Pre-PCI versus immediate post-PCI Impella initiation in acute myocardial infarction complicated by cardiogenic shock

BACKGROUND: In selected patients with an acute myocardial infarction (AMI) complicated by Cardiogenic shock (CS), mechanical circulatory support with Impella may be beneficial, although conclusive evidence is still lacking. Nevertheless, it has been suggested that Impella initiation prior to primary PCI might improve survival. OBJECTIVE: To investigate the effect pre-PCI versus immediate post-PCI Impella initiation on short term mortality. METHODS: A prospective, single center, observational study, was performed including all patients with STEMI complicated by CS, treated with primary PCI and Impella. Thirty day mortality was compared between patients with Impella initiation pre-PCI and immediately post-PCI. RESULTS: A total of 88 patients were included. In the pre-PCI group (n = 21), admission heart rate was lower (84 versus 94 bpm, p = 0.04) and no IABP was implanted before Impella initiation, versus 17.9% in post-PCI group (n = 67), p = 0.04. Total 30-day all-cause mortality was 58%, and was lower in pre-PCI group, 47.6% versus 61.2% in the post-PCI group, however not statistically significant (HR 0.7, 95% CI 0.3-1.3, p = 0.21). Thirty-day cardiac mortality was significantly lower in the pre-PCI group, 19% versus 44.7% in the post-PCI group (HR 0.3, 95% CI 0.09-0.96, p = 0.042). CONCLUSION: Pre-PCI Impella initiation in AMICS patients was not associated with a statistically significant difference in 30-day all-cause mortality, compared to post-PCI Impella initiation

Improved microcirculation in patients with an acute ST-elevation myocardial infarction treated with the Impella LP2.5 percutaneous left ventricular assist device

Circulatory support during percutaneous coronary intervention (PCI) in patients with ST-element elevation myocardial infarction (STEMI) aims at maintaining hemodynamic stability and organ perfusion. However, continuous flow pumps may interfere with the normal pulsatile circulation and the microcirculatory function. Sidestream dark field (SDF) imaging allows the visualization of microvascular structure and function of tissue and may provide information regarding the efficacy of the circulatory support. Sidestream dark field was used to study the sublingual microcirculation (MC) in six anterior STEMI patients treated with PCI; three patients received Impella LP2.5 percutaneous left ventricular support (Impella group) and three patients received no support (control group). MC was assessed at baseline, at 24, 48 and 72 h after PCI. Data were analyzed using a validated scoring method and the microvascular flow index (MFI) and perfused vessel density (PVD) were calculated. MC of three healthy controls was used as normalized standard. Normal MC depending on both functional capillary density (PVD) and flow velocity or quality (MFI), as observed in healthy controls, was only achieved in the Impella group and paralleled improvement in LV function. Functional capillary density in the control and Impella groups were respectively equal and above the level of healthy controls. The quality of microcirculatory flow only in the Impella group reached values of healthy controls. Microcirculation assessed by SDF improved in STEMI patients treated with the Impella LP2.5 to levels observed in healthy persons and remained suboptimal after 72 h in patients without support. Sublingual SDF to assess MC may serve as a monitor of effective myocardial recovery after PCI and optimization of organ perfusio

Catamenial chest pain and spontaneous coronary artery dissection: A case report

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction, presenting mostly in healthy, young women. The pathogenesis is still poorly understood. A 45-year-old woman presented with an ST-elevation myocardial infarction, caused by SCAD of the mid left anterior descending coronary artery. In the six years prior to this event, she frequently experienced chest pain coinciding with her menstruation

Long-term outcomes of a Caucasian cohort presenting with acute coronary syndrome and/or out-of-hospital cardiac arrest caused by coronary spasm

Contains fulltext : 190517.pdf (publisher's version ) (Open Access)BACKGROUND: Coronary artery spasm may be the underlying mechanism in up to 10% of cases of acute coronary syndrome (ACS) and sudden cardiac death. Asian individuals exhibit a 3-times greater incidence of spasm than Caucasians; this is likely due to different types of mechanisms. Consequently, solid data is limited about the long-term prognosis in Caucasian patients presenting with ACS and/or out-of-hospital cardiac arrest (OHCA) caused by coronary spasm. METHODS: Between 2002 and 2015, thirty Caucasian patients with coronary artery spasm presenting with ACS (N = 29) and/or OHCA (N = 11) were enrolled in this prospective registry. Follow-up, consisting of regular outpatient visits, was conducted with a mean follow-up period of 7.5 +/- 3.3 years. Outcomes included presence of stable angina pectoris, recurrence of ACS, occurrence of implantable cardioverter defibrillator (ICD) shocks and death. RESULTS: The majority of patients (60%) remained asymptomatic during the entire follow-up period. At the end of the follow-up period only 3 patients still experienced stable angina (10%). Only 2 patients (7%) had a recurrent cardiac event, in which the ICD provided appropriate shock therapy. Half of the patients treated with stenting (N = 6), required re-interventions. CONCLUSION: Coronary spasm with ACS and/or OHCA in a Caucasian patient cohort has a relatively benign prognosis in the majority of patients in long-term follow-up, if treated appropriately with medical therapy. Both the role of ICD in OHCA secondary to coronary spasm, and the efficacy of stenting to treat vasospastic angina, warrant further study in large-sized prospective clinical trials

Proximal embolic protection in patients undergoing primary angioplasty for acute myocardial infarction (PREPARE): core lab adjudicated angiographic outcomes of a randomised controlled trial

Background Patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) with the Proms system (St Jude Medical, St Paul, MN, USA) achieved significantly better microvascular flow as measured by ST-segment resolution However, no differences were observed in left ventricular ejection fraction or infarct size as obtained by cardiovascular magnetic resonance imaging The goal of the present study was to evaluate the effect of combined proximal embolic protection and thrombus aspiration on core lab adjudicated angiographic outcomes Methods In the PRoximal Embolic Protection in Acute myocardial infarction and Resolution of ST Elevation (PREPARE) study, patients were randomised to primary PCI with the Proms system (n=141) or primary PCI alone (n=143) An independent core laboratory re-evaluated all angiograms and adjudicated the angiographic outcomes and computerised quantitative blush evaluation (QuBE) value Results There were no significant differences in Thrombolysis In Myocardial Infarction (TIMI) flow grade, myocardial blush grade, or angiographic signs of distal embolisation among the two arms QuBE values did not significantly differ between the Proxis-treated patients and control patients (15 1 +/- 5 4 vs 15 8 +/- 5 5, respectively, p=0 34) Conclusion Primary PCI with combined proximal embolic protection and thrombus aspiration in STEMI patients more frequently resulted in complete immediate ST resolution compared with control patients However, there were no significant differences in core laboratory adjudicated angiographic outcomes (Neth Heart J 2010,18 531-6

Characteristics, treatment strategies, and outcome in cardiogenic shock complicating acute myocardial infarction: a contemporary Dutch cohort

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is associated with high morbidity and mortality. Our study aimed to gain insights into patient characteristics, outcomes and treatment strategies in CS patients. Patients with CS who underwent percutaneous coronary intervention (PCI) between 2017 and 2021 were identified in a nationwide registry. Data on medical history, laboratory values, angiographic features and outcomes were retrospectively assessed. A total of 2328 patients with a mean age of 66 years and of whom 73% were male, were included. Mortality at 30 days was 39% for the entire cohort. Non-survivors presented with a lower mean blood pressure and increased heart rate, blood lactate and blood glucose levels (p-value for all Cardiolog