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Percutaneous Coronary Intervention in the Elderly Population—A Single Centre Experience
S188
Abstracts
ABSTRACTS
446 Pericarditis is the Commonest Cause of Normal Coronary Angiography in Patients Referred for Primary Percutaneous Coronary Intervention Sandhir Prasad ∗ , David Richards, Norman Sadick, Andrew Ong, Arun Narayan, Anne-Marie Gerke, Pramesh Kovoor Westmead Hospital, Sydney, Australia Background: Primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). With the current emphasis on reducing door-to-balloon times, the need for rapid assessment creates room for error in diagnosis. False-positive rates of 10–15% are reported in published series. We sought to determine the causes of false-positive diagnosis of STEMI in a large cohort of patients referred for Primary PCI. Methods: We reviewed data on 690 consecutive patients referred for Primary PCI from within a large multi-hospital Primary PCI network between 2004 and 2007. A retrospective folder audit of patients with normal or near-normal coronary angiography was undertaken to ascertain discharge diagnosis. Results: We identified 87 out of 690(13%) patients with normal coronary angiography. Compared to patients with culprit lesions, patients with normal coronary angiography were younger and had fewer cardiac risk factors. The presenting complaint in the normal coronaries group was chest pain in 77 (89%), but atypical features (identified if ‘pleuritic’, ‘pericarditic’ or ‘abdominal/epigastric’ pain was documented in the admission notes) were present in 45 (58%) patients. The discharge diagnosis as coded by treating physicians was pericarditis (n = 72; 83%), myocarditis (n = 3; 3%), Takotsubo cardiomyopathy (n = 2; 2%), coronary spasm secondary to intravenous drug use (n = 2; 2%), PE (n = 1; 1%), cholelithiasis (n = 1; 1%), pneumonia (n = 1; 1%), other (n = 5; 5%). Follow-up troponins were positive in 17 (20%) patients, and were attributed to myopericarditis in the majority. Conclusion: Normal coronary angiography as a result of false-positive diagnosis of STEMI is driven mainly by misdiagnosis of pericarditis. Closer attention to the presenting history and ECG must be emphasised. doi:10.1016/j.hlc.2008.05.447 447 Primary PCI for Acute Myocardial Infarction due to Unprotected Total Left Main Artery Occlusion: A Single Centre Experience Matthew Erickson ∗ , Eric Simillion, Sheryl Kannapin, Geoffrey Cope, Sharrad Shetty, Richard Clugston, Jamie Rankin Royal Perth Hospital, Perth, WA, Australia Background: Total occlusion of the left main coronary artery (LMCA) is an infrequent finding during primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) with a high mortality.
Heart, Lung and Circulation 2008;17S:S1–S209
Methods: We searched our institutions PCI database from December 2002 to January 2008 for procedural characteristics and clinical outcomes of all cases of unprotected total occlusion of the LMCA with TIMI-0 flow, diagnosed during Primary PCI for AMI. Results: LMCA occlusion was identified in 9 of 865 primary PCI cases (1%). Mean age was 68, 78% were male. Eight were in cardiogenic shock, seven received inotrope infusions and four had been intubated. All had ST elevation in aVL and a dominant RCA. Eight patients received IABP, seven prior to commencing PCI. Eight received Abciximab. Seven had extensive visible LMCA thrombus of which four developed distal thrombo-embolism. All patients had the LMCA successfully dilated. Eight underwent LMCA stenting, with LMCA bifurcation stenting in four. Four of the 9 (44.4%) survived to discharge and returned home. One required cardiac transplantation and survived over 3 years. Three remain alive. Of 5 deaths, three occurred in the cathlab (electromechanical dissociation) and two in ICU within 48 h. Only one of five patients who did not regain TIMI-3 flow in the LAD following PCI survived. Symptom to balloon times was similar in survivors and non-survivors (222 min vs. 219 min). Conclusion: Primary PCI for AMI due to unprotected total LMCA occlusion was associated with survival well beyond hospital discharge in almost half of these critically ill patients. doi:10.1016/j.hlc.2008.05.448 448 Percutaneous Coronary Intervention in the Elderly Population—A Single Centre Experience Siobhan Lockwood ∗ , Sarah Hope, Yuvaraj Malaiapan, Mauro Baldi, Herendra Wijesekera, Ian T. Meredith Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Monash University Department of Medicine (MMC), Melbourne, Victoria, Australia Background: With increasing life expectancy, more elderly patients are undergoing percutaneous coronary intervention (PCI). Concerns persist regarding increased morbidity and mortality in this population. We compared the in-hospital outcomes of the young (<70 years, group 1), elderly (70–79 years, group 2) and the very elderly (>80 years, group 3). Method: Baseline characteristics, procedural and clinical data were analyzed for all patients who underwent PCI at Monash Medical Centre, Melbourne from January 2006 to December 2007 (1438 patients; 964 younger, 332 elderly and 142 very elderly patients). Results: There was no difference in the indication for PCI between groups. Advancing age was associated with an increased prevalence of females, non-smokers and hypertension (all p ≤ 0.001). No difference in rates of prescribing standard therapy (aspirin, beta-blockade, ACE inhibitor and statins) between groups (p ≤ 0.001). Neither the number of stents nor stent-type (Drug-eluting or Bare Metal)
Abstracts
were associated with age. There was no difference in either procedural (92%, 91% and 87.5%, groups 1, 2 and 3, respectively) or clinical success (85.5%, 86% and 84%, groups 1, 2 and 3). Although there was an increase in overall in-hospital mortality in the very elderly (6%, p ≤ 0.05), mortality was limited to those undergoing Primary PCI only. Increasing age was associated with increasing length of stay for each indication. Median length of stay was 4, 4 and 5 days, groups 1, 2 and 3, respectively, p ≤ 0.001. Conclusions: PCI in the elderly and very elderly can be performed with similar rates of procedural and clinical success to younger age groups. doi:10.1016/j.hlc.2008.05.449 449 Balloon Mitral Valvotomy—A Viable Option for Critically Sick Patients of Mitral Stenosis Sanjeev Kumar Agarwal ∗ , Azan S. Binbrek Rashid Hospital, Dubai, United Arab Emirates Background: Rheumatic severe mitral stenosis (MS) is an important cause of acute pulmonary oedema in the young patients of Indian subcontinent. Dubai has a sizeable immigrant population from this region. The management of these patients remains controversial. Surgical mortality is high in critically ill patients of severe MS with haemodynamic instability. Methods: A total of 30 balloon mitral valvotomy (BMV) procedures were performed at Rashid hospital, Dubai from July 2003 to December 2007. Four of them were in pulmonary oedema. Three of them presented with fever, cough and rapidly progressive dyspnoea. They had pink froth, bilateral coarse crepts all over the chest, systemic hypotension and desaturation at presentation. All of them required assisted ventilation in addition to inotropes and lasix infusion. Patient #2 had echo and culture proved infective endocarditis. Patient #3 had left atrial appendage clot also. BMV was attempted in three patients. Results: All the three patients had marked improvement in haemodynamic status immediately after BMV and could be extubated within 24 h (Table 1). Patient #2 received 4 weeks of intravenous antibiotic treatment for infective endocarditis. Complication included grade III MR in one patient. All the patients were discharged and continue to be in NYHA class I in follow up.
Table 1. Procedural Parameters and Results of BMV Age (years) Flouroscopy time (min) Procedure time (min) PreBMV Mitral valve area (cm2 ) LA mean (mmHg) Complications
Patient #1
Patient #2
Patient #3
41 18 46
25 16 42
45 20 40
PostBMV
PreBMV
PostBMV
PreBMV
PostBMV
0.6
1.5
0.7
1.7
0.5–0.6
2.1
38
15
33
12
39
26
Nil
Nil
Grade III/IV MR
S189
Conclusion: BMV helps in salvaging critically sick patients of severe mitral stenosis with acute pulmonary oedema and cardiogenic shock. The benefit of procedure far outweighs the risks in such a dismal scenario. doi:10.1016/j.hlc.2008.05.450 450 First Australian Experience of an Endothelial Progenitor Cell (EPC) Capture Stent: Insights from a Multicentre Registry Jairam Aithal 1 , Moyazur Rahman 2 , Nick 3 Andrianopoulos , Tharien Duplessis 1 , Jeanette Dyson 1 , Gishel New 4 , David Eccleston 5 , Robert Lew 6 , Sahib Al-Daher 1 , Thomas Yip 1 , Alexander Black 1 , Martin Sebastian 1,∗ 1 The Geelong Hospital, Geelong, Victoria, Australia; 2 Ottowa Heart Institute, Ontario, Canada; 3 Monash University CCRE, Melbourne, Victoria, Australia; 4 Box Hill Hospital, Melbourne, Victoria, Australia; 5 Royal Melbourne Hospital, Melbourne, Victoria, Australia; 6 Frankston Hospital, Melbourne, Victoria, Australia
Background: Delayed endothelialization promotes thrombotic events after percutaneous coronary intervention (PCI). The genous stent (GS) incorporates Anti-CD34+ monoclonal antibodies attracting circulating EPC, promoting rapid endothelial coverage. This device is not TGA approved, but is currently being evaluated through a worldwide clinical registry including Australian sites. We compared the GS to contemporary bare-metal stents (BMS) and drug-eluting stents (DES). Methods: Data were obtained from the MIG database for 647 procedures (757 lesions) from four centres between March 2006 and August 2007. In patients with stable coronary disease undergoing PCI, the GS (n = 81) was compared to BMS (n = 269) and DES (n = 297) with respect to baseline demographics, procedural results, and 30day/12-month outcomes. Results: Patients were well matched for age, gender, hypertension, dyslipidemia, smoking, previous MI, heart failure, and renal failure. GS and DES use was higher in diabetics (GS 28.4%, DES 34.7%, BMS 21.9%; p = 0.021). Glycoprotein-IIb/IIIa inhibitor use was more frequent in the DES and BMS groups (GS 1.2%, DES 10.4%, BMS 5.2%, p = 0.001). GS and DES were used in smaller vessels (mean stent diameter GS 2.88 ± 0.33 mm, DES 2.71 ± 0.40 mm, BMS 3.04 ± 0.51 mm; p < 0.001). DES were used more frequently in ACC/AHA type B2/C lesions (GS 31.0%, DES 62.0% and BMS 36.2%, p < 0.001). Outcomes
GS (%)
BMS (%)
DES (%)
P
Procedural success
100.0
99.7
99.2
0.26
30-Day target lesion revascularization
0.0
1.1
1.0
0.55
30-Day MACE (death, MI, target-vessel revascularization)
1.2
1.9
2.0
0.67
Conclusion: The genous EPC capture stent yields procedural and 30-day clinical results equivalent to current
ABSTRACTS
Heart, Lung and Circulation 2008;17S:S1–S209
Abstracts
ABSTRACTS
446 Pericarditis is the Commonest Cause of Normal Coronary Angiography in Patients Referred for Primary Percutaneous Coronary Intervention Sandhir Prasad ∗ , David Richards, Norman Sadick, Andrew Ong, Arun Narayan, Anne-Marie Gerke, Pramesh Kovoor Westmead Hospital, Sydney, Australia Background: Primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). With the current emphasis on reducing door-to-balloon times, the need for rapid assessment creates room for error in diagnosis. False-positive rates of 10–15% are reported in published series. We sought to determine the causes of false-positive diagnosis of STEMI in a large cohort of patients referred for Primary PCI. Methods: We reviewed data on 690 consecutive patients referred for Primary PCI from within a large multi-hospital Primary PCI network between 2004 and 2007. A retrospective folder audit of patients with normal or near-normal coronary angiography was undertaken to ascertain discharge diagnosis. Results: We identified 87 out of 690(13%) patients with normal coronary angiography. Compared to patients with culprit lesions, patients with normal coronary angiography were younger and had fewer cardiac risk factors. The presenting complaint in the normal coronaries group was chest pain in 77 (89%), but atypical features (identified if ‘pleuritic’, ‘pericarditic’ or ‘abdominal/epigastric’ pain was documented in the admission notes) were present in 45 (58%) patients. The discharge diagnosis as coded by treating physicians was pericarditis (n = 72; 83%), myocarditis (n = 3; 3%), Takotsubo cardiomyopathy (n = 2; 2%), coronary spasm secondary to intravenous drug use (n = 2; 2%), PE (n = 1; 1%), cholelithiasis (n = 1; 1%), pneumonia (n = 1; 1%), other (n = 5; 5%). Follow-up troponins were positive in 17 (20%) patients, and were attributed to myopericarditis in the majority. Conclusion: Normal coronary angiography as a result of false-positive diagnosis of STEMI is driven mainly by misdiagnosis of pericarditis. Closer attention to the presenting history and ECG must be emphasised. doi:10.1016/j.hlc.2008.05.447 447 Primary PCI for Acute Myocardial Infarction due to Unprotected Total Left Main Artery Occlusion: A Single Centre Experience Matthew Erickson ∗ , Eric Simillion, Sheryl Kannapin, Geoffrey Cope, Sharrad Shetty, Richard Clugston, Jamie Rankin Royal Perth Hospital, Perth, WA, Australia Background: Total occlusion of the left main coronary artery (LMCA) is an infrequent finding during primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) with a high mortality.
Heart, Lung and Circulation 2008;17S:S1–S209
Methods: We searched our institutions PCI database from December 2002 to January 2008 for procedural characteristics and clinical outcomes of all cases of unprotected total occlusion of the LMCA with TIMI-0 flow, diagnosed during Primary PCI for AMI. Results: LMCA occlusion was identified in 9 of 865 primary PCI cases (1%). Mean age was 68, 78% were male. Eight were in cardiogenic shock, seven received inotrope infusions and four had been intubated. All had ST elevation in aVL and a dominant RCA. Eight patients received IABP, seven prior to commencing PCI. Eight received Abciximab. Seven had extensive visible LMCA thrombus of which four developed distal thrombo-embolism. All patients had the LMCA successfully dilated. Eight underwent LMCA stenting, with LMCA bifurcation stenting in four. Four of the 9 (44.4%) survived to discharge and returned home. One required cardiac transplantation and survived over 3 years. Three remain alive. Of 5 deaths, three occurred in the cathlab (electromechanical dissociation) and two in ICU within 48 h. Only one of five patients who did not regain TIMI-3 flow in the LAD following PCI survived. Symptom to balloon times was similar in survivors and non-survivors (222 min vs. 219 min). Conclusion: Primary PCI for AMI due to unprotected total LMCA occlusion was associated with survival well beyond hospital discharge in almost half of these critically ill patients. doi:10.1016/j.hlc.2008.05.448 448 Percutaneous Coronary Intervention in the Elderly Population—A Single Centre Experience Siobhan Lockwood ∗ , Sarah Hope, Yuvaraj Malaiapan, Mauro Baldi, Herendra Wijesekera, Ian T. Meredith Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Monash University Department of Medicine (MMC), Melbourne, Victoria, Australia Background: With increasing life expectancy, more elderly patients are undergoing percutaneous coronary intervention (PCI). Concerns persist regarding increased morbidity and mortality in this population. We compared the in-hospital outcomes of the young (<70 years, group 1), elderly (70–79 years, group 2) and the very elderly (>80 years, group 3). Method: Baseline characteristics, procedural and clinical data were analyzed for all patients who underwent PCI at Monash Medical Centre, Melbourne from January 2006 to December 2007 (1438 patients; 964 younger, 332 elderly and 142 very elderly patients). Results: There was no difference in the indication for PCI between groups. Advancing age was associated with an increased prevalence of females, non-smokers and hypertension (all p ≤ 0.001). No difference in rates of prescribing standard therapy (aspirin, beta-blockade, ACE inhibitor and statins) between groups (p ≤ 0.001). Neither the number of stents nor stent-type (Drug-eluting or Bare Metal)
Abstracts
were associated with age. There was no difference in either procedural (92%, 91% and 87.5%, groups 1, 2 and 3, respectively) or clinical success (85.5%, 86% and 84%, groups 1, 2 and 3). Although there was an increase in overall in-hospital mortality in the very elderly (6%, p ≤ 0.05), mortality was limited to those undergoing Primary PCI only. Increasing age was associated with increasing length of stay for each indication. Median length of stay was 4, 4 and 5 days, groups 1, 2 and 3, respectively, p ≤ 0.001. Conclusions: PCI in the elderly and very elderly can be performed with similar rates of procedural and clinical success to younger age groups. doi:10.1016/j.hlc.2008.05.449 449 Balloon Mitral Valvotomy—A Viable Option for Critically Sick Patients of Mitral Stenosis Sanjeev Kumar Agarwal ∗ , Azan S. Binbrek Rashid Hospital, Dubai, United Arab Emirates Background: Rheumatic severe mitral stenosis (MS) is an important cause of acute pulmonary oedema in the young patients of Indian subcontinent. Dubai has a sizeable immigrant population from this region. The management of these patients remains controversial. Surgical mortality is high in critically ill patients of severe MS with haemodynamic instability. Methods: A total of 30 balloon mitral valvotomy (BMV) procedures were performed at Rashid hospital, Dubai from July 2003 to December 2007. Four of them were in pulmonary oedema. Three of them presented with fever, cough and rapidly progressive dyspnoea. They had pink froth, bilateral coarse crepts all over the chest, systemic hypotension and desaturation at presentation. All of them required assisted ventilation in addition to inotropes and lasix infusion. Patient #2 had echo and culture proved infective endocarditis. Patient #3 had left atrial appendage clot also. BMV was attempted in three patients. Results: All the three patients had marked improvement in haemodynamic status immediately after BMV and could be extubated within 24 h (Table 1). Patient #2 received 4 weeks of intravenous antibiotic treatment for infective endocarditis. Complication included grade III MR in one patient. All the patients were discharged and continue to be in NYHA class I in follow up.
Table 1. Procedural Parameters and Results of BMV Age (years) Flouroscopy time (min) Procedure time (min) PreBMV Mitral valve area (cm2 ) LA mean (mmHg) Complications
Patient #1
Patient #2
Patient #3
41 18 46
25 16 42
45 20 40
PostBMV
PreBMV
PostBMV
PreBMV
PostBMV
0.6
1.5
0.7
1.7
0.5–0.6
2.1
38
15
33
12
39
26
Nil
Nil
Grade III/IV MR
S189
Conclusion: BMV helps in salvaging critically sick patients of severe mitral stenosis with acute pulmonary oedema and cardiogenic shock. The benefit of procedure far outweighs the risks in such a dismal scenario. doi:10.1016/j.hlc.2008.05.450 450 First Australian Experience of an Endothelial Progenitor Cell (EPC) Capture Stent: Insights from a Multicentre Registry Jairam Aithal 1 , Moyazur Rahman 2 , Nick 3 Andrianopoulos , Tharien Duplessis 1 , Jeanette Dyson 1 , Gishel New 4 , David Eccleston 5 , Robert Lew 6 , Sahib Al-Daher 1 , Thomas Yip 1 , Alexander Black 1 , Martin Sebastian 1,∗ 1 The Geelong Hospital, Geelong, Victoria, Australia; 2 Ottowa Heart Institute, Ontario, Canada; 3 Monash University CCRE, Melbourne, Victoria, Australia; 4 Box Hill Hospital, Melbourne, Victoria, Australia; 5 Royal Melbourne Hospital, Melbourne, Victoria, Australia; 6 Frankston Hospital, Melbourne, Victoria, Australia
Background: Delayed endothelialization promotes thrombotic events after percutaneous coronary intervention (PCI). The genous stent (GS) incorporates Anti-CD34+ monoclonal antibodies attracting circulating EPC, promoting rapid endothelial coverage. This device is not TGA approved, but is currently being evaluated through a worldwide clinical registry including Australian sites. We compared the GS to contemporary bare-metal stents (BMS) and drug-eluting stents (DES). Methods: Data were obtained from the MIG database for 647 procedures (757 lesions) from four centres between March 2006 and August 2007. In patients with stable coronary disease undergoing PCI, the GS (n = 81) was compared to BMS (n = 269) and DES (n = 297) with respect to baseline demographics, procedural results, and 30day/12-month outcomes. Results: Patients were well matched for age, gender, hypertension, dyslipidemia, smoking, previous MI, heart failure, and renal failure. GS and DES use was higher in diabetics (GS 28.4%, DES 34.7%, BMS 21.9%; p = 0.021). Glycoprotein-IIb/IIIa inhibitor use was more frequent in the DES and BMS groups (GS 1.2%, DES 10.4%, BMS 5.2%, p = 0.001). GS and DES were used in smaller vessels (mean stent diameter GS 2.88 ± 0.33 mm, DES 2.71 ± 0.40 mm, BMS 3.04 ± 0.51 mm; p < 0.001). DES were used more frequently in ACC/AHA type B2/C lesions (GS 31.0%, DES 62.0% and BMS 36.2%, p < 0.001). Outcomes
GS (%)
BMS (%)
DES (%)
P
Procedural success
100.0
99.7
99.2
0.26
30-Day target lesion revascularization
0.0
1.1
1.0
0.55
30-Day MACE (death, MI, target-vessel revascularization)
1.2
1.9
2.0
0.67
Conclusion: The genous EPC capture stent yields procedural and 30-day clinical results equivalent to current
ABSTRACTS
Heart, Lung and Circulation 2008;17S:S1–S209