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The percutaneous treatment of saphenous vein graft lesions containing angiographically massive thrombus is associated with a high risk of distal embolisation and no-reflow. The optimal management for these lesions remains unclear and a challenge to the interventional cardiologist. Five cases are described in whom the risks of percutaneous angioplasty were felt to be excessive owing to a high thrombus load. Each case was treated with a bolus and infusion of abciximab (ReoPro; Eli Lilly—a platelet glycoprotein IIb/IIIa receptor antagonist) at least 24 hours before further angiography. Repeat angiography of the culprit vein graft, following treatment with abciximab alone, demonstrated a major reduction in the thrombus score and the presence of TIMI 3 flow in each case. Immediately following repeat angiography, angioplasty with stent insertion was performed successfully with no distal embolisation or no-reflow phenomenon. This staged approach, with abciximab used alone to reduce thrombus load, is a new treatment for vein graft lesions containing massive thrombus. Keywords: thrombus; abciximab; glycoprotein IIb/IIIa receptor antagonists; interventional cardiology; angioplasty

Introduction Mortality following ST-elevation myocardial infarction has declined significantly with the advent of primary PCI (PPCI). Concurrent use of antiplatelet agents has further decreased complication rates and mortality; however, these agents confer an increased bleeding risk, an independent risk factor for mortality. This retrospective study assesses the effect of blood loss on short- and long-term mortality and its association with clinical characteristics in a real world population of patients undergoing PPCI at a tertiary referral centre in the UK. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were eligible for inclusion in the study. Patient data were obtained from our Cardiac Services Database System (Phillips CVIS) and mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by one-way ANOVA. Categorical variables were compared using the chi-squared test. A P value of Results 1403 patients with recorded admission and discharge haemoglobin levels were included in this analysis. Characteristics and clinical outcomes were compared in three groups according to the degree of haemoglobin reduction (Table 1). Patients with a reduction in haemoglobin were more likely to be female, slightly older and have prior history of MI. Patients with a significant reduction in haemoglobin were more likely to have received abciximab. Thirty-day mortality was significantly higher in the group with a haemoglobin drop (Table 1) as was overall mortality (hazard ratio 1.8, 95% CI 1.2–2.5) during a mean follow-up period of 2.1 years (Figure 1). Conclusions Our retrospective analysis in a large cohort of patients confirms recent data suggesting an adverse association between a reduction in haemoglobin following PPCI and long-term mortality. Further work is required on strategies to reduce bleeding risk and hence improve clinical outcome following PPCI.

Aims Current national and international guidelines continue to recommend activation of the primary percutaneous coronary intervention (PPCI) pathway in patients presenting with chest pain and presumed new-onset left bundle branch block (LBBB). Previous research has suggested that a lower proportion of patients presenting with LBBB require emergency intervention. In this study we have compared baseline clinical characteristics, angiographic findings and subsequent outcome in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for PPCI. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were included in the study. Patient data obtained from our Cardiac Services Database System (Phillips CVIS) were analysed and angiographic images reviewed on our Cardiac Image Database (McKesson Horizon). Mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by an unpaired t test. Categorical variables were compared using the χ 2 test. A p value of Results During the study period, 1875 patients were referred for PPCI of whom 155 (8.3%) had LBBB. Compared with STEMI, patients with LBBB were significantly older, more likely to be female and have prior history of MI and CABG (table 1). Patients with LBBB had similar door-to-balloon (DTB) and call-to-balloon (CTB) times. PCI was performed in 40 (26%) patients with LBBB although an acutely occluded culprit vessel was found in only 19 (12.2%) patients (table 2). Furthermore, 85 (54.8%) patients had non-flow limiting coronary artery disease and of those with significant disease 12 (7.7%) patients required CABG (figure 1). Overall, an acute coronary syndrome (defined as ischaemic chest pain with positive troponin) was confirmed in only 67 (43.2%) of patients presenting with LBBB. 30-day mortality was similar between LBBB and STEMI patients (table 2). However, during a mean follow-up period of 2.1 years, overall mortality was significantly higher in the LBBB group compared to STEMI (HR 2.01, 95% CI 1.26 to 3.20) (figure 2). Conclusions Our study shows that, in contrast to STEMI, only a small proportion of patients presenting with chest pain and LBBB had an acutely occluded coronary artery. Although short-term mortality was similar between the two groups, long-term outcome was significantly worse in patients with LBBB. Further work is needed to identify those patients presenting with LBBB who are most likely to have an acute coronary occlusion, in order to facilitate the appropriate use of emergency coronary angiography and PPCI.

The trandolapril cardiac evaluation (TRACE) investigators reported a male to female ratio of sudden cardiac death (SCD) in coronary disease of 1.4 : 1.1 This confirmed that women with coronary artery disease were at a higher risk of SCD than the Framingham investigators had suggested.2 The low proportion of female subjects undergoing implantable cardioverter-defibrillator (ICD) implantation is well recognised and these data lead us to question whether there could be a sex bias in the referral or prescription of ICDs in patients with coronary artery disease. We analysed the characteristics of 514 ICD implants performed between January 1990 and October 2002. Early ICD recipients were largely implanted for secondary prevention following aborted SCD. Subsequent implant practice evolved in line with the results of large clinical trials (AVID (anti-arrhythmics versus implantable defibrillators) and MADIT-1 (multicenter automated defibrillator implantation trial)). There was no upper age limit for ICD implantation. Demographic information contained in our ICD database was entered prospectively at the time of implant. All subjects underwent coronary angiography. Ejection fraction was estimated by either echocardiography or left ventricular angiography. Patients were reviewed at ICD clinic visits and therapies were documented as appropriate, inappropriate, or electrical storm following review of stored electrograms. Before the advent of generator electrogram storage, this …