KINETICS OF FORMATION AND DISSOCIATION OF TETRACYANONICKELATE(II) AND THEACID DECOMPOSITION OF THE HYDROXO-NICKEL(II) TETRAMER

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Initial experience with a continuous mechanical aspiration system for thrombus removal before percutaneous coronary intervention.

Objectives: Here we investigate the safety and efficacy of a continuous mechanical aspiration system when used before percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). Background: Historically, trials of routine manual aspiration thrombectomy in ACS patients have reported mixed results. This may be due to the technical limitations of manual aspiration, which suffers from decreasing vacuum power as aspiration is performed. Methods: This is a retrospective case series of all patients treated with continuous mechanical aspiration (Indigo CAT RX Aspiration System; Penumbra Inc.) before PCI between August 2017 and July 2020 at five centers in the United States. Data regarding angiographic assessments, procedure, and safety were examined. Results: Seventy-two patients (mean age 60 ± 12.5 years, 34.7% female) with ST Elevation Myocardial Infarction (STEMI) (80.6%) or Non-ST Elevation Myocardial Infarction (NSTEMI) (19.4%) were included. Target vessels were the right coronary (43.1%), left anterior descending (33.3%), and left circumflex (23.6%). Preprocedure, 94.4% had a high thrombus burden (thrombolysis in myocardial infarction [TIMI] thrombus grade ≥ 3). Median aspiration time was 35 s and median access-to-reperfusion time was 10 min. After CAT RX alone, 86.1% had complete perfusion (TIMI flow grade 3). After the procedure, 94.4% had TIMI thrombus grade \u3c3% and 97.2% had TIMI flow grade 3. There were no cases of ischemic stroke. Cardiovascular mortality at 30 days was 1.4%. Conclusions: In our initial experience, aspirating thrombus from ACS patients using the Indigo CAT RX Aspiration System before PCI was safe and effective for reducing thrombus burden and restoring flow

Antiplatelet Therapy in Acute Myocardial Infarction and Cardiogenic Shock: Insights From the National Cardiogenic Shock Initiative

BACKGROUND: Patients presenting with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) are at high risk for impaired antiplatelet activity secondary to malabsorption, systemic hypoperfusion, hypothermia, need for mechanical ventilation, and high use of analgesics. The use of antiplatelet therapy in these high-risk patients is not well studied. METHODS: Using the National Cardiogenic Shock Initiative database, we analyzed patients who presented with AMI-CS at 60 hospitals from March 2018 to December 2020. All patients were treated using a standard shock protocol. Herein, the patterns of antiplatelet use are described. RESULTS: A total of 204 patients were included in the analysis, of which 174 (85.3%) presented with ST-segment elevation myocardial infarction (STEMI). The majority (84.3%) received antiplatelet therapy before percutaneous coronary intervention (PCI); of those who received antiplatelets, 77.9% received aspirin, 55.2% received an oral P2Y12 inhibitor, and 19.2% received intravenous (IV) antiplatelet therapy. Ticagrelor was the most common P2Y12 inhibitor administered (41.9%), followed by clopidogrel (12.2%) and prasugrel (1.2%). Only 18.6% of oral antiplatelet agents were crushed. Baseline characteristics of patients who received IV vs non-IV antiplatelet agents were similar. Thrombolysis in Myocardial Infarction (TIMI) 0 flow was present in 69.6% of patients before PCI and aspiration thrombectomy was performed in 24.5% of patients. The presence of STEMI, cardiac arrest, cardiopulmonary resuscitation, hypothermia, vasopressor use, elevated lactate levels, or number of vessels treated did not influence the use of IV antiplatelet agents. CONCLUSIONS: The use of crushed and IV antiplatelet agents in AMI-CS is low. Further studies are needed in this high-risk population to assess whether more potent antiplatelet inhibition will improve outcomes

TCT CONNECT-29 Vasopressors Have Independent Adverse Impact on Survival in Patients With Acute Myocardial Infarction Cardiogenic Shock

Background: Increasing doses of vasopressors are associated with increased mortality in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS). A causal link to independent harm is confounded by the fact that higher levels of vasopressors may be related to decreasing intrinsic cardiac power output (CPO). Methods: The NCSI is a single-arm prospective trial using mechanical circulatory support (MCS) with Impella for patients with AMICS. Early initiation of MCS placement pre–percutaneous coronary intervention (PCI) and rapid de-escalation of vasopressors guided by systematic use of hemodynamic measures led to a 70% in hospital survival rate for the first 300 patients enrolled from July 2016 to December 2019 in 57 sites. Because MCS can enhance CPO and decrease needs for vasopressors, we were able to assess the independent impact of increasing dosing of vasopressors on survival. Results: Hemodynamic measurements were obtained on patients immediately after MCS and PCI. Survival curves were constructed based on CPO and use of vasopressors (Figure). For patients with CPO ≤0.6 W, survival rate was (77.3%, 45.0%, and 35.3; p = 0.02) when 0, 1, or ≥2 inotropes were used, respectively. Similarly, for patients with CPO ≥0.6 W, survival rate was (81.7%, 72.6%, and 56.8%; p = 0.01), respectively. Logistic regression analysis demonstrates that increasing requirements for inotropes were independently associated with an increase in mortality (p = 0.02). Conclusion: Increasing requirements for vasopressors are associated with an increase in mortality in AMICS irrespective of underlying CPO. Methods to decrease need for vasopressors may enhance survival in AMICS

Vasopressors independently associated with mortality in acute myocardial infarction and cardiogenic shock

BACKGROUND: Increasing vasopressor dose is associated with increasing mortality in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS). It is unknown whether the use of vasopressors is independently harmful or if their use is secondary to decreasing intrinsic cardiac power output (CPO). Mechanical circulatory support (MCS) devices enhance CPO. We sought to evaluate the independent impact of increasing vasopressor dose on survival in the National Cardiogenic Shock Initiative (NCSI). METHODS: The NCSI is a single arm prospective trial evaluating outcomes associated with the use of MCS using Impella in patients with AMICS. Early initiation of MCS placement before percutaneous coronary intervention (PCI) and rapid de-escalation of vasopressors guided by systematic use of invasive hemodynamic measures led to 70% in-hospital survival for the first 300 patients enrolled from July 2016 to December 2019 in 57 U.S. sites. RESULTS: Hemodynamic measures were obtained immediately after MCS and PCI. Survival curves were constructed based on CPO and use of vasopressors. For patients with CPO ≤0.6 W, survival was 77.3%, 45.0%, and 35.3% when 0, 1, or ≥ 2 vasopressors were used (p = 0.02). Similarly, for patients with CPO \u3e0.6 W survival was 81.7%, 72.6%, and 56.8%, respectively (p = 0.01). Logistic regression analysis demonstrated that increasing vasopressor requirements were independently associated with increasing mortality (p = 0.02). CONCLUSION: Increasing vasopressor requirement is associated with increased mortality in AMICS independent of underlying CPO. Methods to decrease the need for vasopressors may enhance survival in AMICS