Ultra-minimum contrast percutaneous coronary intervention for a patient with complex coronary artery disease and end-stage diabetic nephropathy

A pivotal trial indicated that an initial invasive strategy did not improve the clinical outcomes in patients with moderate or severe ischemic heart disease and advanced chronic kidney disease (CKD) as compared with an initial conservative strategy. It is well known that contrast-induced nephropathy (CIN) is associated with worse prognosis after percutaneous coronary intervention (PCI). Minimum contrast PCI may lower the risk of CIN and improve the clinical outcomes of ischemic heart disease and advanced CKD. Here we report a case involving a 46-year-old woman with ischemic cardiomyopathy who was scheduled to start hemodialysis for end-stage diabetic nephropathy but exhibited improved renal function in accordance with the left ventricular function after PCI with an extremely low contrast dose. Accordingly, dialysis was not performed, and the patient did not require it for >2 years after coronary revascularization. The present case supports aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has complex coronary lesions and end-stage CKD. <Learning objective: It is important to treat with aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has end-stage chronic kidney disease (CKD). The technique of catheterization with minimum contrast is required for a special patient group. Coronary revascularization with an extremely small amount of contrast medium could improve renal function in patients with end-stage CKD and severely ischemic cardiomyopathy.>.

Contemporary prevalence, trends, and outcomes of coronary chronic total occlusions in acute myocardial infarction with cardiogenic shock

Background

There are limited data on the prevalence and outcomes of chronic total occlusions (CTO) of the coronary artery in acute myocardial infarction with cardiogenic shock (AMI-CS) patients.

Methods

Using the National Inpatient Sample, all admissions with AMI-CS that underwent diagnostic angiography between January 1, 2008, and December 31, 2014, were included. CTO, percutaneous coronary intervention (PCI), comorbidities and concomitant cardiac arrest was identified for all admissions. Outcomes of interest included temporal trends, in-hospital mortality, and resource utilization in cohorts with and without CTO.

Results

In this 7-year period, 163,628 admissions with AMI-CS admissions met the inclusion criteria, with 68% being ST-elevation AMI-CS. CTO was noted in 27,343 (16.7%) admissions, with an increase in prevalence during the study period. The cohort with CTOs was more likely to be male and bearing private insurance. The CTO cohort had higher cardiovascular comorbidity, higher rates of cardiac arrest and higher use of PCI and mechanical circulatory support. The presence of a CTO was independently associated with higher in-hospital mortality (adjusted odds ratio 1.20 [95% confidence interval 1.16–1.23]; p < 0.001). The cohort with CTO had lower resource utilization (hospital stay and hospitalization costs) but was discharged more frequently to other hospitals. The presence of a CTO was associated with higher in-hospital mortality in the sub-groups of ST-elevation AMI-CS (31.5% vs. 28.7%; p < 0.001) and non-ST-elevation AMI-CS (24.8% vs. 23.2%; p < 0.001).

Conclusions

In this cohort of AMI-CS admissions that underwent diagnostic angiography, the presence of a CTO identified a higher risk cohort that had higher in-hospital mortality.

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CTOs are seen in 17% of all AMI-CS admissions with higher rates in STEMI.

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The CTO cohort had higher cardiac arrest, PCI & mechanical circulatory support use.

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Presence of a CTO was a marker of higher adjusted in-hospital mortality.