Acute myocardial infarction treatment : from prehospital care to secondary prevention

Cardiovascular disease remains the leading cause of mortality in the western World, but significant improvements have been made in its treatment and prevention. This thesis shows that consistent implementation of a structured regional treatment and prevention program for acute myocardial infarction patients is feasible when health professionals of various disciplines collaborate.The aim of the main part of this thesis was to evaluate the implementation of the MISSION! AMI protocol in clinical practice at various stages of the program (from pre-hospital care to secondary prevention), to evaluate efficacy and safety of sirolimus-eluting stents at 3-year follow-up, and to study differences in stent edge characteristics in a subgroup of patients by the use of virtual histology-intravascular ultrasound imaging.UBL - phd migration 201

Long-term outcome after ablative therapy of post-operative atrial tachyarrhythmias in patients with congenital heart disease and characteristics of atrial tachyarrhythmia recurrences

Developmen

Long-Term Outcome After Ablative Therapy of Postoperative Atrial Tachyarrhythmia in Patients With Congenital Heart Disease and Characteristics of Atrial Tachyarrhythmia Recurrences

Background-Catheter ablation has evolved as a possible curative treatment modality for atrial tachyarrhythmia (AT) in patients with congenital heart defects (CHD). However, data on long-term outcome are scarce. We examined characteristics of recurrent AT after ablation of postoperative AT during long-term follow-up in CHD patients. Methods and Results-CHD patients (n = 53; 27 men; age, 38 +/- 15 years) referred for catheter ablation of AT were studied during a follow-up period of 5 +/- 3 years. After ablative therapy of the first AT (n = 53, 27 atrial flutter, cycle length = 288 +/- 81 ms; 22 intra-atrial reentrant tachycardia, cycle length = 309 +/- 81 ms; 5 focal atrial tachycardia, cycle length = 380 +/- 147 ms; success rate, 65%), AT recurred (59% within the first year) in 29 patients; 15 underwent repetitive ablative therapy. Mechanisms underlying recurrent AT were similar in 7 patients (intra-atrial reentrant tachycardia, 2; atrial flutter, 5). The location of arrhythmogenic substrates of recurrent AT (intra-atrial reentrant tachycardia, focal atrial tachycardia) was different for all but 1 patient. After 5 +/- 3 years, 5 patients died of heart failure, 3 were lost to follow-up, and the remaining patients had sinus rhythm (n = 31), AT (n = 5), or atrial flutter (n = 14). Antiarrhythmic drugs were used by 18 (57%) sinus rhythm patients. Conclusions-Successive postoperative AT in CHD patients developing over time may be caused by different mechanisms, including focal and reentrant mechanisms. Recurrent AT originated from different locations, suggesting that these new AT were not caused by arrhythmogenicity of previous ablative lesions. Long-term outcome is often complicated by development of atrial fibrillation. Despite frequent need for repeat ablative therapy, most patients are in sinus rhythm. (Circ Arrhythm Electrophysiol. 2010;3:148-154.)Developmen

PREVALENCE OF DYSSYNCHRONY AND RELATION WITH LONG-TERM OUTCOME IN PATIENTS AFTER ACUTE MYOCARDIAL INFARCTION

Ventricular Dysfunction & Heart Failur

Distribution of culprit lesions in patients with ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention

Cardiolog

Aspiration Thrombectomy During Primary Percutaneous Coronary Intervention as Adjunctive Therapy to Early (in-ambulance) Abciximab Administration in Patients with Acute ST Elevation Myocardial Infarction: An Analysis from Leiden MISSION! Acute Myocardial Infarction Treatment Optimization Program

Background:  The benefits of early abciximab administration and thrombus aspiration in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI) have previously been elaborated. However, whether there is an adjunctive effect of thrombus aspiration among STEMI patients, with angiographic evidence of thrombus, receiving early prehospital abciximab remains unclear. Methods:  In the context of a fixed protocol for PPCI, 158 consecutive patients with STEMI were enrolled, in whom abciximab was started early before hospital arrival (in-ambulance); 79 patients who had PPCI with thrombus aspiration (thrombectomy-facilitated PCI group), were compared to 79 who had PPCI without thrombus aspiration (conventional PCI group) in a prospective nonrandomized study. The primary end-point was complete ST-segment resolution within 90 minutes. Secondary end points included distal embolization, enzymatic infarct size as well as left ventricular ejection fraction (LVEF) assessed by gated single-photon emission computed tomography. Major adverse cardiac events (MACEs) were evaluated up to 12 months. Results:  Both groups were comparable for baseline characteristics. ST-segment resolution was significantly higher in the thrombectomy-facilitated group (P = 0.002), and multivariate analysis identified thrombectomy as an independent predictor of ST-segment resolution (OR = 9.4, 95% CI = 2.6-33.5, P = 0.001). Distal embolization was higher in the conventional PCI group among patients with higher thrombus grades. No difference was observed between both groups in infarct size assessed by peak creatine kinase (p = 0.689) and peak Tn-T levels (P = 0.435). Also, the LVEF at 3 months was similar (P = 0.957). At 12 month clinical follow-up, thrombus aspiration was, however, associated with reduced all-cause mortality (log-rank p = 0.032). Conclusion:  Among STEMI patients treated with PPCI and in-ambulance abciximab, it appears that a selective strategy of thrombus aspiration still has additive benefit. (J Interven Cardiol 2012;25:1-9).Cardiolog

Left atrial strain is related to adverse events in patients after acute myocardial infarction treated with primary percutaneous coronary intervention

Cardiac Dysfunction and Arrhythmia

Analysis of stably expressed genes with low-dose etoposide for toxicological studies in osteosarcoma

Cardiolog

Right ventricular stimulation threshold at ICD implant predicts device therapy in primary prevention patients with ischaemic heart disease

Myocardial excitability is known (amongst other reasons) to be related to the degree of ischaemia, contractile dysfunction and heart failure. It was hypothesized that the right ventricular (RV) stimulation threshold has prognostic value with respect to the occurrence of ventricular arrhythmias (VAs) and patient survival in recipients of an implantable cardioverter defibrillator (ICD). Ischaemic heart disease patients receiving an ICD at Leiden University Medical Center as primary prevention for sudden cardiac death were included in this study. Right ventricular thresholds were determined at ICD implant. Data were collected on VAs triggering ICD therapy and on all-cause mortality. A total of 689 consecutive patients were included (87% male, age 63 +/- 11 years, left ventricular ejection fraction (LVEF) 29 +/- 11%) and followed for a median of 28 months. Post-implant RV-threshold was 0.7 +/- 0.5 volt (V) at 0.5 ms pulse duration. Best dichotomous separation was reached at a cut-off of 1 V. During follow-up, 167 (24%) patients received appropriate ICD therapy, 88 (13%) had appropriate shocks and 134 (19%) died. Cumulative appropriate shock incidence for patients with RV threshold >= 1 V (n = 166) was 16% at 1 year, 24% at 3 years and 34% at 5 years compared with 4, 11 and 17% for patients with an RV-threshold = 1 V was 2.0 (95% CI: 1.4-2.9) for appropriate therapy, 3.3 (95% CI: 2.0-5.4) for appropriate shocks and 1.6 (95% CI: 1.1-2.5) for mortality. The RV stimulation threshold at ICD implant has a strong independent prognostic value for the occurrence of VAs triggering appropriate ICD therapy, appropriate shocks and mortality.Cardiac Dysfunction and Arrhythmia