Real-world percutaneous coronary intervention experience comparing Taxus paclitaxel-eluting with Cypher sirolimus-eluting stent platforms

Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129 Percutaneous closure of patent foramen ovale: technical success and clinical outcomes of an infrequently-performed procedure F Aslam Ali, Islamabad, Pakistan Objective: Procedural volume is thought to be a surrogate for quality, but this may not hold true for less frequently performed procedures. At most institutions, patent foramen ovale (PFO) closure will be performed infrequently as long as conservative indications for it are followed. We analyzed the safety and efficacy of infrequently performed PFO closure procedures. Methods: Fifty-two patients with cryptogenic stroke or transient ischemic attack undergoing PFO closure from June 2001 to December 2005 were analyzed for technical success and clinical outcomes. All patients had transesophageal echocardiography before PFO closure. CardioSEAL (NMT Medical, Boston, MA), Amplatzer (AGA Medical Corporation, Minneapolis, MN), or CardiaStar (Cardia, Inc, Burnsville, MN) devices were used. Patients were discharged on aspirin, clopidogrel or (at the discretion of the neurologist), coumadin for 6 months. Possible late neurologic events were evaluated by a neurologist. Echocardiograms were obtained at 6 months and telephone follow-up was performed at an average of 28±10 months post procedure. Results: The study population was young (mean age, 45 years) and included 25 men (48%). Presentation was stroke in 66%. Comorbidities included diabetes (25%), hypertension (54%), hypercholesterolemia (59%), and mildmoderate aortic atherosclerosis in 28 (54%). Hypercoagulability disorders included methylenetetrahydrofolate reductase mutation in 27 (52%), all with normal homocysteine, low protein S in 2 (4%), and cardiolipin antibodies in 6 (12%). Seventeen patients (33%) had atrial septal aneurysms. Balloonstretched PFO size ranged from 6 to 25 mm. Deployment success was 100%; mild residual shunting persisted in 19 (37%). Mean length of stay was 1 day. Predischarge complications included bleeding in 4 patients and arrhythmia in 3 patients. At 28 months of follow-up, 4 patients reported spells of uncertain etiology, and 1 had paroxysmal atrial fibrillation. There were no transient ischemic attacks or strokes. One patient died of renal failure and sepsis unrelated to PFO closure. Conclusions: Low-volume PFO closure (15 per year) can be performed safely and effectively in a moderate-volume interventional laboratory with good short-term and long-term clinical results. doi:10.1016/j.carrev.2008.02.015

Carotid artery stenting before coronary artery bypass graft: a better alternative to treat concomitant coronary and carotid artery disease F Aslam Ali, Islamabad, Pakistan Introduction: Coronary and carotid artery atherosclerotic disease can be life-threatening. Stroke is a significant devastating complication of coronary artery bypass graft (CABG), and carotid artery disease is a significant risk factor. Myocardial infarction is most common cause of morbidity and mortality during and following carotid endarterectomy (CEA). Nearly 25% of patients presenting for CEA and CABG have concomitant disease. The purpose of this study is to evaluate the safety and efficacy of carotid artery stenting (CAS) before CABG in patients with concomitant surgical coronary and significant carotid artery disease. Methods: A retrospective analysis was performed in 35 consecutive patients who underwent CAS before CABG. Patients were with symptomatic or asymptomatic carotid artery stenosis, with more than 60% luminal diameter on duplex ultrasonography in fully accredited vascular laboratory and with surgical coronary artery disease. All patients received periprocedural intravenous glycoprotein IIb/IIIa inhibitor and fractionated heparin to maintain activated clotting time of 200 to 250 seconds during the procedure. GP IIb/IIIa inhibitor was continued for up to 48 hours, after which, CABG was performed. The primary end point of this study was angiographic success and cumulative incidence of periprocedural events, transient ischemic attacks (TIA), stroke, myocardial infarction (MI) and death during hospital stay and within 30 days post CABG.

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Results: The angiographic success was achieved in all 35 patients without any periprocedural events. There was no incidence of TIA, stroke, MI or death occurring during both procedures (CABG and CAS) or during the hospital stay. All the events occurring from hospital discharge to 30 days were included. There was no incidence of TIA, stroke, MI or death within the 30-day follow-up period. Conclusion: CAS before CABG is safe and effective in management of concomitant surgical coronary artery disease and significant carotid artery disease and it eliminates the increased morbidity and mortality associated with staged or combined CEA and CABG. doi:10.1016/j.carrev.2008.02.016

Superior efficacy of low-molecular-weight heparin vs unfractionated heparin in acute coronary syndrome without ST elevation F Aslam Ali, Islamabad, Pakistan Background: In acute coronary syndrome (ACS) without ST elevation, there is conflicting evidence regarding the efficacy of low-molecular-weight heparin (LMWH) vs unfractionated heparin (UFH). We performed a metaanalysis of trials comparing LMWH vs UFH on the combined criteria of death or myocardial infarction in ACS. Methods: Randomized trials were identified using Medline and Google scholar. Relative risk (RR) was calculated with published data. Seven trials including 15 678 patients fulfilled the inclusion criteria [Gurfinkel, Fragmin to Unstable Coronary Artery Disease Study (FRIC), FRICS, FRICS II, Efficacy and Safety of Subcutaneous enoxaparin in Non-Q-wave Coronary Events (ESSENCE), Thrombolysis in Myocardial Infarction (TIMI phase II), Fraxiparine in Ischaemic Syndrome (FRAXIS)]. Results: Meta-analysis of these trials demonstrated superiority of LMWH vs UFH to reduce death or MI during the acute phase (6-8 days) (RR, 0.83; 95% CI, 0.7-0.99). Heterogeneity test was not significant (P=.47), but subgroup analysis according to the type of LMWH showed that amplitude of benefit was highest with enoxaprin (RR, 0.78; 95% CI, 0.630.96; P=.02) compared to deltaparin (RR, 1.09; 95% CI, 0.65-1.82) or nardoparin (RR, 0.92; 95% CI, 0.62-1.37). Meta-analysis of long-term LMWH administration trials showed that no additional benefit (RR, 0.98; 95% CI, 0.82-1.18; P=.78) was obtained when considering only events occurring after the acute phase. During the acute phase, no significant difference was observed for major bleeding (RR, 1.01; 95% CI, 0.811.26). However minor bleeding was significantly increased by LMWH (RR, 1.96; 95% CI, 1.65-2.61; Pb.001). Prolonged administration significantly increased the major bleeding rate (RR, 2.27; 95% CI, 1.63-3.18; Pb.001). Conclusion: When considering ischemic events during the first week of ACS, there is significant favorable class effect for LMWH compared to UFH. However, prolonged LMWH treatment increases major bleeding without significant additional benefit on ischemic events. doi:10.1016/j.carrev.2008.02.017

Real-world percutaneous coronary intervention experience comparing Taxus paclitaxel-eluting with Cypher sirolimus-eluting stent platforms MS Sidhu, JR Brown, DJ Malenka, AV Kaplan, JT Devries, BJ Friedman, BD Hettleman, NW Niles, JF Robb, CA Thompson Dartmouth Hitchcock Medical Center, Lebanon, NH Background: Limited extended follow-up data on target vessel revascularization and mortality exist comparing unselected utilization of sirolimuseluting stents (SES) and paclitaxel eluting stents (PES) in percutaneous coronary intervention (PCI). Methods: We prospectively followed 2363 consecutive patients undergoing primary PCI at Dartmouth Hitchcock Medical Center who received either SES (n=1012) or PES (n=1332) from April 2004 to July 2006. All-cause

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Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129 Significance of hypertension in hypertophic cardiomyopathy F Aslam Ali, Islamabad, Pakistan

Fig. 1.

mortality was ascertained from the social security master death file. Target vessel revascularization was defined as a repeat intervention on the same vessel (right, left, circumflex, or left main) or death during the study period. Kaplan Meier and Cox proportional hazard survival methods were performed, adjusted for age, sex, diabetes, priority indication, prior coronary artery bypass graft, congestive heart failure, renal function, number of stents implanted, and number of diseased vessels. Results: There was 2.3 years of follow-up (mean, 1.1 years). Target vessel revascularization at 1 (2.7% SES vs 3.8% PES, P=.12) and at 2.3 (3.8% SES vs. 5.4% PES, P=.06) years was similar between the stent platforms. Overall, 2.3-year mortality was 3.0% for SES and 4.3% for PES (P=.08). Target vessel revascularization–free survival at 2.3 years was 91.3% for SES and 86.6% for PES (P=.06) with adjusted hazard ratio of 1.39 (95% CI, 0.99-1.97). Conclusion: Sirolimus-eluting stents and PES platforms had similar outcomes and both performed well in this contemporary, unselected, realworld PCI experience. Fig. 1 doi:10.1016/j.carrev.2008.02.018

Relief of migraine headaches associated with closure of patent foramen ovale F Aslam Ali, Islamabad, Pakistan Objective: The incidence of patent foramen ovale (PFO) in patients with migraine is at least twice that of the general population. However, few reports demonstrate the impact of PFO closure on the relief of migraine headaches. We retrospectively surveyed PFO closure patients to determine if those with migraines were improved after PFO closure. Methods: Between January 2001 and December 2004, 52 PFOs were closed percutaneously using the Cardioseal or Amplatzer devices for patients with a history of prior transient ischemic attack or stroke. At a mean of 28 months post PFO closure, all patients were called to identify the presence, frequency, and type of migraine headache (MH) episode occurring pre- and postprocedure. Migraine headache and associated aura were defined according to the criteria of the International Headache Society. Patients were not informed that PFO closure might have any impact on MH. Results: Among a total of 52 PFO closure patients, 22 (42%) had MH and 12 of 22 had aura. The average age of MH patients was 44 years, and 55% were women. Follow-up transthoracic echocardiography showed complete PFO closure in all patients. Of 22, 8 (36%) had complete relief of MH, and 8 (36%) had partial relief. There was a cumulative reduction in the frequency of MH from 3.06 to 0.05 episodes per patient per month. Conclusion: This observational study demonstrated that PFO closure can reduce, and frequently eliminate, migraine episodes and suggests that, in some patients with MH, PFOs may have a role in the genesis of the headache. doi:10.1016/j.carrev.2008.02.019

Background: Systemic hypertension (SH) and hypertrophic cardiomyopathy (HCM) are important causes of left ventricular hypertrophy. The frequency of coexistence of the 2 conditions increases with age and poses significant diagnostic and management challenges. It is unclear to what extent one disease affects the cardiac phenotypic expression and clinical outcome of the other. The purpose of this study was to compare the echocardiographic and clinical outcome of patients with HCM and with and without SH. Methods: From 1995 to 2005, 196 adults with HCM were evaluated at our institution. Hypertrophic cardiomyopathy was defined as primarily nonuniformly hypertrophied heart with a minimum left ventricular wall thickness of 15 mm. Among these, 122 (62%, group 1) also had SH, defined as blood pressure above 140/90 mm Hg. The clinical presentation, management, outcome, and echocardiographic findings of these patients were compared to 74 (38%, group 2) without SH. Results: Patients in group 1 were older at the time of HCM diagnosis and had higher prevalence of diabetes (28% vs 9%, P=.02) and coronary artery disease (40% vs 25%, P=.03). In addition, echocardiography showed significantly higher prevalence of systolic anterior motion of the anterior mitral valve in association with dynamic left ventricular outflow obstruction (52% vs 19%, P=.02) and mitral annular calcification (27% vs 13%, P=.03) in group 1 patients. Left ventricular wall thickness (17 vs 19 mm), enddiastolic diameter (42 vs 42 mm), resting outflow tract gradient above 30 mm Hg (17% vs 16%), and ejection fraction (65% vs 64%) were similar in the 2 groups. Follow-up (mean months) did not reveal statistically significant difference in angina, syncope, heart failure, atrial fibrillation, or stroke between the 2 groups. Although total mortality was similar (39 vs 15, P=.07), more group 1 patients died of noncardiac causes (30 vs 11, P=.01). Conclusion: Hypertrophic cardiomyopathy frequently coexists with SH in the adult population. Presence of SH in HCM patients is associated with older age and higher risk of diabetes, coronary artery disease, and noncardiac death. Cardiac morphologic findings are largely similar in HCM patients with and without SH. doi:10.1016/j.carrev.2008.02.020

Clinical features and outcomes of patients with apical hypertrophic cardiomyopathy F Aslam Ali, Islamabad, Pakistan Background: The apical hypertrophic cardiomyopathy (ApHCM) is a relatively rare form of hypertrophic cardiomyopathy (HCM) in which the hypertrophy of myocardium predominantly involves the apex of left ventricle. The characteristic feature of ApHCM is the presence of deep symmetrical T-wave inversion on electrocardiogram (ECG) and a spadelike configuration of the left ventricular cavity at end diastole on echo. Aim: The aim of this study was to analyze clinical characteristics and outcome of patients with ApHCM. Methods: We analyzed 196 patients with echocardiographically documented HCM at our tertiary care center from 1995 to 2005. Among them, there were 14 patients with ApHCM. All patients were assessed on at least 2 occasions, and data were collected retrospectively on demographic characteristics, symptoms, ECG and results of transthoracic echocardiography (TTE). Results: There were 5 male patients with a mean age of 65 years. Symptoms on initial presentation included chest pain (35%), palpitation (35%), and heart failure (14%). On ECG, 9 patients had T-wave inversion. Transthoracic echocardiography revealed a mean apical wall thickness of 15.3 mm, and mean ratio of apical to posterior wall thickness was 1.6. There was no case of apical aneurysm in our study population. During the mean follow-up of 3±2 years, 3 patients died, 1 of cardiac and 2 of noncardiac causes. One