti utjecaj vremena od dolaska u prvu zdravstvenu ustanovu do postizanja reperfuzije (engl. door-to-balloon time) i vremena od početka simptoma do postizanja reperfuzije (engl. symptom onset-to-balloon time) na prognozu bolesnika s akutnim infarktom miokarda s ST-elevacijom (STEMI ) liječenih primarnom perkutanom koronarnom intervencijom (PCI) u sklopu Hrvatske mreže primarne PCI. Autori su prospektivno istraživali 1190 bolesnika s akutnim STEMI liječenih primarnom PCI u osam centara u svim dijelovima Republike Hrvatske (677 netransferiranih, 513 transferiranih). Bolesnici su podijeljeni prema vremenu door-to-balloon u tri podskupine (180 minuta), kao i prema vremenu symptom onset-to-balloon (360 minuta). Između podskupina su uspoređivani postproceduralni TIMI protok, unutarbolnička smrtnost i veliki nepovoljni kardiovaskularni događaji (smrtnost, angina pektoris, restenoza, reinfarkt, aortokoronarno premoštenje i cerebrovaskularni incident) tijekom šestomjesečnog praćenja. Hrvatska mreža primarne PCI osigurava rezultate liječenja akutnog STEMI usporedive s inozemnim randomiziranim studijama i registrima. Između poskupina prema vremenu door-to-balloon niti jedna od rezultatskih razlika nije bila statistički značajna. Između podskupina prema vremenu symptom onset-to-balloon statistički značajna razlika na multivarijatnoj razini bila je ona najviše unutarbolničke smrtnosti u podskupini s najduljim navedenim vremenom (4,5 nasuprot 2,6 nasuprot 5,7%; p=0,04). Vrijeme door-to-balloon je jedna od mjera organizacijske kvalitete mreže primarne PCI i cilj za poboljšanje kvalitete iste, ali bez utjecaja na rane i šestomjesečne rezultate liječenja akutnog STEMI . Vrijeme symptom onset-to-balloon je preciznije za potonje potrebe. Skraćenje vremena symptom onset-to-balloon je, nažalost, složenije nego skraćenje prvoga vremena

Sedmogodišnji trendovi u rezultatima hrvatske mreže primarne perkutane koronarne intervencije

The authors investigated trends in the Croatian primary Percutaneous Coronary Intervention (pPCI) Network results among three consecutive time intervals (2005-2007, first phase; 2008-2009, second phase; and 2010-2011, third phase). Data on 5650 patients with acute myocardial infarction with ST-elevation (STEMI ) transferred or directly admitted and treated with pPCI in 11 Croatian PCI centers during the study period were collected and analyzed. The number of patients with acute STEMI treated with pPCI per year rose continuously during the study period (581 vs.1272 vs. 1949 patients/year). The patient risk profile worsened during the study period: age (60 vs. 61 vs. 63 years; p<0.01), anterior myocardial wall involvement (43% vs. 44% vs. 51%; p<0.01), shock rate (7% vs. 9% vs. 11%; p<0.05), and percentage of transferred patients (42% vs. 36% vs. 46%; p<0.01). While the door-to-balloon time shortened (108 vs. 98 vs. 75 min; p<0.01), the symptom onset-to-door time increased (130 vs. 175 vs. 195 min; p<0.01), but without statistically significant influence on the total ischemic time. Multivariate log-linear analysis eliminated influence of a higher risk profile on the results of treatment and yielded no statistically significant changes in final TIMI 3 flow (Thrombolysis In Myocardial Infarction 3), in-hospital mortality, and six-month mortality rate, but revealed a significant increase in the rate of angina pectoris (12 vs. 22 vs. 36%; p<0.01) and other major adverse cardiovascular events (MACE; 6 vs. 23 vs. 14%; p<0.01) during follow up. In conclusion, the Croatian pPCI Network continuously ensures very good results of STEMI treatment in this economically less developed European country despite worsening of the risk profile in treated patients and opening of new, less experienced PCI centers. The higher percentage of MACE over time could be explained by changes in the pPCI strategy introduced over time (the culprit lesion only) and higher availability of PCI centers for additional PCI after acute STEMI. However, there is room for improvement, especially in reducing prehospital delay.Autori su istražili trendove u rezultatima Hrvatske mreže primarne perkutane koronarne intervencije (primary percutaneous coronary intervention, pPCI) između tri razdoblja (2005.-2007. (prva faza), 2008.-2009. (druga faza), 2010.-2011. (treća faza)). Prikupljeni su i izračunati podaci o 5650 bolesnika s akutnim infarktom sa ST-elevacijom (STEMI ) transportiranih ili izravno zaprimljenih i liječenih pomoću pPCI u 11 hrvatskih PCI centara tijekom toga vremena. Godišnji broj bolesnika s akutnim STEMI liječenih pomoću pPCI kontinuirano je rastao tijekom istraživanog vremena (581 prema 1272 prema 1949 bolesnika/godina). Rizični profil bolesnika se pogoršao kroz istraživano vrijeme: dob (60 prema 61 prema 63 godine; p<0,01), zahvaćanje prednje miokardijalne stijenke (43% prema 44% prema 51%; p<0,01), udio šoka (7% prema 9% prema 11%; p<0,05), postotak transportiranih bolesnika (42% prema 36% prema 46%; p<0,01). Dok se vrijeme od dolaska u bolnicu do uvođenja balona skraćivalo (108 prema 98 prema 75 min; p<0,01), vrijeme od nastupa simptoma do dolaska u bolnicu se produžavalo (130 prema 175 prema 195 min; p<0,01), ali bez statistički značajnog utjecaja na ukupno vrijeme ishemije. Multivarijatna log-linearna analiza, eliminirajući utjecaj višeg rizičnog profila na rezultate liječenja, nije pronašla statistički značajne promjene u završnom protoku TIMI 3 (Thrombolysis In Myocardial Infarction 3), bolničkom pobolu i smrtnosti tijekom šest mjeseci, ali je pokazala značajan porast učestalosti pektoralne angine (12% prema 22% prema 36%; p<0,01) i drugih velikih nepovoljnih kardiovaskularnih događaja (major adverse cardiovascular events, MACE) (6% prema 23% prema 14%; p<0,01) za vrijeme praćenja. Zaključno, Hrvatska mreža pPCI kontinuirano osigurava vrlo dobre rezultate liječenja STEMI u ovoj slabije razvijenoj zapadnoj zemlji unatoč pogoršanju rizičnog profila liječenih bolesnika, kao i otvaranju novih i manje iskusnih PCI centara. Povećanje postotka MACE može se objasniti promjenama u strategiji pPCI tijekom vremena (pPCI samo za ciljne lezije) i većom dostupnošću PCI centara za dodatnu PCI tijekom praćenja nakon akutnog STEMI . Ipak ima prostora za poboljšanje, osobito u skraćenju predbolničkog kašnjenja