P397 PROGNOSTIC VALUE OF CORONARY CALCIUM IN PATIENTS WITH COVID–19 AND SUSPECTED INTERSTITIAL PNEUMONIA: A CASE–CONTROL STUDY

Background

Short–term prognosis of SARS–CoV2 infection is mainly conditioned by the extent and severity of COVID–19 interstitial pneumonia. Coexistence of cardiac disease is however important and independently associated with an adverse outcome. Coronary calcium (CAC), detected at the time of chest computed tomography, can be a useful prognostic tool, as suggested by some cohort studies.

Material and Methods

We performed a retrospective, multi–centre, case–control (1:2) study in 195 COVID–19 patients admitted from 01–03–2020 to 30–04–2020. Cases were consecutive patients died within 30 days or admitted to the Intensive Care Units for invasive ventilation during the hospitalization (primary outcome measure). Controls were age– and sex–matched patients surviving until 30 days without need for invasive ventilation. For each case, we selected two controls, matched by age and sex dividing cases in age strata of 10 years, assuring within each age stratum twice the number of controls with an identical gender proportion. CAC estimation was performed with a with a semi–quantitative score (0 to 30) based on 10 segments and 4 degrees of severity of the calcification. Estimation of interstitial pneumonia, was similarly performed with a semi–quantitative score (from 0 to 20), based on 5 lobes and 5 degrees of severity of interstitial involvement. CT scans were acquired according to a standard protocol for non–cardio–synchronized chest CT, always on a multi–detector scanner with at least 16 layers.

Results

The mean CAC value in cases was significantly higher (p = 0.001) compared to controls: 5,52±1,38 vs 3,28±0,54 (mean value ± 95% CI). The percentage of cases with moderate–severe CAC was significantly higher (p = 0.013) compared to controls (41.5% vs 22.8%, OR 2.27 95% CI 1.20–4.29; primary end–point of the study). In multivariate analysis, independent predictors of outcome were (in descending order): interstitial pneumonia severity score (Wald 8.143, p = 0.004), CC score (Wald 5.569, p = 0.018), and the LDH value on admission (Wald 3.335, p = 0.034).

Conclusions

In our case–control study, the severity and extent of CAC is the main prognostic factor for the occurrence of adverse clinical outcome, beside the severity of interstitial pneumonia. These data suggest that a semi–quantitative estimation of CAC, feasible on any CT detector without the need of dedicated software, is clinically useful for the prognostic assessment of patients with COVID–19 interstitial pneumonia.

[Periprocedural management of anticoagulation therapy and in-hospital outcomes in patients with warfarin indication undergoing percutaneous coronary intervention. Data from the WAR-STENT registry]

BACKGROUND

In patients with an indication for oral anticoagulation (OAC) with warfarin, the management of OAC peri-procedure of percutaneous coronary intervention (PCI) is still not fully defined. To investigate clinical practice and outcomes associated with continuation vs interruption of OAC, with or without bridging with low-molecular-weight heparin (LMWH), we examined the database of the observational, prospective, multicenter Italian WAR-STENT registry.

METHODS

The WAR-STENT registry was conducted in 2008-2010 in 37 Italian centers and included 411 consecutive patients in 157 of whom the peri-procedural international normalized ratio (INR) value was available. In relation to the continuation vs interruption of OAC, patients were divided into group 1 (n = 106) and group 2 (n = 51) respectively, and compared.

RESULTS

The basal characteristics of the two groups were similar. The most frequent indication for OAC was atrial fibrillation and for PCI acute coronary syndromes, respectively. The pre-procedural mean value of INR was significantly different in group 1 vs group 2 (2.3 ± 0.4 vs 1.5 ± 0.2; p <0.001), while the use of antithrombotic drugs did not differ, except for LMWH which, albeit limited to only 14% of cases, was used significantly more frequently in group 2 (14% vs 2%; p=0.006). The radial approach was used significantly more often in group 1 vs group 2 (72% vs 45%; p=0.002). The in-hospital incidence of major bleeding complications was similar in groups 1 and 2 (4% vs 8%; p=0.27), as well as the occurrence of major adverse cardio-cerebrovascular events, including cardiovascular death, non-fatal myocardial infarction, re-revascularization of the treated vessel, stent thrombosis, stroke and venous thromboembolism (6% vs 6%; p=0.95). There was a tendency towards a higher incidence of minor access-site bleeding complications in group 1 patients treated by the femoral route.

CONCLUSIONS

In unselected patients with an indication for OAC with warfarin and undergoing PCI, the continuation vs interruption of OAC (essentially without LMWH bridging) strategies appears similar in terms of efficacy and safety. In consideration of the superior convenience, peri-procedural continuation of OAC should therefore generally be preferred, with the possible exception of patients in whom the femoral approach is required for the procedure.

Impact of the COVID-19 pandemic on coronary invasive procedures at two Italian high-volume referral centers

AIMS

The purpose of this study was to verify the impact on the number and characteristics of coronary invasive procedures for acute coronary syndrome (ACS) of two hub centers with cardiac catheterization facilities, during the first month of lockdown following the COVID-19 pandemic.

MATERIALS AND METHODS

Procedural data of ACS patients admitted between 10 March and 10 April 2020 were compared with those of the same period of 2019.

RESULTS

We observed a 23.4% reduction in ACS admissions during 2020, with a decrease for both ST-elevation myocardial infarction (STEMI) (-5.6%) and non-ST-elevation myocardial infarction (-34.5%), albeit not statistically significant (P = 0.2). During the first 15 days of the examined periods, the reduction in ACS admissions reached 52.5% (-25% for STEMI and -70.3% for non-ST-elevation myocardial infarction, P = 0.04). Among STEMI patients, the rate of those with a time delay from symptoms onset longer than 180 min was significantly higher during the lockdown period (P = 0.01). Radiograph exposure (P = 0.01) was higher in STEMI patients treated in 2020 with a slightly higher amount of contrast medium (P = 0.1) and number of stents implanted (P = 0.1), whereas the number of treated vessels was reduced (P = 0.03). Percutaneous coronary intervention procedural success and in-hospital mortality were not different between the two groups and in STEMI patients (P NS for all).

CONCLUSION

During the early phase, the COVID-19 outbreak was associated with a lower rate of admissions for ACS, with a substantial impact on the time delay presentation of STEMI patients, but apparently without affecting the in-hospital outcomes.

[Impact of the COVID-19 pandemic on admissions for acute coronary syndrome: review of the literature and single-center experience]

During the early phase of the lockdown following the COVID-19 pandemic, an alarm on the impact on cardiology admissions for cardiac causes, particularly in the field of acute coronary syndromes (ACS), has emerged. In order to evaluate this trend, we analyzed the literature data published since the beginning of the COVID-19 pandemic to date, in addition to our intensive cardiac care unit (ICCU) experience. This analysis showed (i) a reduction of the overall ICCU admissions up to 50%; (ii) a 40-50% reduction of ACS admissions, greater for non-ST-elevation myocardial infarction (NSTEMI) than for ST-elevation myocardial infarction (STEMI); (iii) a reduction greater than 50% of coronary angiography and percutaneous coronary angioplasty; (iv) a higher time delay of STEMI; and (v) a higher number of ICCU admissions for non-primarily cardiac problems. In conclusion, the lockdown imposed due to the spread of COVID-19 infection has led to a change in the number and type of cardiology admissions. It seems therefore necessary that patients, especially for time-dependent diseases such as ACS, continue to refer to hospital care; that contemporary standard of care for acute cardiac disease should be guaranteed, and that intensivist cardiologists acquire specific skills for the treatment of patients with clinical conditions normally treated by other specialists.

Difficulties in conducting pure academic research, obstacles in data collection and quality of informations: The example of the INTERCEPTOR study

PURPOSE/OBJECTIVE

On September 2009: We started a randomized multicenter phase III study comparing chemoradiation (CRT) (Aldestein RTOG regimen) versus induction chemotherapy followed by Cetuximab radiation (IBRT). The main study's aim was comparison of overall survival but no formal analyses have been made between the two arms because of low accrual and high amount of missing data. The goal of this paper is to identify the reasons of difference in accrual and quality of data among participating centers.

MATERIAL/METHODS

Statistic: We correlated data collection quality with relevance of the centers, accrual and number of scientific papers (both specific on HNC and other topics) of each PI. We created an HNC publishing score dividing the number of HNC specific papers for the overall number of published papers.

RESULTS

We observed a strong difference in the accrual of pts as well as in the quality of data among the participating centers. The accrual was independent from the quality of data since some centers with low accrual produced high quality data with an excellent follow up. We found a correlation among both number of published papers of each PI and HNC publishing score with the quality of data.

CONCLUSION

The study demonstrated that expertise in HNC is important not only to ensure a better outcomes but also to provide high quality data in phase III trials.

A randomized, phase 2 study of cetuximab plus cisplatin with or without paclitaxel for the first-line treatment of patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

B490 (EudraCT# 2011-002564-24) is a randomized, phase 2b, noninferiority study investigating the efficacy and safety of first-line cetuximab plus cisplatin with/without paclitaxel (CetCis versus CetCisPac) in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN).

PATIENTS AND METHODS

Eligible patients had confirmed R/M SCCHN (oral cavity/oropharynx/larynx/hypopharynx/paranasal sinus) and no prior therapy for R/M disease. Cetuximab was administered on day 1 (2-h infusion, 400 mg/m2), then weekly (1-h infusions, 250 mg/m2). Cisplatin was given as a 1-h infusion (CetCis arm: 100 mg/m2; CetCisPac arm: 75 mg/m2) on day 1 of each cycle for a maximum of six cycles. Paclitaxel was administered as a 3-h infusion (175 mg/m2) on day 1 of each cycle. After six cycles, maintenance cetuximab was administered until disease progression or unacceptable toxicity. The primary end point was progression-free survival (PFS). We assumed a noninferiority margin of 1.40 as compatible with efficacy.

RESULTS

A total of 201 patients were randomized 1 : 1 to each regimen; 191 were assessable. PFS with CetCis (median, 6 months) was noninferior to PFS with CetCisPac (median, 7 months) [HR for CetCis versus CetCisPac 0.99; 95% CI: 0.72-1.36, P = 0.906; margin of noninferiority (90% CI of 1.4) not reached]. Median overall survival was 13 versus 11 months (HR = 0.77; 95% CI: 0.53-1.11, P = 0.117). The overall response rates were 41.8% versus 51.7%, respectively (OR = 0.69; 95% CI: 0.38-1.20, P = 0.181). Grade ≥3 adverse event rates were 76% and 73% for CetCis versus CetCisPac, respectively, while grade 4 toxicities were lower in the two-drug versus three-drug arm (14% versus 33%, P = 0.015). No toxic death or sepsis were reported and cardiac events were negligible (1%).

CONCLUSION

The two-drug CetCis regimen proved to be noninferior in PFS to a three-drug combination with CetCisPac. The median OS of both regimens is comparable with that observed in EXTREME, while the life-threatening toxicity rate appeared reduced.

CLINICAL TRIAL NUMBER

EudraCT# 2011-002564-24.

Mercury Vapour Long-Lasting Exposure: Lymphocyte Muscarinic Receptors as Neurochemical Markers of Accidental Intoxication

Introduction. Chronic poisoning may result in home setting after mercury (Hg) vapours inhalation from damaged devices. We report a chronic, nonoccupational Hg poisoning due to 10-year indoor exposure to mercury spillage. Case Report. A 72-year-old man with polyneuropathy of suspected toxic origin. At hospitalization, toxicological clinical evaluations confirmed the altered neurological picture documented across the last decade. Periodic blood and urine Hg levels (BHg, UHg) monitoring were performed from admission (t0), until 1 year later (t2), paralleled by blood neurochemical markers assessment, that is, lymphocytes muscarinic receptors (l-MRs). At t0: BHg and UHg were 27 and 1.4 microg/L, respectively (normal values: BHg 1-4.5; UHg 0.1-4.5), associated with l-MRs increase, 185.82 femtomoL/million lymphocytes (normal range: 8.0-16.0). At t1 (two days after DMSA-mobilization test), BHg weak reduction, paralleled by UHg 3.7-fold increase, was measured together with further l-MRs enhancement (205.43 femtomoL/million lymphocytes). At t2 (eight months after two cycles of DMSA chelating therapy ending), gradual improving of clinical manifestations was accompanied by progressive decrease of BHg and UHg (4.0 and 2.8 microg/L, resp.) and peripheral l-MRs neurochemical marker (24.89 femtomoL/million lymphocytes). Conclusion. l-MRs modulatory effect supports their use as peripheral neurochemical marker in Hg poisoning diagnosis and chelation therapy monitoring.

Left main percutaneous coronary intervention in ACS or stable coronary artery disease: acute and long-term results

BACKGROUND

The aim of this study was to assess in-hospital and long-term results of the novo unprotected left main (UPLM) percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) or stable coronary artery disease (CAD), in an unselected population admitted to a single high- volume cath-lab without on-site cardiac surgery.

METHODS

From 2008 to 2011, among 317 PCI performed in patients with the novo UPLM stenosis, 49 patients presented ST-elevation myocardial infarction (STEMI), 152 non ST-elevation MI/unstable angina (NSTEMI/UA), 116 stable CAD.

RESULTS

In-hospital mortality was 20% in STEMI, 5.3% in NSTEMI/UA and 1.7% in stable CAD patients (P<0.001). Two-year total mortality was 24.5%, 25.6% and 6% in the 3 groups, and cardiac death was 20%, 13.8% and 3.4% (P=0.002). Left main target lesion revascularization (TLR) was similar in the 3 groups, as the clinically-driven TLR (10% vs. 11% vs. 7.7%, P=0.642), with neither definite nor probable stent thrombosis. Multivariate analysis showed the following independent predictors of 2-year mortality: bare-metal stent use (OR 4.53, P<0.001), Syntax Score >32 (OR 3.53, P=0.012), ACS as the indication (OR 3.24, P=0.012), peripheral artery disease (OR 2.20, P=0.042), and age >75 years (OR 2.09, P=0.05).

CONCLUSIONS

Our experience showed acceptable results of UPLM PCI in STEMI patients, where short-term prognosis was related to hemodynamic conditions, good results in NSTEMI/UA patients where mortality increased in the follow-up due to comorbidities, and very good results in patients with stable CAD.

Percutaneous intervention of de novo unprotected left main stenosis in patients with acute coronary syndrome or stable coronary artery disease: in-hospital and long-term results

OBJECTIVES

to assess in-hospital and long-term results of the novo unprotected left main (UPLM) percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) or stable coronary artery disease (CAD), in an unselected population admitted to a single high- volume cathlab without on-site cardiac surgery.

METHODS

from 2008 to 2011, among 317 PCI performed in patients with the novo UPLM stenosis, 49 patients presented ST-elevation myocardial infarction (STEMI), 152 non ST-elevation MI/unstable angina (NSTEMI/UA), 116 stable CAD.

RESULTS

in-hospital mortality was 20% in STEMI, 5.3% in NSTEMI/UA and 1.7% in stable CAD patients (p<0.001). Two-year total mortality was 24.5%, 25.6% and 6% in the 3 groups, and cardiac death was 20%, 13.8% and 3.4% (p=0.002). Left main target lesion revascularization (TLR) was similar in the 3 groups, as the clinically- driven TLR (10% vs 11% vs 7.7% , p= 0.642), with neither definite nor probable stent thrombosis. Multivariate analysis showed the following independent predictors of 2-year mortality: bare-metal stent use (OR 4.53, p<0.001), Syntax score >32 (OR 3.53, p=0.012), ACS as the indication (OR 3.24, p=0.012), peripheral artery disease (OR 2.20, p=0.042), and age > 75 years (OR 2.09, p=0.05).

CONCLUSIONS

our experience showed acceptable results of UPLM PCI in STEMI patients, where short-term prognosis was related to hemodynamic conditions, good results in NSTEMI/UA patients where mortality increased in the follow-up due to comorbidities, and very good results in patients with stable CAD.

Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.

Neurotoxicity of European viperids in Italy: Pavia Poison Control Centre case series 2001-2011

CONTEXT

Some clinical aspects about neurotoxicity after snakebites by European viper species remain to be elucidated.

OBJECTIVE

This observational case series aims to analyze neurological manifestations due to viper envenomation in Italy in order to describe the characteristic of neurotoxicity and to evaluate the clinical response to the antidotic treatment, the outcome, and the influence of individual variability in determining the appearance of neurotoxic effects.

MATERIALS AND METHODS

All cases of snakebite referred to Pavia Poison Centre (PPC) presenting peripheral neurotoxic effects from 2001 to 2011 were included. Cases were assessed for time from bite to PPC evaluation, Grade Severity Score (GSS), onset/duration of clinical manifestations, severity/time course of local, non-neurological and neurological effects, and antidotic treatment.

RESULTS

Twenty-four were included (age, 3-75 years) and represented on average of 2.2 cases/year (about 5% of total envenomed patients). The mean interval time of PPC evaluation from snakebite was 10.80 ± 19.93 hours. GSS at ED-admission was 0 (1 case), 1 (10 cases), and 2 (13 cases). All patients showed local signs: 41.6%, minor; 58.4%, extensive swelling and necrosis. The main systemic non-neurological effects were as follows: vomiting (86.7%), diarrhea (66.7%), abdominal discomfort (53.3%), and hypotension (20%). Neurotoxic effects were accommodation troubles and diplopia (100%), ptosis (91.7%), ophtalmoplegia (58.3%), dysphagia (20.8%), drowsiness (16.6%), cranial muscle weakness (12.5%), and dyspnea (4.2%). Neurotoxicity was the unique systemic manifestation in 9 cases; in 4 cases, they were associated with only mild local swelling. In 10 patients the onset of neurotoxic effects followed the resolution of systemic non-neurological effects. Antidote was intravenously administered in 19 (79.2%) patients. The mean duration of manifestations in untreated versus treated groups was 53.5 ± 62.91 versus 41.75 ± 21.18 hours (p = 0.68, local effects) and 9.77 ± 3.29 versus 8.25 ± 12.23 hours (p = 0.1, systemic non-neurological effects) and 43.4 ± 14.69 versus 26.58 ± 20.62 hours (p = 0.03, neurotoxic effects).

CONCLUSIONS

Neurotoxicity may appear late (11 hours after the bite in 58.3% of cases), in contrast with the data reported in medical literature. Neurotoxic effects have been reversible in all cases and may be the unique systemic manifestation of envenomation. Neurotoxic effects are shorter in treated group. The antidotic treatment of patients considered as GSS 2 only for neurotoxic effects (with mild local effects) may not be necessary. Variable factors such as different amount of venom injected, concentration of PLA2 component, and individual susceptibility may explain the less percentage of patients presenting neurotoxic effects.

Percutaneous rheolytic thrombectomy with the AngioJet System for the treatment of intermediate-risk acute pulmonary embolism: a case report and an appraisal of contemporary indications and technique

Percutaneous mechanical thrombectomy (PMT) for treatment of clinically significant pulmonary embolism (PE) has been shown to be technically feasible and effective, aiming at thrombus resolution without increase in major bleeding. Despite its success, use of PMT in clinical practise has not become widespread, because it is challenging. Among several devices proposed, AngioJet rheolytic thrombectomy (ART) appears as the most effective and easy-to-use. We present the case of a 69-year-old woman who developed acute intermediate-risk PE, with right ventricular dysfunction and major myocardial necrosis, who was successfully treated by ART. The peculiarities of the case, toghether with the principles, tecnique and tips and tricks of ART, its effectiveness and potential complications are discussed.

Biosensors for monitoring the isothermal breakdown kinetics of peanut oil heated at 180°C. Comparison with results obtained for extra virgin olive oil

The present research was devoted to studying the kinetics of the artificial rancidification of peanut oil (PO) when a sample of this oil was isothermally heated at 180°C in an air stream. The formation of radical species due to heating was evaluated using a radical index whose value was determined using a biosensor method based on a superoxide dismutase (SOD), while the increasing toxicity was monitored using a suitable toxicity measuring probe based on the Clark electrode and immobilized yeast cells. An extra virgin olive oil was isothermally rancidified under the same experimental conditions and the corresponding data were used for the purpose of comparison. Both the so-called "model-fitting" and the classical kinetic methods were applied to the isothermal process biosensor data in order to obtain the kinetic constant rate value at 180°C.

Acute myocardial infarction caused by multivessel spontaneous coronary artery dissection in a postpartum woman

Spontaneous coronary artery dissection is a rare cause of acute ischemic coronary events and sudden cardiac death. It usually occurs in young women not experiencing traditional risk factors for coronary artery disease during pregnancy or postpartum period. The pathophysiology of spontaneous arterial dissection remains uncertain and the management may be challenging. Herein, we report a case of a 41-year woman with no apparent cardiovascular risk factors, who underwent a successfull in vitro fertilization and embryo transfer with a subsequent at term cesarean section of a twin pregnancy. Six days after delivery, she presented with anterior ST-segment elevation myocardial infarction. Coronary angiography revealed dissection of all three coronary arteries with involvement of left main stem, which was successfully treated with percutaneous coronary intervention and drug-eluting stents implantation. The peculiarities of the case, toghether with the treatment strategy and the clinical and angiographic six-month follow-up are discussed.

Coronary stenting for ST-elevation myocardial infarction vs. other indications in patients on oral anticoagulation: any difference in in-hospital management and outcome?

AIM

The aim of this paper was to compare the in-hospital management and outcome of patients on oral anticoagulation (OAC) undergoing coronary artery stenting (PCI-S) for ST-elevation myocardial infarction (STEMI) vs. other indications.

METHODS

One hundred and sixteen patients on OAC at the time of PCI-S who were prospectively enrolled in a multi-center, observational registry, were evaluated. Patients were segregated according to whether PCI-S was performed for STEMI (group 1) or other indications, such as non ST-elevation acute coronary syndromes, stable angina, silent ischemia, etc. (group 2), and the pharmacological and procedural management, as well as the in-hospital outcome, were compared.

RESULTS

No significant differences were observed in vascular access site, sheath size and type of stent implanted, nor was significantly different the use of glycoprotein IIb/IIIa inhibitors, and the use and dose of intravenous unfractionated heparin. Although not statistically different, the in-hospital occurrence of death (3.7% vs. 1.1%; OR 3.3; 95% confidence intervals [CI] 0.2-56.0), stent thrombosis (3.7% vs. 1.1%; OR 3.3; 95% CI 0.2-56.0) and major bleeding (7.4% vs. 2.2%; OR 3.4; 95% CI 0.4-25.9) was consistently about 3-fold higher in group 1.

CONCLUSION

The in-hospital pharmacological and procedural management of OAC patients undergoing PCI-S for STEMI vs. other indications appears not different. Although not significantly different however, the in-hospital occurrence of major bleeding, as well as of death and stent thrombosis, appears substantially higher in patients treated for STEMI, warranting therefore further larger, prospective studies.

Incidence and management of restenosis after treatment of unprotected left main disease with drug-eluting stents 70 restenotic cases from a cohort of 718 patients: FAILS (Failure in Left Main Study)

OBJECTIVES

This study sought to retrospectively appraise the incidence and management of restenosis after drug-eluting stent (DES) implantation for unprotected left main (ULM) disease.

BACKGROUND

The promising role of DES for ULM has been reported. However, no detailed data are available on subsequent restenosis.

METHODS

From the total sample of patients with ULM treated with DES, we identified those presenting with angiographic ULM restenosis. The primary end point was the long-term rate of major adverse cardiac events (MACE), that is, death, myocardial infarction (MI), or target lesion revascularization (TLR). We also adjudicated stent thrombosis according to the Academic Research Consortium.

RESULTS

Post-DES restenosis in ULM occurred in 70 of 718 patients (9.7%). Of these, 59 (84.3%) were treated percutaneously (34 [48.6%] with additional DES, 22 [31.4%] with standard or cutting balloons, 2 [2.9%] with rotational atherectomy, and 1 [1.4%] with a bare-metal stent), whereas 7 (10%) patients underwent bypass surgery and 4 (5.7%) were treated medically. In-hospital MACE included no periprocedural MI and only 1 (1.4%) death. After 27.2 +/- 15.4 months, MACE occurred cumulatively in 18 (25.7%) patients, with death in 4 (5.7%), MI in 2 (2.9%), and TLR in 15 (21.4%). Patients treated with medical, interventional, and surgical therapy had the following MACE rates, respectively: 50%, 25.4%, and 14.3%. Definite, probable, and possible stent thrombosis occurred in 0 (0%), 1 (1.4%), and 1 (1.4%) patient, respectively.

CONCLUSIONS

DES restenosis in the ULM artery can be managed in most cases with a minimally invasive approach, achieving favorable early and late results.

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism

OBJECTIVES

To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE).

BACKGROUND

The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate.

METHODS

We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index >or= 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all-cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT.

RESULTS

Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in-hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long-term follow-up (35.5 +/- 21.7 months) except three who expired due to cancer and acute myocardial infarction.

CONCLUSIONS

In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed.