Outcomes After Percutaneous Coronary Intervention (PCI) in Contemporary Australian Practice: Insights FROM a large Multi-Centre Registry

to assess our practice of managing acute STEMI, identify processes associated with time delays, instrument changes to our management protocol and assess their effectiveness of improving our door to balloon time. Methods: We analysed consecutive patients presenting with STEMI (April–September 2005 (group A) and the corresponding period in 2006 (group B), and compared patients presenting “in hours” [0700–1800 (Monday to Friday)] versus “out of hours” (all other times). Results: In group A, 38 patients presented with a STEMI who were treated with primary PCI. The median door to balloon time for primary PCI was significantly greater for “out of hours” than “in hours” (120 min versus 67 min). The greatest time delay to PCI was from the PCI decision time to catheter laboratory arrival. Local changes were implemented, including treating all STEMI patients with primary PCI, to improve “out of hours” times. These changes led to the initiation of “Code AMI”. There were 59 patients in group B. Code AMI led to 30% improvement in “out of hours” door to balloon time (median time = 82 min) with 69% being managed ≤90 min (group B). Conclusion: We found that “Code AMI” has led to improved door to balloon times in “out of hours”. On-going review via a quality improvement program improves door to balloon times which is integral in management of patients with acute STEMI treated with primary PCI. doi:10.1016/j.hlc.2007.06.339 335 Percutaneous Closure of Post Myocardial Infarction Ventricular Septal Defects J. Ahmed ∗ , P.N. Ruygrok, N.J. Wilson, M.W.I. Webster, S. Greaves, I. Gerber Green Lane Cardiovascular Service, Auckland, New Zealand Background: Ventricular septal defect (VSD) is a serious complication of myocardial infarction (MI) occurring in 0.2% of cases. Untreated mortality is high and early surgical repair is difficult because of friable necrotic tissue. Percutaneous closure is an attractive option in selected patients. Methods: We report our complete single centre experience of percutaneous post MI VSD closure using the Amplatzer device in five consecutive patients. The VSD was closed at variable times after MI under general anaesthesia with fluoroscopic and transoesophageal echocardiographic guidance. Clinical characteristics and outcomes are reported. Results: Patients’ age ranged from 66 to 76 years. VSD closure was performed in two patients after surgical patch dehiscence (infero-apical and infero-posterior VSDs). Closure was attempted from 1 to 64 days post MI. The procedure was successful in 4 patients with failure to cross the interventricular septum in 5th. Overall survival was 60%: 100% in late closure and 0% in early closure, suggesting that attempts at percutaneous VSD closure should be deferred after MI.

Abstracts

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Conclusion: Percutaneous VSD closure post MI appears to provide favourable outcomes compared to surgical repair. Greater success is evident if closure is delayed as long as possible after MI. Patient

Age/ Gender

Time MI to Closure (days)

Time Procedure to Death or FU

Residual Shunt

Comment

1

75M

56

Alive at 42 months

Small

Late dehiscence

2

74F

50

Alive at 16 months

Very small

3

69F

13

Deceased at 5 days Moderate

4

66M

64

Alive at 9 months

Trivial

Post CABG

5

76F

1

Deceased at day 0

–

Acute post MI

Haemolysis Early dehiscence

doi:10.1016/j.hlc.2007.06.340 336 Outcomes After Percutaneous Coronary Intervention (PCI) in Contemporary Australian Practice: Insights FROM a large Multi-Centre Registry David Clark 1 , A. Al-Fiadh 1,∗ , K. Charter 1 , S. Duffy 2 , R. Lew 3 , O. Farouque 1 , B. Yan 4 , G. New 5 , M.C.G. Horrigan 1 , H. Lim 1 , A. Black 6 , A. Brennan 7 , C. Reid 7 , A. Ajani 4,7 , On behalf of the Melbourne Interventional Group (MIG) Investigators 1 Department

of Cardiology, Austin Hospital, Monash University, Melbourne, Vic., Australia; 2 Department of Cardiology, Alfred Hospital, Monash University, Melbourne, Vic., Australia; 3 Department of Cardiology, Frankston Hospital, Monash University, Melbourne, Vic., Australia; 4 Department of Cardiology, Royal Melbourne Hospital, Monash University, Melbourne, Vic., Australia; 5 Department of Cardiology, Box Hill Hospital, Monash University, Melbourne, Vic., Australia; 6 Department of Cardiology, Geelong Hospital, Monash University, Melbourne, Vic., Australia; 7 NHMRC Centre of Clinical Research Excellence in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia Background: In an era where patients are at increasing high-risk and device technology is evolving rapidly, there is limited information on the outcome of PCI in Australia. Methods: We prospectively enrolled 5069 patients undergoing consecutive PCI of 6231 lesions at 8 Victorian hospitals from April 2004 to January 2007. In-hospital outcomes were available in all 5069 with 4499 and 2358 patients were eligible for 30 day and 1 year outcomes, respectively. Results: The mean age ± S.D. was 64.9 ± 12.0 years. Females comprised 27.2%, diabetics 23% and 61.1% had acute coronary syndromes (ACS). Cardiogenic shock was present in 2.1%. Drug-eluting stents were used in 51.9% and IIbIIIa inhibitors in 26.7%. In-hospital outcomes were n (%): death 71 (1.4%), myocardial infarction 75 (1.5%), emergency PCI 48 (1.0%), unplanned CABGs 40 (0.8%), congestive heart failure 94 (1.9%), stroke 16 (0.3%), and

ABSTRACTS

Heart, Lung and Circulation 2007;16:S1–S201

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Abstracts

Heart, Lung and Circulation 2007;16:S1–S201

ABSTRACTS

cardiac tamponade 8 (0.2%).

Procedural Complications:

Unfractionated Heparin n (%)

LMWH n (%)

Outcomes

30 Day n = 4499

1 Year n = 2358

Major branch closure

3 (1.4)

1 (0.8)

Death—total cohort (%)

2.0

4.2

No re-flow

4 (1.8)

0

Myocardial infarction (%)

2.6

5.7

Major dissection

1 (0.5)

Target vessel revascularization (%)

2.7

7.8

1 (0.8) wire induced

Thrombotic occlusion

1 (0.5)

0

Peri-procedural MI*

5 (2.4)

3 (2.3)

Total

14(6.6)

5 (4) p = 0.05

Conclusion: Amongst patients undergoing PCI, the majority of which have ACS and receive DES, there is a low incidence of death, myocardial infarction and target vessel revascularization in the medium term. However, the critical need for studies with long-term follow up after PCI remains. doi:10.1016/j.hlc.2007.06.341 337 Unselected Use of Low Molecular Weight Heparin (Enoxaparin) During Percutaneous Coronary Intervention (PCI) B. Costa ∗ , E. Yamen, D. Brieger Concord Hospital, Sydney, Australia Background: There is a reluctance to use low molecular weight heparin (LMWH) in the catheterisation laboratory. This stems from a concern over bleeding risk and uncertainties regarding optimal regimens for LMWH in patients undergoing PCI. Intravenous administration in the setting of coronary intervention allows a stable anticoagulant effect without accumulation that predisposes to bleeding complications. Aim: To examine the feasibility and safety of intravenous clexane in comparison to unfractionated heparin (UFH) in unselected patients undergoing percutaneous coronary angioplasty (PCI). Methods: Consecutive patients from March to December 2006 received either intravenous (IV) LMWH (enoxaparin) or standard therapy UFH during PCI. Drug allocation was determined by individual operator preference. Sheaths were removed immediately post procedure following LMWH and 1–6 h following UFH. Results: Of 343 consecutive patients, 132 received LMWH 0.5 mg/kg IV with a repeat dose of 0.25 mg/kg IV if the procedure exceeded 1 h. 211 patients received UFH.

There were no major haematomas and no retroperitoneal bleeding events.Conclusion: The ease of use of enoxaparin together with comparable efficacy suggests LMWH be considered anticoagulant of choice for unselected patients undergoing PCI. doi:10.1016/j.hlc.2007.06.342 338 Discharge Antiplatelet Prescription after Percutaneous Coronary Intervention (PCI): A Tale of Two Hospitals A. Bennett 1,3,∗ , L. Selim 2 , I. Davidson 3 , A. Wardell 3 , N. Sammel 3 , J. Brien 1,3,4 1 Faculty of Pharmacy, The University of Sydney, Sydney, NSW,

Australia; 2 Faculty of Pharmacy, Uppsala University, Uppsala, Sweden; 3 St. Vincent’s Hospital Campus, Sydney, NSW, Australia; 4 Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia Background: Guidelines vary in their recommendations re antiplatelets post-PCI. Variation in guideline adherence has been reported among academic and non-academic hospitals. Controversy has arisen in patients receiving drug-eluting stents (DES) regarding antiplatelet duration. Aim: To describe discharge antiplatelet medications prescribed for patients’ post-PCI in a public teaching and a colocated private hospital. Methods: Patients who underwent PCI between September 2005 and March 2006 were identified retrospectively. Clinical data was collected. Descriptive analyses using Excel were undertaken and chi-square for differences between the hospitals calculated. Results: Data from 252 public hospital (PH) patients and 299 private hospital (PrivH) patients were reviewed. Demographics of the two hospital populations were similar. 63% of PH and 99% of PrivH PCI patients received DES, p ≤ 0.001. Information regarding antiplatelet use post-PCI was documented in catheter reports and discharge letters in the PH but only in the discharge letter in the PrivH. 10% of PH patients had a disparity between the catheter report and discharge letter. There was wide variation in aspirin dosing in the PH. 22% of PH and 81% of PrivH patients who received DES were prescribed 300 mg aspirin at discharge, p ≤ 0.001. Information regarding aspirin and clopidogrel duration was missing in 16.7% and 13.9% of PH