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Has the Frequency of Peri-Procedural Myocardial Infarction Reduced Using Third Universal Definition?
Heart, Lung and Circulation 2013;22:S126–S266
S137 ABSTRACTS
aim to formulate normative ranges for MDCT derived dimensions in an unselected cohort and evaluate the percentage of subjects who are anatomically unsuitable for TAVI using CoreValve. Methods and results: Two hundred and fifty consecutive patients (49.2% male; 58.55 ± 11.82 years) who underwent 320-slice MDCT to evaluate coronary anatomy were enrolled. Scans were assessed using the 3MensioTM analysis program. The basal plane was analysed in the short-axis at the lowest nadir of each coronary cusp and further measurements made in relation to this plane. The mean basal plane minimum diameter was 21.18 ± 2.41 mm and maximum 27.35 ± 2.89 mm, yielding an eccentricity index (EI) of 0.22 ± 0.06. The LVOT was more eccentric (EI 0.32 ± 0.06). The mean sinus of valsalva height was 22.73 ± 3.43 mm, sinus diameter 31.49 ± 3.66 mm, average height of the left main coronary artery 14.97 ± 3.56 mm and right coronary artery 18.04 ± 2.95 mm. Based on anatomic dimensions 32 (12.8%) of subjects would not be suitable for TAVI with a CoreValve prosthesis. Of these eight had annuli that were too large, one had an annulus that was too small, one had inadequate sinus width and one had ascending aorta dilatation. In addition 22 subjects had inadequate coronary height. Conclusion: Normative ranges for MDCT derived dimensions of the aortic annulus and associated structures may allow population specific development of new TAVI prostheses. This study demonstrates that currently a significant minority of people are anatomically unsuitable for TAVI using the CoreValve prosthesis.
CSANZ 2013 Abstracts
Results: Radial access went from 1% to 60.3% of all cases over a five-month period with a 4.1% radial access failure rate. An audit at 12 months following program initiation demonstrated radial access rates were maintained. There was a tendency for more obese (BMI 29.7 vs 28.9, p = 0.20) and significantly younger (64.0 yo vs 65.8 yo, p = 0.03) subjects to have radial procedures. Procedure times and radiation doses were similar (p = ns for both). A graded satisfaction score demonstrated significantly higher satisfaction with radial access (p = 0.008). Acute and subacute access site complication rates were 4.5% of all cases the majority occurring with femoral access (20/21). ACUITY defined major access site complications were 5/500 (five femoral and no radial). Femoral access complications included two pseudoaneurysms (one transfused), two haematomas >5 cm (one transfused) and one retroperitoneal bleed. Two femoral and no radial cases were associated with a >3 g/dl Hb drop. Conclusion: Graduated introduction of operator guided radial access for coronary procedures is associated with a potential decrease in major complications and improved patient satisfaction.
http://dx.doi.org/10.1016/j.hlc.2013.05.325 http://dx.doi.org/10.1016/j.hlc.2013.05.326
324 Graduated Introduction of an Operator Guided Radial Access Program for Coronary Procedures at an Australian Tertiary Hospital is not Associated with Adverse Access Site Complications C. Judkins 1,∗ , S. Palmer 1 , P. Williams 1 , L. Yang 1,2 1 St
Vincent’s Hospital, Melbourne, Australia University, Australia
2 Melbourne
Radial access for coronary procedures is becoming the route of choice for a wide range of indications including STEMIs. Starting a radial program presents numerous procedural and logistical challenges despite significant benefits. We describe one Australian tertiary centre’s experience with the introduction of a radial program. Method: Prospective data collection on 500 consecutive coronary catheterisations (February–July 2012) with choice of access at the operators discretion.
325 Has the Frequency of Peri-Procedural Myocardial Infarction Reduced Using Third Universal Definition? H. Idris 1,2,∗ , I. Shugman 1,2 , Y. Saad 1,2 , S. Lo 1,2 , A. Hopkins 1,2 , L. Hee 1,2 , C. Mussap 1,2 , D. Leung 1,2 , L. Thomas 1,2 , C. Juergen 1,2 , J. French 1,2 1 SWS
Clinical School, the University of New South Wales, Sydney, NSW, Australia 2 Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia Recurrent myocardial infarction (MI), including postpercutaneous coronary intervention (PCI) is important, both prognostically and as a clinical trials endpoint. Methods and results: To determine whether the frequency of peri-procedural MI (PMI) was reduced using the 2012 MI universal definition (requiring imaging changes and bio-marker elevation(s)), compared with the 2007 PMI definition. We studied 747 post-PCI patients (18% stableCHD, 43%NSTEMI and 40% unstable angina), mean age 64 ± 12 years, 75% male and 28% had diabetes. Pre-PCI TnT levels were normal (<0.03 g/L [URL]) in 494 (66%) patients, and elevated in 253 (34%) though these were
S138
Heart, Lung and Circulation 2013;22:S126–S266
CSANZ 2013 Abstracts
ABSTRACTS
stable or falling. Among patients with normal pre-PCI TnT levels, 11% had post-PCI TnT levels >5×URL, 89 (18%) had TnT >3×URL. Patients with elevated pre-PCI TnT, 88 (35%) had >20% elevation in TnT levels post-PCI. PMI occurred in 177 (24%) patients using 2007 MI definition whereas 142(19%) had post-PCI TnT levels either >5×URL or >20% increased above elevated pre-PCI levels (p < 0.0001). Only 7% had chest pain and ECG PMI criteria. At 37 [IQR 17–52] months, rates of death/MI in patients with stable-CHD were 28% and 10% in those with, and without, post-PCI TnT levels >5×URL, respectively (p = 0.05), whereas these event rates in ACS patients with, and without, post-PCI TnT levels >5×URL or >20% above elevated pre-PCI TnT levels were 26% and 24%, respectively (p = 0.58). Conclusion: PMI was less frequent using the 2012, compared to the 2007, universal MI definition. This has implications for clinical trial endpoint frequency and consequently trial costs. PMI using the 2012 definition was prognostic in patients with stable-CHD. http://dx.doi.org/10.1016/j.hlc.2013.05.327 326 Higher Mortality in Smokers Following Percutaneous Coronary Intervention A. Huang 1,∗ , J. O’Brien 1 , N. Andrianopoulos 2 , D. Clark 3 , A. Ajani 4 , A. Brennan 2 , R. Sharma 1 , G. New 5 , A. Black 6 , C. Reid 2 , T. Dart 1 , S. Duffy 1 1 Alfred
Hospital, Australia Monash University, Australia 3 Austin Hospital, Australia 4 Royal Melbourne Hospital, Australia 5 Box Hill Hospital, Australia 6 Geelong Hospital, Australia 2 CCRET,
Background: “Smoker’s paradox” refers to the observation that smokers, compared to non-smokers, appear to have lower mortality following myocardial infarction (MI). In some studies, this unexpected survival benefit remains despite multivariate analysis. We sought to determine the prognosis of smokers in a contemporary Australian cohort following percutaneous coronary intervention (PCI). Methods and results: We compared the demographic and clinical features between smokers, ex-smokers and non-smokers in the Melbourne Interventional Group Registry. Of 15,463 patients identified, 23.6% were current smokers, 44.1% were ex-smokers and 32.4% were nonsmokers. Compared to non-smokers, current smokers were younger than non-smokers (56.5 years vs. 67.6 years, p < 0.001) and more likely to be male (79.9% vs. 61.7%, p < 0.001). They were less likely to have previous history of MI, coronary revascularisation, heart failure, impaired renal function, cerebrovascular disease, or cardiac risk factors including hypertension and diabetes (all p < 0.001). Smokers were more likely to have their index PCI for acute coronary syndrome (80.8% vs. 63.0%, p < 0.001). Unadjusted analysis showed that current smokers had lower mortality. However, in multivariate analysis, smokers had
the highest mortality, followed by ex-smokers then nonsmokers Conclusions: Smoking status is associated with higher mortality following PCI. The purported survival benefits of the “smoker’s paradox” likely reflect younger age and fewer co-morbidities.
http://dx.doi.org/10.1016/j.hlc.2013.05.328 327 Improvements in Left Atria and Vascular Function 24 h Following the Reversal of Chronic Atrial Stretch C. Schultz 1,∗ , S. Wiloughby 1 , S. Kumar 2 , S. Nair 2 , A. Srivastava 2 , S. Chandy 2 , B. John 2 , P. Sanders 1 1 Centre
for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Australia 2 Christian Medical Center, Vellore, India Introduction: Chronic atrial stretch is associated with many conditions which predisposed to the development of atrial fibrillation and increased risk of systemic thromboembolism. This study examined how reversal of atrial stretch by balloon mitral valvuloplasty (BMV) alters factors vascular function, inflammation and thrombogenesis. Methods: Nineteen patients with chronic atrial stretch due (aged 32 ± 8 years, nine males), undergoing percutaneous BMV were studied. Blood samples were obtained at the beginning, and at 24 h post procedure. Plasma levels of Endothelin-1 (ET-1), Interleukin-6 (IL-6) and Plasminogen activator inhibitor (PAI), were measure as markers of vasoconstriction, inflammation and thrombogenesis respectively. An echocardiograph was performed prior to and 24 h following procedure to measure LA dimensions. Results: BMV was associated with a significant decrease in LA pressure (23.38 ± 7.3 vs 10.12 ± 3.9, P < 0.0001) in all patients. In addition, there was an increase in LA (62.6 ± 8 vs 67.4 ± 6, P = 0.02) and size and volume (63.3 ± 7 vs 58.3 ± 8, P = 0.06, and 51.7 ± 8 vs 48.2 ± 8, P = 0.2, respectively). ET-1 levels were significantly decreased following a reduction in chronic atrial stretch (2.03 ± 1.4 vs 0.9 ± 0.2, P = 0.001). IL-6 and PAI were also decreased although this did not reach significance in this population (7.4 ± 10.7 vs 13.7 ± 12, P = 0.1 and 36.9 ± 27 vs 56.0 ± 36, P = 0.07). Conclusions: The reversal of chronic atrial stretch is associated with a significant decrease in LA pressure and an increase in ejection fraction. This was also associated with a decrease in ET-1 levels, showing a relationship between improved LA function and increase vaso-responsiveness, which may lead to a decline in disease progression. http://dx.doi.org/10.1016/j.hlc.2013.05.329
S137 ABSTRACTS
aim to formulate normative ranges for MDCT derived dimensions in an unselected cohort and evaluate the percentage of subjects who are anatomically unsuitable for TAVI using CoreValve. Methods and results: Two hundred and fifty consecutive patients (49.2% male; 58.55 ± 11.82 years) who underwent 320-slice MDCT to evaluate coronary anatomy were enrolled. Scans were assessed using the 3MensioTM analysis program. The basal plane was analysed in the short-axis at the lowest nadir of each coronary cusp and further measurements made in relation to this plane. The mean basal plane minimum diameter was 21.18 ± 2.41 mm and maximum 27.35 ± 2.89 mm, yielding an eccentricity index (EI) of 0.22 ± 0.06. The LVOT was more eccentric (EI 0.32 ± 0.06). The mean sinus of valsalva height was 22.73 ± 3.43 mm, sinus diameter 31.49 ± 3.66 mm, average height of the left main coronary artery 14.97 ± 3.56 mm and right coronary artery 18.04 ± 2.95 mm. Based on anatomic dimensions 32 (12.8%) of subjects would not be suitable for TAVI with a CoreValve prosthesis. Of these eight had annuli that were too large, one had an annulus that was too small, one had inadequate sinus width and one had ascending aorta dilatation. In addition 22 subjects had inadequate coronary height. Conclusion: Normative ranges for MDCT derived dimensions of the aortic annulus and associated structures may allow population specific development of new TAVI prostheses. This study demonstrates that currently a significant minority of people are anatomically unsuitable for TAVI using the CoreValve prosthesis.
CSANZ 2013 Abstracts
Results: Radial access went from 1% to 60.3% of all cases over a five-month period with a 4.1% radial access failure rate. An audit at 12 months following program initiation demonstrated radial access rates were maintained. There was a tendency for more obese (BMI 29.7 vs 28.9, p = 0.20) and significantly younger (64.0 yo vs 65.8 yo, p = 0.03) subjects to have radial procedures. Procedure times and radiation doses were similar (p = ns for both). A graded satisfaction score demonstrated significantly higher satisfaction with radial access (p = 0.008). Acute and subacute access site complication rates were 4.5% of all cases the majority occurring with femoral access (20/21). ACUITY defined major access site complications were 5/500 (five femoral and no radial). Femoral access complications included two pseudoaneurysms (one transfused), two haematomas >5 cm (one transfused) and one retroperitoneal bleed. Two femoral and no radial cases were associated with a >3 g/dl Hb drop. Conclusion: Graduated introduction of operator guided radial access for coronary procedures is associated with a potential decrease in major complications and improved patient satisfaction.
http://dx.doi.org/10.1016/j.hlc.2013.05.325 http://dx.doi.org/10.1016/j.hlc.2013.05.326
324 Graduated Introduction of an Operator Guided Radial Access Program for Coronary Procedures at an Australian Tertiary Hospital is not Associated with Adverse Access Site Complications C. Judkins 1,∗ , S. Palmer 1 , P. Williams 1 , L. Yang 1,2 1 St
Vincent’s Hospital, Melbourne, Australia University, Australia
2 Melbourne
Radial access for coronary procedures is becoming the route of choice for a wide range of indications including STEMIs. Starting a radial program presents numerous procedural and logistical challenges despite significant benefits. We describe one Australian tertiary centre’s experience with the introduction of a radial program. Method: Prospective data collection on 500 consecutive coronary catheterisations (February–July 2012) with choice of access at the operators discretion.
325 Has the Frequency of Peri-Procedural Myocardial Infarction Reduced Using Third Universal Definition? H. Idris 1,2,∗ , I. Shugman 1,2 , Y. Saad 1,2 , S. Lo 1,2 , A. Hopkins 1,2 , L. Hee 1,2 , C. Mussap 1,2 , D. Leung 1,2 , L. Thomas 1,2 , C. Juergen 1,2 , J. French 1,2 1 SWS
Clinical School, the University of New South Wales, Sydney, NSW, Australia 2 Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia Recurrent myocardial infarction (MI), including postpercutaneous coronary intervention (PCI) is important, both prognostically and as a clinical trials endpoint. Methods and results: To determine whether the frequency of peri-procedural MI (PMI) was reduced using the 2012 MI universal definition (requiring imaging changes and bio-marker elevation(s)), compared with the 2007 PMI definition. We studied 747 post-PCI patients (18% stableCHD, 43%NSTEMI and 40% unstable angina), mean age 64 ± 12 years, 75% male and 28% had diabetes. Pre-PCI TnT levels were normal (<0.03 g/L [URL]) in 494 (66%) patients, and elevated in 253 (34%) though these were
S138
Heart, Lung and Circulation 2013;22:S126–S266
CSANZ 2013 Abstracts
ABSTRACTS
stable or falling. Among patients with normal pre-PCI TnT levels, 11% had post-PCI TnT levels >5×URL, 89 (18%) had TnT >3×URL. Patients with elevated pre-PCI TnT, 88 (35%) had >20% elevation in TnT levels post-PCI. PMI occurred in 177 (24%) patients using 2007 MI definition whereas 142(19%) had post-PCI TnT levels either >5×URL or >20% increased above elevated pre-PCI levels (p < 0.0001). Only 7% had chest pain and ECG PMI criteria. At 37 [IQR 17–52] months, rates of death/MI in patients with stable-CHD were 28% and 10% in those with, and without, post-PCI TnT levels >5×URL, respectively (p = 0.05), whereas these event rates in ACS patients with, and without, post-PCI TnT levels >5×URL or >20% above elevated pre-PCI TnT levels were 26% and 24%, respectively (p = 0.58). Conclusion: PMI was less frequent using the 2012, compared to the 2007, universal MI definition. This has implications for clinical trial endpoint frequency and consequently trial costs. PMI using the 2012 definition was prognostic in patients with stable-CHD. http://dx.doi.org/10.1016/j.hlc.2013.05.327 326 Higher Mortality in Smokers Following Percutaneous Coronary Intervention A. Huang 1,∗ , J. O’Brien 1 , N. Andrianopoulos 2 , D. Clark 3 , A. Ajani 4 , A. Brennan 2 , R. Sharma 1 , G. New 5 , A. Black 6 , C. Reid 2 , T. Dart 1 , S. Duffy 1 1 Alfred
Hospital, Australia Monash University, Australia 3 Austin Hospital, Australia 4 Royal Melbourne Hospital, Australia 5 Box Hill Hospital, Australia 6 Geelong Hospital, Australia 2 CCRET,
Background: “Smoker’s paradox” refers to the observation that smokers, compared to non-smokers, appear to have lower mortality following myocardial infarction (MI). In some studies, this unexpected survival benefit remains despite multivariate analysis. We sought to determine the prognosis of smokers in a contemporary Australian cohort following percutaneous coronary intervention (PCI). Methods and results: We compared the demographic and clinical features between smokers, ex-smokers and non-smokers in the Melbourne Interventional Group Registry. Of 15,463 patients identified, 23.6% were current smokers, 44.1% were ex-smokers and 32.4% were nonsmokers. Compared to non-smokers, current smokers were younger than non-smokers (56.5 years vs. 67.6 years, p < 0.001) and more likely to be male (79.9% vs. 61.7%, p < 0.001). They were less likely to have previous history of MI, coronary revascularisation, heart failure, impaired renal function, cerebrovascular disease, or cardiac risk factors including hypertension and diabetes (all p < 0.001). Smokers were more likely to have their index PCI for acute coronary syndrome (80.8% vs. 63.0%, p < 0.001). Unadjusted analysis showed that current smokers had lower mortality. However, in multivariate analysis, smokers had
the highest mortality, followed by ex-smokers then nonsmokers Conclusions: Smoking status is associated with higher mortality following PCI. The purported survival benefits of the “smoker’s paradox” likely reflect younger age and fewer co-morbidities.
http://dx.doi.org/10.1016/j.hlc.2013.05.328 327 Improvements in Left Atria and Vascular Function 24 h Following the Reversal of Chronic Atrial Stretch C. Schultz 1,∗ , S. Wiloughby 1 , S. Kumar 2 , S. Nair 2 , A. Srivastava 2 , S. Chandy 2 , B. John 2 , P. Sanders 1 1 Centre
for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Australia 2 Christian Medical Center, Vellore, India Introduction: Chronic atrial stretch is associated with many conditions which predisposed to the development of atrial fibrillation and increased risk of systemic thromboembolism. This study examined how reversal of atrial stretch by balloon mitral valvuloplasty (BMV) alters factors vascular function, inflammation and thrombogenesis. Methods: Nineteen patients with chronic atrial stretch due (aged 32 ± 8 years, nine males), undergoing percutaneous BMV were studied. Blood samples were obtained at the beginning, and at 24 h post procedure. Plasma levels of Endothelin-1 (ET-1), Interleukin-6 (IL-6) and Plasminogen activator inhibitor (PAI), were measure as markers of vasoconstriction, inflammation and thrombogenesis respectively. An echocardiograph was performed prior to and 24 h following procedure to measure LA dimensions. Results: BMV was associated with a significant decrease in LA pressure (23.38 ± 7.3 vs 10.12 ± 3.9, P < 0.0001) in all patients. In addition, there was an increase in LA (62.6 ± 8 vs 67.4 ± 6, P = 0.02) and size and volume (63.3 ± 7 vs 58.3 ± 8, P = 0.06, and 51.7 ± 8 vs 48.2 ± 8, P = 0.2, respectively). ET-1 levels were significantly decreased following a reduction in chronic atrial stretch (2.03 ± 1.4 vs 0.9 ± 0.2, P = 0.001). IL-6 and PAI were also decreased although this did not reach significance in this population (7.4 ± 10.7 vs 13.7 ± 12, P = 0.1 and 36.9 ± 27 vs 56.0 ± 36, P = 0.07). Conclusions: The reversal of chronic atrial stretch is associated with a significant decrease in LA pressure and an increase in ejection fraction. This was also associated with a decrease in ET-1 levels, showing a relationship between improved LA function and increase vaso-responsiveness, which may lead to a decline in disease progression. http://dx.doi.org/10.1016/j.hlc.2013.05.329