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Background Neointimal strut coverage significantly reduces risk of stent thrombosis, which may allow abbreviated dual anti-platelet therapy if clinically necessary. Optical coherence tomography (OCT) provides unparalleled axial resolution to define strut coverage. We used OCT to assess neointimal strut coverage of Bioresorbable Vascular Scaffolds (BVS) at an earlier timepoint than published studies. Methods OCT imaging was performed at baseline and 1–4 months post-implantation in patients receiving BVS. OCT scaffold strut coverage (strut thickness >160 μm), mean flow/scaffold area (MFA/MSA) and incomplete strut apposition (ISA) were assessed every 1 mm (n = 865 frames) longitudinally throughout the scaffold. Measures were compared at baseline and follow up. Results 20 BVS (median 3.0 × 18 mm) were included in the analysis. 90% of patients were male and mean age was 54.4 ± 9.2 yrs. Median follow up was 70 (range 29–112) days. 16 (80%) stented lesions were classified as AHA B2 or C. At follow-up, only 91/3,280 struts (2.8%) were uncovered. ISA was observed for 60 struts (2.0%) at baseline and 14 struts (0.5%) at follow up (p 2 at baseline to 7.37 mm 2 , at follow up (Δ-5.43%, p 2 ). MSA was not significantly different at follow up (-0.11 mm 2 , Δ-1.27%, p = 0.45). Conclusions BVS exhibited low rates of uncovered struts within four months following implantation. Although MFA had reduced due to neointimal growth, MSA was preserved, implying adequate BVS radial strength despite the complex lesion subset. These data suggest that abbreviated dual-antiplatelet therapy may be possible following BVS implantation if clinically necessary.

Background Factors affecting prognosis after primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) include age at presentation, the presence of diabetes mellitus, left ventricular function and/or cardiogenic shock. Although the debate continues over a strategy of complete revascularisation (immediate or staged) vs culprit-only, little is known about the impact of the extent of coronary disease at presentation on prognosis after PPCI. The SYNTAX score, designed to stratify outcomes in multivessel PCI and CABG, has been validated in unselected populations undergoing elective PCI; to date, no studies have assessed its utility in PPCI. Methods Consecutive patients attending a single UK tertiary centre for PPCI between September 2008 and June 2010 (n=695) were included. SYNTAX scoring was performed by a single trained operator blinded to patient details and outcome. Scoring was validated by analysis of 3 separate cohorts by 2 other experienced operators. Patients were split into 3 subgroups as in the SYNTAX trial (score ≤22 (low, L), 22.5–32 (intermediate, IM) and ≥32.5 (high, H)), and patient data and outcome measures obtained by interrogation of local and national databases. Results 671 of 695 patients were included in the analysis with 24 being excluded owing to inability to score (previous CABG, images unavailable). The ability to allocate a SYNTAX tertile was reproducible between observers (r=0.94). Median scores in the 3 groups were: L 14, IM 26, H 36 (Abstract 43 figure 1A). Although there was no correlation between SYNTAX score and patient sex or diabetic status, there was a linear relationship with patient age (r 2 =0.03; p Conclusions The SYNTAX score, when applied to an unselected population of patients undergoing PPCI for STEMI, provides important prognostic information regarding 1-year survival from death and revascularisation. These findings may provide supporting evidence towards routine complete revascularisation of obstructive coronary artery disease after PPCI.

Introduction Randomised controlled trials have demonstrated that transradial (TR) percutaneous coronary intervention (PCI) reduces bleeding and improves survival compared with transfemoral access (TF). This benefit may be most marked in the context of primary PCI (pPCI) for ST-elevation myocardial infarction. Due to the learning curve associated with TR PCI, these benefits may not translate immediately into real-world practice.Our study sought to determine the effect on clinical outcomes, as our institution switched from TF to TR access. Methods Consecutive patients presenting for PCI over a four year period (1.1.2008–31.12.2011) were included.The choice of access site and, interventional strategy were left to operator discretion. Haemorrhagic complications were identified and classified according to the Bleeding Academic Research Consortium (BARC) definitions. Results 8166 patients (mean age 64.8 ± 11.5 yrs, 76.2% male) were included. Over the study period, TR access became more prevalent (2008- 2.0%, 2011- 42.7%), and the haemorrhagic complication rate fell (2008- 1.64%, 2011- 0.95%, p = 0.05).TR PCI was associated with lower combined rates of BARC 2, 3 and 5 bleeding compared with TF access (0.30% vs. 1.45%, p As TR access became more prevalent (2009–11), a significant survival benefit was observed at 30 days (TR 99.4% vs. TF 98.5%, p = 0.01) and 1 year (TR 97.7% vs. TF 96.5%, p = 0.03).This benefit was most marked in pPCI (TR 98.0% vs. TF 95.7%, p = 0.06 at 30 days and TR 96.6% vs. TF 92.8%, p = 0.02 at 1 year), and occurred despite comparable levels of cardiogenic shock (TR 0.8% vs. TF 1.2%, p = 0.27) and chronic kidney disease (TR 0.7% vs. TF 1.1%, p = 0.21).Further analysis revealed that TR access was most beneficial in pPCI patients receiving glycoprotein IIb/IIIa inhibitors (1 year survival TR 99.2% vs. TF 93.5%, p = 0.01), with no survival benefit in those not receiving these drugs. Discussion In real-world practice, despite the learning curve, TR access is associated with a reduced rate of access-site related bleeding and a significant survival benefit at 30 days and 1 year. This beneficial effect is most marked in pPCI and specifically when strong antithrombotic agents (e.g. glycoprotein IIb/IIIa inhibitors) are used. Our data supports the hypothesis that reduced bleeding may, in part, be responsible for the survival differences observed between TF and TR access.

A 39-year-old normotensive lady with Ebstein anomaly was admitted with palpitations and chest discomfort. Her ECG demonstrated a narrow complex tachycardia, left axis deviation and T-wave inversion in I, avL and V5-6 (panel A). She received oral β blockers and reverted to sinus rhythm. Subsequent serial ECGs demonstrated a global change of …

Background Rotational atherectomy (RA) is an established treatment of heavily-calcified coronary stenoses. Previous data suggest higher procedural complication rates when Burr-to-Artery (BTA) ratios exceed 0.7; the manufacturer-recommended BTA being 0.6. Little contemporary data exists regarding safe and optimal burr sizing, which may be important when considering RA via the radial approach with lower-caliber guiding catheters. Methods Single-centre retrospective review of patients undergoing elective RA between 2004 and 2011. Procedural success was defined as successful stent deployment with residual stenosis Results Elective RA was successful in 197/220 cases (89.5%) with 72% of cases male and 22% diabetic (mean age 71.1±8.9 years). Target vessel was LAD (50.9%), RCA (35.0%), LCx (10.9%) and LMS (3.2%). Mean reference diameter was 3.45±0.6 mm and mean diameter stenosis (DS) 71.9±12.9%. Maximum burr size/case ranged from 1.25–2 mm (mode 1.5 mm) with mean BTA 0.43±0.08. 10 procedural complications occurred (4.5%); one wire fracture, two dissections, three perforations, two emergency CABG, one unretractable burr and one death. No difference in mean BTA was observed between procedures with/without complications (0.38±0.03 vs 0.43±0.08; p=0.33), but residual DS was higher in those with complications (12.3±21.2 vs 58.8±31.2; p Conclusions Elective RA with low BTA is associated with high procedural success and low complication rates. These data imply that elective RA with a lower BTA than recommended is both safe and effective and need not preclude a transradial approach.

Introduction Randomised trial data suggest that direct stenting (DS) during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) is associated with improved markers of reperfusion, such as ST segment resolution, myocardial blush grade and TIMI flow. However, there are few data as to whether these angiographic surrogates translate into a mortality benefit. Methods Consecutive patients attending two high-volume centres undergoing PPCI for STEMI between September 2008 and December 2010 were included in the analysis. All patients received aspirin 300 mg and clopidogrel 600 mg at point of STEMI diagnosis in the community. Use of predilatation (PD), manual thrombus aspiration (TA) and glycoprotein inhibitors (GPI) were at operator discretion. Demographic data and clinical outcomes were obtained by interrogation of local and national databases. Results A total of 1664 patients (mean age 65.3±12.5 years, 74.7% male) underwent PPCI during the study period. We excluded 77 who were not stented from the final analysis. Overall in hospital mortality was 3.0% (47/1587), with 30-day and 1-year mortality of 4.2% (66/1587) and 7.2% (114/1587) respectively. There was a significant 1-year survival advantage in patients who underwent DS (30.2%) compared with those who were stented after PD (3.16% vs 8.63%; p Conclusion In an unselected real-world population undergoing PPCI for STEMI, DS is associated with a significant reduction in 1-year mortality. This effect appears to be independent of both GPI and TA use.

Background The activation criteria for primary percutaneous coronary intervention (PPCI) includes chest pain in association with either ST-segment elevation (STEMI) or new-onset left bundle branch block (LBBB) on the ECG. However, defining LBBB as new is challenging acutely and the poor specificity of indeterminate chronicity LBBB may result in unnecessary PPCI activations. Published data are conflicting with regard to the utility of LBBB as a triage criterion for PPCI and subsequent outcomes are undefined. Methods Consecutive patients attending a single UK tertiary centre for presumed PPCI between September 2008 and December 2010 were included (n=1328). The activation ECG was obtained from the hospital PPCI database, as were demographic data. Outcome data were obtained from notes and national databases. MACE was defined as a composite of mortality and unplanned revascularisation. Two interventionists blinded to patient outcome reviewed the angiographic images and adjudicated if the activation was appropriate. Results Chest pain with LBBB (LBBB-activation) occurred in 88 patients (6.6%) of the PPCI cohort. Comparing LBBB-activations to those with STEMI demonstrated that LBBB-activations were older (mean age 70.3±12.4 vs 64.6±13.4 years; p Conclusions Less than half of LBBB-activations had an ACS and, of these, only half had a thrombotic coronary occlusion requiring PPCI. However, LBBB-activations have a significantly worse prognosis and merit urgent referral. Enhanced triage methods are required to correctly identify acute MI requiring PPCI in those with LBBB.