Risk Score, Causes, and Clinical Impact of Failure of Transradial Approach for Percutaneous Coronary Interventions

ObjectivesTo study the causes of and to develop a risk score for failure of transradial approach (TRA) for percutaneous coronary intervention (PCI).BackgroundTRA-PCI failure has been reported in 5% to 10% of cases.MethodsTRA-PCI failure was categorized as primary (clinical reasons) or crossover failure. Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed.ResultsFrom January to June 2010, TRA-PCI was attempted in 1,609 (97.3%) consecutive patients, whereas 45 (2.7%) had primary TRA-PCI failure. Crossover TRA-PCI failure occurred in 30 (1.8%) patients. Causes of primary TRA-PCI failure included chronic radial artery occlusion (11%), previous coronary artery bypass graft (27%), and cardiogenic shock (20%). Causes for crossover TRA-PCI failure included: inadequate puncture in 17 patients (57%); radial artery spasm in 5 (17%); radial loop in 4 (13%); subclavian tortuosity in 2 (7%); and inadequate guide catheter support in 2 (7%) patients. Female sex (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.95 to 5.26, p < 0.0001), previous coronary artery bypass graft (OR: 6.1; 95% CI: 3.63 to 10.05, p < 0.0001), and cardiogenic shock (OR: 11.2; 95% CI: 2.78 to 41.2, p = 0.0011) were independent predictors of TRA-PCI failure. Risk score values from 0 to 7 predicted a TRA-PCI failure rate from 2% to 80%.ConclusionsIn a high-volume radial center, 2.7% of patients undergoing PCI are excluded from initial TRA on clinical grounds, whereas crossover to femoral approach is required in only 1.8% of the cases. A new simple clinical risk score is developed to predict TRA-PCI failure

Unilateral pleural effusion in ovarian hyperstimulation syndrome

peer reviewedOvarian hyperstimulation syndrome is the most severe iatrogenic complication of fertilization modern methods. This syndrome is characterized by a massive cystic ovarian enlargement associated with an acute body fluid shift. Ascite is the most frequent manifestation of this syndrome. In some rare cases ovarian hyperstimulation syndrome is complicated by massive unilateral pleural effusion without ascite. We describe the case of a 36 year old woman who developed a massive unilateral pleural effusion without ascite. An ovarian hyperstimulation syndrome was diagnosed. Chest tube drainage improved patient parameters and symptoms. We discuss the diagnostic approach of pleural effusions

An alien in the heart: giant infective endocarditis.

peer reviewe

One-year mortality of patients with ST-elevation myocardial infarction: prognostic impact of creatinine-based equations to estimate glomerular filtration rate

BACKGROUND:Renal dysfunction is associated with worse outcomes after primary percutaneous coronary intervention (PCI). However, whether glomerular filtration rate (GFR) estimated with various equations can equally predict outcomes after ST-Elevation Myocardial Infarction (STEMI) is still debated. METHODS:We compared the clinical impact of 3 different creatinine-based equations (Cockcroft and Gault (CG), CKD-epidemiology (CKD-EPI) and Full Age Spectrum (FAS)) to predict 1-year mortality in STEMI patients. RESULTS:Among 1755 consecutive STEMI patients who had undergone primary PCI included between 2006 and 2011, median estimated GFR was 79 (61;96) with the CG, 81 (65;95) with CKD-EPI and 75 (60;91) mL/min/1.73 m2 with FAS equation. Reduced GFR values were independently associated with 1-year mortality risk with the 3 equations. Receiver operating curves (ROC) of CG and FAS equations were significantly superior to the CKD-EPI equation, p = 0.03 and p = 0.01, respectively. Better prediction with FAS and CG equations was confirmed by net reclassification index. CONCLUSIONS:Our results suggest that in STEMI patients who have undergone primary PCI, 1-year mortality is better predicted by CG or FAS equations compared to CKD-EPI

One-year mortality of patients with ST-Elevation myocardial infarction: Prognostic impact of creatinine-based equations to estimate glomerular filtration rate.

BACKGROUND:Renal dysfunction is associated with worse outcomes after primary percutaneous coronary intervention (PCI). However, whether glomerular filtration rate (GFR) estimated with various equations can equally predict outcomes after ST-Elevation Myocardial Infarction (STEMI) is still debated. METHODS:We compared the clinical impact of 3 different creatinine-based equations (Cockcroft and Gault (CG), CKD-epidemiology (CKD-EPI) and Full Age Spectrum (FAS)) to predict 1-year mortality in STEMI patients. RESULTS:Among 1755 consecutive STEMI patients who had undergone primary PCI included between 2006 and 2011, median estimated GFR was 79 (61;96) with the CG, 81 (65;95) with CKD-EPI and 75 (60;91) mL/min/1.73 m2 with FAS equation. Reduced GFR values were independently associated with 1-year mortality risk with the 3 equations. Receiver operating curves (ROC) of CG and FAS equations were significantly superior to the CKD-EPI equation, p = 0.03 and p = 0.01, respectively. Better prediction with FAS and CG equations was confirmed by net reclassification index. CONCLUSIONS:Our results suggest that in STEMI patients who have undergone primary PCI, 1-year mortality is better predicted by CG or FAS equations compared to CKD-EPI

Image of the Month. Cardiac Amylosis

peer reviewe

Percutaneous coronary interventions of chronic total ­occlusions : a review of clinical indications, treatment strategy and current practice

Chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to the perception of limited clinical benefit, high complexity and cost of intervention, and perceived risk of complications. Numerous observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit remains debated. Nevertheless, over the past decade the interest in CTO-PCI has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. A number of factors must be taken into consideration in selecting patients for CTO-PCI, including presence of symptoms attributable to the CTO, extent of ischaemia distal to the occlusion, and degree of myocardial viability. In this review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection. Data regarding efficacy and safety of recent advances in PCI-CTO techniques will be discussed. Steps involved in setting up a dedicated CTO program will be outlined and the current CTO landscape in Belgium will be briefly highlighted. The overall aim of this review is to promote a more balanced approach to management of patients with a CTO

Right coronary artery chronic total occlusion after bypass grafting successfully treated using reverse controlled antegrade and retrograde subintimal tracking (cart) technique via the gastroepiploic artery : a case report

Objective: Unusual setting of medical care Background: Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is a well-established treatment option, improving health status and angina in selected patients with angina and/or a large area of documented ischemia and suitable anatomy. It has been used in patients with a history of coronary artery bypass grafting (CABG) but remains controversial in unusual bypass constructions. This report is of a 63-year-old man with angina due to right coronary CTO, 6 years following CABG, successfully treated using the reverse controlled antegrade and retrograde subintimal tracking technique (reverse CART technique) via the gastroepiploic (GE) artery. Case Report: A 63-year-old man with a history of extensive coronary artery disease, including a CTO of the right coronary artery (RCA), previously treated with a right GE artery bypass graft, presented with unacceptable angina despite optimal medical treatment. A vascular CT scan suggested severe stenosis at the level of the anastomosis between the GE artery graft and the posterior descending (PD) artery. A PCI of the native RCA CTO was successfully performed using the GE artery bypass graft as a retrograde conduit, with good angiographical and clinical outcomes. Conclusions: PCI of a CTO via the GE artery has been described only occasionally before, and remains a rare treatment. This report shows that retrograde coronary artery recanalization of CTO using the reverse CART technique, via the GE artery bypass graft, was safe and effective in this case, and that it can and should be considered in selected patients