Impact of patient delay in a modern real world STEMI network

Background: The impact of patient delay on left ventricular ejection fraction (LVEF), when system delay has performance that meets the current recommended guidelines, is poorly investigated. Methods: We evaluated a cohort of STEMI patients treated with primary percutaneous coronary intervention (pPCI) and with an ECG STEMI diagnosis to wire crossing time (ETW) 64120 min. Independent predictors of pre-discharge decreased LVEF ( 6445%) were analyzed. Results: 490 STEMI patients with both ETW time 64120 min and available pre-discharge LVEF were evaluated. Mean age was 64.2 \ub1 12 years, 76.2% were male, 19.5% were diabetics, 42.7% had and anterior myocardial infarction (MI), and 9.8% were in Killip class III\u2013IV. Median time of patient's response to initial symptoms (patient delay) was 58,5 (IQR 30;157) minutes and median ETW time was 78 (IQR 62\u201395) minutes. 115 patients (23.4%) had pre-discharge LVEF 6445%. At multivariable analysis independent predictors of decreased LVEF ( 6445%) were anterior MI (OR 4,659, 95% CI 2,618-8,289, p < 0,001), Killip class (OR 1,449, 95% CI 1,090-1,928, p = 0,011) and patients delay above the median (OR 2,030, 95% CI 1,151\u20133.578, p = 0,014). These independent predictors were confirmed in patients with ETW time 6490 min. Conclusions: When system delay meets the recommended criteria for pPCI, patient delay becomes an independent predictor of pre-discharge LVEF. These findings provide further insights into the potential optimization of STEMI management and identify a target that needs to be improved, considering that still a significant proportion of patients continue to delay seeking medical care

Right ventricular dysfunction in right coronary artery infarction: A primary PCI registry analysis

Right ventricular involvement in inferior myocardial infarction (MI) was historically associated with a poor prognosis. However, few studies addressed the impact of right ventricular (RV) dysfunction in the primary percutaneous intervention (pPCI) era. Our aim was to assess the prognostic significance of RV dysfunction in right coronary artery (RCA) related MI treated with pPCI. Methods: A total of 298 patients with a RCA related MI undergone pPCI between January 2011 and June 2015 were included. RV dysfunction was defined by a RV-FAC <35% at echocardiographic examination and further divided into mild (RV-FAC between 35 and 25%) and moderate-severe (RV-FAC <25%). RV function before discharge was reassessed in 95% of the study cohort. The primary endpoint was overall mortality. Median follow-up was 29 months. Results: In RCA related MI, moderate-severe (HR 5.882, p = 0.002, 95% CI 1.882-18.385) but not mild RV dysfunction independently predicted lower survival at follow-up along with age (HR 1.104, p <0.001, CI 1.045-1.167). Importantly, patients recovering RV function at discharge showed a lower mortality (p = 0.001) vs patients with persistent moderate-severe RV dysfunction) that approached the risk of patients without RV dysfunction at presentation. Conclusion: In RCA related MI treated with pPCI, RV dysfunction was one of the strongest independent predictor of lower overall survival. However, patients with only transient RV dysfunction showed a better prognosis compared to patients who had persistent RV dysfunction. The focus on intensive support management of the RV in the first hours after pPCI may be important to overcome the acute phase and to promote RV recovery

Insufficienza tricuspidale e indicazioni al trattamento

Tricuspid regurgitation is a frequent valvular heart disease, particularly in the elderly and in association with other left-sided heart diseases. It has an adverse prognostic impact, with progressively increasing mortality as the degree of regurgitation increases. Isolated or combined (with mitral and/or aortic) surgery remains the treatment of choice, provided operative risk is acceptable. Several transcatheter treatment techniques, currently in early clinical or preclinical study phase, could provide alternative treatment options for patients with high surgical risk

Hat-Marker Orientation to Minimize Neo-Commissural Overlap With Coronaries During CoreValve Evolut TAVR

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Effect of prehospital treatment in STEMI patients undergoing primary PCI

11Background: The appropriate timing to administer antithrombotic therapies in ST-elevation myocardial infarction (STEMI) remains uncertain. This study aims to evaluate the role of antithrombotic therapy administration at first medical contact (FMC) compared with the administration in the Cathlab. Methods: We conducted a “before-after” observational study enrolling STEMI undergoing primary percutaneous coronary intervention (PCI). Outcomes were evaluated during two successive periods, before (control group: aspirin only at FMC) and after (pretreated intervention group: heparin, aspirin plus ticagrelor at FMC) the introduction of a new regional pretreatment protocol. Results: A total of 537 consecutive patients (300 in control vs. 237 in intervention group) were enrolled. The pretreated compared with no pretreated population showed better basal reperfusion, expressed as basal Thrombolysis in Myocardial Infarction (TIMI)-flow (p for trend p < 0.001). Pretreated population showed lower frequency of TIMI 0 (56.5% vs. 73.7%, odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.32–0.67, p < 0.001) and higher frequency of TIMI 2-3 (33.3% vs. 19.3% OR: 2.0, 95% CI: 1.38–2.00, p < 0.001) and TIMI 3 (14.3% vs. 9.7%, OR: 1.56, 95% CI: (0.92–2.65), p = 0.094). Pretreated compared with no pretreated population showed reduced infarct size expressed as Troponin Peak (20,286 (8726–75,027) versus 48,676 (17,229–113,900), p = 0.001), and higher left ventricular ejection fraction at discharge (53% (44–59) vs. 50% (44–56), p = 0.027). In-hospital BARC ≥ 2 bleeding were similar (2.1% vs. 2.0%, p = 0.929, in pretreated versus no pretreated population, respectively). Conclusion: This study provides support for an early pretreatment strategy in STEMI patients and confirmed the importance of an efficient organization of STEMI networks which allow initiation of antithrombotic treatment at FMC.openopenFabris E.; Menzio S.; Gregorio C.; Pezzato A.; Stolfo D.; Aleksova A.; Vitrella G.; Rakar S.; Perkan A.; van't Hof A.W.J.; Sinagra G.Fabris, E.; Menzio, S.; Gregorio, C.; Pezzato, A.; Stolfo, D.; Aleksova, A.; Vitrella, G.; Rakar, S.; Perkan, A.; van't Hof, A. W. J.; Sinagra, G