Complete Percutaneous Revascularization in Patients Aged ≥85 Years With Acute Coronary Syndrome and Multivessel Coronary Artery Disease

Multivessel coronary disease is frequent in older patients who underwent coronary angiography for acute coronary syndrome. Whether a complete revascularization or a culprit-only approach is preferable in these patients is still debated. We included consecutive patients aged ≥85 years, presenting with acute coronary syndrome and showing multivessel coronary disease at coronary angiography. Patients were grouped according to complete (residual SYNTAX score [RSS] 0 to 8) or incomplete (RSS >8) revascularization. Primary end point was the rate of major adverse cardiovascular events (MACEs, the composite of cardiovascular death, re-myocardial infarction [re-MI], clinically driven percutaneous coronary intervention, and rehospitalization because of cardiac disease) at 2 years follow-up. A total of 166 patients met the criteria for enrollment; 108 patients had a final RSS 0 to 8 (complete revascularization) and 58 patients had a final RSS >8 (incomplete revascularization). The rate of MACE was reduced in patients who underwent complete revascularization (35.2% vs 51.7%, p = 0.039, adjusted hazard ratio 0.60, 95% confidence interval 0.37 to 0.98, p = 0.04), a difference mainly driven by a reduction in re-MI (8.3% vs 19.0%, p = 0.045), clinically driven percutaneous coronary intervention (2.8% vs 19.0%, p <0.001), and rehospitalization for cardiac disease (9.3% vs 24.1%, p = 0.009). Other independent predictors of MACE were active malignancy, previous MI, left ventricle ejection fraction <35% (increasing risk of events), and radial access (reducing risk of events). In conclusion, in patients aged ≥85 years, a complete revascularization is associated with a better prognosis, especially in terms of nonfatal events.

[Management of acute coronary syndromes in elderly patients: a single-center experience]

Demographic studies show an ever increasing number of subjects >65 years among the Italian population. In particular, subjects aged >75 years represent nowadays 9% of the Italian population and are expected to exceed 14% by 2030. In the district of Crema (Italy), subjects aged >75 years are 16 000, and are expected to reach 25 000 by 2030. This phenomenon will result in an increasing number of elderly patients with acute coronary syndromes (ACS) admitted to our hospital. It is therefore necessary to define appropriate guidelines for clinical management of this subset of patients, in order to pursue a reduction in mortality rates and rehospitalizations, while maintaining an acceptable quality of life. These strategies are not adequately supported by international guidelines or randomized studies, where advanced age often represents an exclusion criterion. In our Cardiology Unit, hemodynamic evaluation is performed in all patients >75 years presenting with ST-elevation myocardial infarction (STEMI), ACS, positive troponin I, recurrent episodes of heart failure associated with clinical and instrumental suspicion of ischemia, or in survivors of cardiac arrest without neurological deficit. In all patients, presence of comorbidities is also evaluated, in particular renal insufficiency, disabling cerebrovascular disease, and residual quality of life. From February 2011 to February 2012, 974 coronary angiographies and 692 coronary angioplasties (PTCA) were performed. Of these, 194 procedures were performed in patients ≥75 years, the remaining in younger patients. The reason for hospitalization was ACS in 71% of elderly patients versus 53% in younger patients. In elderly patients, drug-eluting stents were used in 30% of the procedures. PTCA was successful in 98% of cases. Main complications included major bleeding (0.8%), access site-related bleeding (all femoral) (2%), and arterial rupture (n = 1). From a technical viewpoint, the radial access was predominantly used (78%), single plain old balloon angioplasty was performed in 12% of the procedures, with tirofiban administration in 42% of cases. Periprocedural and in-hospital mortality was 5%, mainly occurring in patients with STEMI and/or diffuse coronary artery disease. During follow-up, 80% of patients achieved a fairly good quality of life; 15% of patients required rehospitalization for cardiovascular reasons. In conclusion, patient's age should not be regarded as the main key factor for decision-making when evaluating different clinical approaches to patients with ACS.

[Cryoablation: patient selection and current results]

During the last years, cyoablation of atrial fibrillation has become a widely used method for pulmonary vein isolation. This evolution in the use of cryoenergy has been largely justified by the reduction in complications that occurs with radiofrequency energy (pulmonary vein stenosis and atrial-esophageal fistula), in the use of three-dimensional navigation technology, and hence procedural costs. The purpose of this paper is to evaluate the results of this new technology and its safety in terms of its risk-to-benefit profile.

[Coronary angioplasty of anomalous coronary arteries]

BACKGROUND

The aim of this study was to evaluate the incidence of coronary artery anomalies in a homogeneous population undergoing coronary angiography, and to assess acute and follow-up results of coronary angioplasty (PTCA).

METHODS

From September 2001 to May 2010, 23 complex coronary artery anomalies were observed among 6300 patients undergoing coronary angiography (0.36%) at our cath lab. Mean age of the study population (20 males, 3 females) was 61.8 years (range 35-79 years). Seventeen patients presented with acute coronary syndrome associated with severe coronary stenosis, and 6 patients showed angina and ventricular arrhythmias associated with inducible ischemia on stress testing and no coronary artery lesions. PTCA was performed in 16 patients, 9 of whom with an anomalous origin of the coronary artery.

RESULTS

The most frequent coronary artery anomaly was the anomalous origin of the right coronary artery from the left coronary cusp, running between the aorta and the pulmonary artery (n = 10, 8 males, 2 females; PTCA of the anomalous coronary artery performed in 4 cases). Eight patients showed an anomalous origin of the circumflex artery arising from the right coronary artery with a retroaortic course (PTCA of the anomalous coronary artery performed in 4 cases), and 2 patients (1 male, 1 female) an anomalous origin of the left main coronary artery from the right coronary cusp with a septal course. The remaining 3 patients showed an isolated anomalous origin of the left coronary artery from the right coronary artery with interarterial course, the left anterior descending artery from the right coronary artery, and the left anterior descending artery from the right coronary cusp, respectively.

CONCLUSIONS

PTCA proved to be effective in the treatment of coronary artery anomalies showing no procedure-related complications and stable results over time. The high number of coronary artery anomalies in our study patients may help estimating the actual incidence of these anomalies in the Italian population by providing a rationale for implementing a national registry.

[24-hour primary angioplasty service for acute myocardial infarction at the Crema Hospital: considerations after one year of experience]

The aim of this contribution is to draw considerations on the first year of activity of a cath lab on call 24/24 h for primary coronary angioplasty (PTCA) (April 2007-April 2008) of a small hospital without surgical backup. We performed 152 primary PTCA in 156 patients presenting to the emergency room with ST-elevation myocardial infarction. The mean time from arrival to the emergency room to the insertion of the arterial introducer was 48 min. Patient management included a 12-lead ECG and family history, the telephone call to the hospital cardiologist and then to the cath lab operator and nurse. Procedural success was obtained in 97% of cases. Mortality was 6%. Other complications occurred in 4% of patients. The no-reflow phenomenon occurred in 4% of patients. We used 1.9 stents/patient. Direct stenting was performed in 43% of cases. In 14% of lesions, the procedure was concluded with only balloon angioplasty. The radial access was used in 15% of patients, whereas the femoral access was used in the remainder. Drug-eluting stents were implanted in 1% only of patients with acute myocardial infarction. Glycoprotein IIb/IIIa inhibitors and clopidogrel were extensively used prior to the procedure. Our data, although obtained in a smaller population sample and referring to a relatively short period of time, are similar to those of the American registry on PTCA. In conclusion, the results obtained in our center with the invasive management of acute myocardial infarction appear consistent with those of other centers and encourage us to continue along our chosen path.

[Outsourced service management of the catheterization laboratory in the cardiology department: lights and shadows]

BACKGROUND

The aim of this study was to compare the economic impact and results achieved by recourse to outsourced management of the procedures carried out in the electrophysiology and catheterization laboratory of the Department of Cardiology of the Crema Hospital with the in-house setting up and operation of the same activities.

METHODS

The comparison between the two possible options, "make" or "buy in", was made using the methodology of advanced direct costing, which provides for the allocation of only direct fixed and variable costs to clinical procedures, the subject of calculation. In addition to the financial evaluation, the quality variables showing the advantages and limitations of outsourcing in terms of organizational improvements, streamlining of the organizational structure, operational efficiency and improvement of the quality of service, were examined.

RESULTS

The financial evaluation from 2002 to 2006 came out in favor of "make" as opposed to "buy in". Income derived from diagnosis-related-group payments for the more than 4000 procedures carried out was Euro26.239.034,96. On the basis of the economical evaluation the second contribution margin was slightly inferior with the "buy in" than with the "make" hypothesis. Specifically, it is Euro16.397.669,96 in the "buy in" and Euro16.753.579,16 in the "make" hypothesis, with a difference of Euro355.909,20 (-2%).

CONCLUSIONS

The economic advantage lies with the "make" alternative compared with "buy in", nevertheless, outsourcing offers greater operational efficiency, better cost control, setting up of the laboratory within a very short time, simplified administration (single point of contact) and an opportunity to concentrate on core business. However, there are limitations due to greater dependence on the supplier, not all the equipment provided for under the contract was used, and loss of management know-how in non-core business areas.

Right coronary artery aneurysm: percutaneous treatment with graft-coated stent during the acute phase of myocardial infarction

We report a case of acute myocardial infarction due to acute thrombosis of the right coronary artery just before a large atherosclerotic aneurysm. The patient was treated with primary percutaneous coronary angioplasty (PCA) and deployment of graft-coated stent with optimal final result. Patients with atherosclerotic coronary aneurysms usually show the same cardiovascular risk factors and the same clinical presentation of patients with atherosclerotic obstructive coronary artery disease, but with an increased risk of endovascular thrombosis and consequently more frequent episodes of distal coronary embolism. Furthermore, they may develop other specific complications, such as rapid aneurysm enlargement and rupture leading to cardiac tamponade. In conclusion, our report shows that percutaneous approach to coronary aneurysms with exclusion of aneurismal lumen by placement of graft-coated stent is a feasible and safety procedure even during the acute phase of myocardial infarction, and it may probably reduce the risk of subsequent distal embolization, improving myocardial perfusion.

Progressive decrease of outflow gradient and septum thickness after percutaneous alcoholization of the interventricular septum in hypertrophic obstructive cardiomyopathy

BACKGROUND

The aim of this study was to evaluate the immediate- and mid-term results of percutaneous transluminal septal myocardial ablation (PTSMA) of the interventricular septum performed in 15 consecutive patients with hypertrophic obstructive cardiomyopathy between 1996 and 1999.

METHODS

Prior to intervention, all patients (7 males, 8 females, mean age 62 +/- 11 years) complained of severe dyspnea (NYHA functional class III-IV) despite medical treatment with beta-blockers and/or verapamil. Family history of hypertrophic cardiomyopathy was present in 2 cases. Dehydrated alcohol (4.8 +/- 1.5 ml/pt) was selectively infused into the first septal perforator artery through over-the-wire balloon catheters. In 5 patients a second or a third septal branch was treated because the intraventricular gradient persisted above 50 mmHg after the initial alcohol infusion.

RESULTS

Alcohol infusion induced an average peak creatine phosphokinase level of 1,524 +/- 427 IU/l. No iterating ventricular arrhythmias occurred during the procedure or in the 2-3 days of continuous ECG monitoring after the procedure. Two patients (13%) developed a complete atrioventricular block after the procedure, requiring permanent double-chamber pacing. Electrocardiographic changes included a > 2 mm ST segment elevation and transient right bundle branch block or left anterior/left posterior hemiblock in all patients. Peak basal intraventricular gradient decreased from 80 +/- 27 to 24 +/- 27 mmHg (p < 0.01) during cardiac catheterization and from 81 +/- 27 to 35 +/- 25 mmHg (p < 0.01) at the echocardiographic control performed during the hospital stay. At follow-up (mean 5.1 +/- 3.6 months), all patients were in NYHA functional class I or II. Repeat echocardiography showed a further significant decrease in intraventricular gradient to 25 +/- 26 mmHg (p < 0.01) and a progressive decrease in intraventricular septum thickness (25 +/- 5 mm before treatment, 21 +/- 6 mm before hospital discharge, 17 +/- 3 mm at follow-up, p < 0.01).

CONCLUSIONS

PTSMA of the intraventricular septum effectively relieves symptoms in selected patients with hypertrophic obstructive cardiomyopathy. The immediate decrease in intraventricular gradient is followed by a further decline at follow-up with a progressive reduction in the intraventricular septum thickness.