Search

Objectives: The objective of this study is to analyze the clinical outcomes and treatment strategies of coronary wire perforations (WPs) in the era of heparin use compared to the era of bivalirudin use. Background: Percutaneous coronary intervention (PCI) advances have led to progressive decrease in complications. Therefore, complex coronary lesions such as chronic total occlusions and calcified lesions are being attempted with stiff/hydrophilic wires with resultant higher incidence of coronary WP. Methods: A single-center retrospective data analysis of coronary perforation (CP) for the last 4 years with review of coronary angiograms was done and WPs were identified. A simple classification scheme based on angiographic appearance of CP was made: Type I (“myocardial stain,” with no frank dye extravasation) and type II (“myocardial fan,” with dye extravasation to pericardial cavity or cardiac chambers). Results: Overall incidence of CP was 0.49% (82/16,859). Of these 50 (61%) were caused by WP; 30 occurred with heparin use (Group A) and 20 with bivalirudin use (Group B). WPs always occurred in type B2/C lesions (100%) and commonly with use of hydrophilic guidewires (70%). Major adverse cardiac events and cardiac tamponade were frequent in group A (50%) and none in group B (0%); P < 0.01. All WP in group B responded to stopping anticoagulation and prolonged balloon inflation, while group A type II perforations frequently required additional interventions (pericardiocentesis, coil embolization). Conclusions: Cardiac tamponade and major adverse cardiac events from WPs were less frequent with bivalirudin use compared to heparin use. This beneficial effect of bivalirudin may be explained on the basis of its short half-life and reversible thrombin inhibition property. Therefore, bivalirudin may offer a safer alternative for anticoagulation in complex PCI. © 2009 Wiley-Liss, Inc.

The present study was done to analyze if glycoprotein IIb/IIIa inhibitors (GPI) bolus-only will reduce vascular/bleeding complications and cost with similar major adverse cardiac events (MACE) when compared with GPI bolus + infusion. Evidence-based therapy of GPI inhibitors during percutaneous coronary intervention (PCI) incorporates intravenous bolus followed by 12 to 18 hours of infusion. However, GPI bolus + infusion may increase vascular/bleeding complications and may not reduce MACE when compared with GPI bolus-only.From January 1, 2003, to December 31, 2004, 2,629 consecutive patients received GPI during PCI at a single center. Of these, 1,064 patients received GPI bolus + infusion in 2003 and were compared with 1,565 patients that received GPI bolus-only in 2004. Baseline characteristics were similar in both groups.Patients receiving GPI bolus-only had reduced vascular/bleeding complications when compared with bolus + infusion (4.9% vs 7%, P.05, odds ratio 0.62, 95% confidence interval 0.45-0.89). Furthermore, ischemic complications were similar in both groups, including periprocedural creatine kinase-MB enzyme release (12.8% vs 15.3%, P = NS), MACE at 30 days (3.2% vs 3%, P = NS), and death and myocardial infarction at 1 year (7.1% vs 7.8%, P = NS). In addition, GPI bolus-only reduced cost in US dollars ($323 vs $706, P.001) and increased ambulatory PCI (13.1% vs 3.2%, P.01), with reduced length of stay (1.1 vs 1.6 days, P.01), when compared with GPI bolus + infusion.Glycoprotein inhibitor bolus-only reduces vascular/bleeding complications with similar MACE and reduced cost when compared with GPI bolus + infusion. In addition, GPI bolus-only improved ambulatory PCI and reduced length of stay. These results are consistent with a safer and cost-effective strategy for bolus-only when GPI therapy is considered during PCI.

Percutaneous coronary interventions (PCI) of bifurcation lesions using simultaneous kissing stents (SKS) technique have shown to have good short-term and mid-term results. Limited data are available regarding long-term outcome with this strategy. Methods: We analyzed the long-term outcome of 300 consecutive patients treated with drug-eluting stenting using SKS technique for 305 de novo bifurcation lesions. Cypher stents were used in 265 lesions and Taxus stents were used in 40 lesions, from May 2003 to September 2006 at Mount Sinai Hospital. Clinical follow-up was obtained in 98.6%. All pts were given Aspirin and Plavix 75 mg daily for one year and GP IIb/IIIa inhibitors were used in 72% of cases. Results: Overall procedural success was 99% for main vessel (MV) and 98% for side-branch (SB), with one case of intra-procedural stent thrombosis of left main bifurcation. 30-day MACE (MI, death, repeat target vascularization or stent thrombosis) occurred in 5% of cases. Long-term follow-up results at a mean of 14 ± 5 months are shown in the Table . Overall incidence of stent thrombosis was 1.7% (1.5% for Cypher vs. 2.5% for Taxus). Multivariate predictors of TVR were left main (LM) intervention (odds ratio [OR] 4.97; 95% confidence interval [CI] 2.00 to 12.37, p = 0.01) and diabetes mellitus (OR 4.21; 95% CI 1.15 to 18.56, p = 0.04) and of follow-up MACE were LM intervention (OR 3.79; 95% CI 1.76 to 8.14, p = 0.01) and acute MI (OR 3.24; 95% CI 0.95 to 15.32, p = 0.02). Conclusions: The SKS technique for bifurcation lesions using Cypher or Taxus DES is associated with long-term favorable outcomes in this complex, high-risk PCI group. Delayed stent thrombosis with dual antiplatelet therapy remains within acceptable limits. Further work is needed to lower the event rates in some specific subgroups such as LM lesions and AMI settings (perhaps by IVUS guidance and Plavix 75 mg twice a day).

Primary stenting during acute myocardial infarction (MI) is often complicated by slow-flow/no-reflow due to distal embolization of intracoronary thrombus. The AngioJet thrombectomy catheter has been utilized in this setting in order to limit distal embolization and improve flow. The effect of AngioJet during primary stenting in acute MI with high-grade thrombus (greater than or equal to grade 3, as per thrombolysis in MI [TIMI] classification) is not known.We analyzed 95 consecutive acute MI patients with thrombus gradeor = 3 who underwent primary stenting with AngioJet (n = 52) and without AngioJet (n = 43) for epicardial and microvascular flow, and followed for 30-day major adverse cardiac events (MACE) and 1-year survival. Baseline characteristics and in-hospital events were obtained from the interventional database. Two independent operators analyzed pre- and post-procedure TIMI flow rates, corrected TIMI frame count (CTFC) and TIMI myocardial perfusion grade (TMPG).Baseline clinical and angiographic characteristics were comparable between the two groups. AngioJet use was associated with better TIMI flow, TMP grade, CTFC and a trend towards lower 30-day and 1-year MACE. Use of AngioJet thrombectomy prior to stenting of acute MI patients with high-grade thrombus improves epicardial and microvascular flow, with a trend toward better short- and long-term outcome.