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

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

6-Versus 24-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents in Patients Nonresistant to Aspirin Final Results of the ITALIC Trial (Is There a Life for DES After Discontinuation of Clopidogrel)

OBJECTIVES The aim of this study was to test the hypothesis that 6-month dual antiplatelet therapy (DAPT) is non-inferior to 24-month DAPT in aspirin-sensitive patients. BACKGROUND The ITALIC (Is There a Life for DES After Discontinuation of Clopidogrel) trial showed that rates of bleeding and thrombotic events at 1 year were much the same with 6 versus 12 months of DAPT after percutaneous coronary intervention with second-generation drug-eluting stents. In this report, 2-year follow-up is presented. METHODS In a multicenter randomized study, patients with confirmed nonresistance to aspirin undergoing drug-eluting stent implantation were allocated to 6 or 24 months of DAPT. The primary endpoint was a composite of death, myocardial infarction, urgent target vessel revascularization, stroke, and major bleeding at 12 months post-percutaneous coronary intervention. The secondary endpoints comprised the same composite endpoint at 24 months and each individual component. RESULTS Overall, 2,031 patients from 70 centers were screened; 926 were randomized to 6-month and 924 to 24-month DAPT. Noninferiority was demonstrated for 6-versus 12-month DAPT, with an absolute risk difference of 0.11% (95% confidence interval: -1.04% to 1.26%; p = 0.0002). At 2 years, the composite endpoint was unchanged, at 3.5% for 6 months and 3.7% for 24 months (p = 0.79), and rates of myocardial infarction (1.3% vs. 1.0%; p = 0.51), stroke (0.6% vs. 0.8%; p = 0.77), and target vessel revascularization (1.0% vs. 0.3%; p = 0.09) were likewise similar. There was a trend toward higher mortality with longer DAPT (2.2% vs. 1.2%; p = 0.11). Four patients (0.4%) in the 24-month group and none in the 6-month group had major bleeding. CONCLUSIONS Two-year outcomes in the ITALIC trial confirmed the 1-year results and showed that patients receiving 6-month DAPT after percutaneous coronary intervention with second-generation drug-eluting stent have similar outcomes to those receiving 24-month DAPT. (C) 2017 by the American College of Cardiology Foundation