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TCT-388 Does ST Segment Elevation in Lead aVR Correlate with Left Main Occlusion?
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
collateral quality decay
Collateral quality decay
Collateral quality improvement
LVEF B
LVEF 4M
LVEDV B
LVEDV
(%)
(%)
p-value
(ml)
4M (ml)
p-value
41.1
45.5
0.022*
232.4
208 [171-
0.845*
[29.8-
[35.3-
[189-265]
252]
47.3]
55.0]
21.4 [7.6-
36.2
21.4]
[27.9-
0.180
ˇ
CATEGORIES STRUCTURAL: Valvular Disease: Aortic
Table 1. CMR measurements at baseline (B) and 4 month (4m) follow-up in patients with and without
312.1[305-
271.8
312]
[193-359]
190 [166-
205 [169-
247]
245]
0.180
ˇ
cardiogenic shock and high log.ES. Indication for TAVR in these patients (high log.ES and cardiogenic shock) needs to be intensively discussed before the procedure specifically for each patient. Patients with lower log.ES seem to have a low 30-day mortality. High device success shows that the procedure in this very sick patient population is feasible and safe. Overall, echocardiographic LVEF and hemodynamic CO and SV improved directly after TAVR despite very sick patients with severe reduced LV function.
B159
47.8] No collateral quality change
OUTCOMES AFTER PRIMARY PCI - II
43.4
45.1
[32.6-
[37.6-
51.1]
52.3]
0.006#
0.063#
ˇ
*n¼18, n¼2, #n¼67
Abstract nos: 387 - 391 TCT-387 Collateral quality decay several days after primary PCI: a novel observation from the EXPLORE trial. Ivo M. van Dongen,1 Joelle Elias,2 K. Gert van Houwelingen,3 Pierfrancesco Agostoni,4 Bimmer EPM Claessen,1 Loes P. Hoebers,1 Dagmar Ouweneel,5 Rene van der Schaaf,6 Jan Tijssen,7 Jose PS Henriques1 1 Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 2Academic Medical Centre (AMC) - University of Amsterdam, Amsterdam, Netherlands; 3Thoraxcentrum Twente, MST Enschede, Enschede, Netherlands; 4Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands; 5Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 6OLVG, Amsterdam, Netherlands; 7AMC, Naarden, Netherlands BACKGROUND Collaterals towards a concomitant CTO are associated with improved outcome.In the EXPLORE trial, a novel observation was encountered: a decrease in collateral quality to the CTO right before CTO PCI. We have assessed the impact of this on functional and clinical outcome. METHODS All angiograms were corelab analyzed.Well-developed (Rentrop grade 2-3) and poorly-developed (grade 0-1) collaterals were identified.LVF was measured with CMR.Long-term follow-up (median 3.9 years) was collected prospectively. RESULTS Before CTO PCI, a decay in collateral quality compared to primary PCI was observed in 34 of patients randomized to CTO PCI, and in 4 patients an increase was seen.CMR outcomes are shown in table 1.KM curves of MACE and all-cause death are shown in figure 1.
CONCLUSION An unique notion was made in the EXPLORE trial: 23.1% of patients with well-developed collaterals to the CTO during STEMI PCI show quality decay of the collateralization within one week.This is associated with a modest difference in cardiac function and long-term outcomes (mainly MACE) compared to patients without any change in collateral quality, which could suggest that the capability to improve quality of collaterals to a CTO during STEMI may have a protective role.However, this should be further investigated in a larger CTO population. CATEGORIES CORONARY: PCI Outcomes TCT-388 Does ST Segment Elevation in Lead aVR Correlate with Left Main Occlusion? Ahmed Harhash,1 Sridhar Reddy,1 Jennifer Huang-Tsang,1 Balaji Natarajan,1 Mahesh Balakrishnan,1 Ranjith Shetty,1 Mathew Hutchinson,1 Karl Kern2 1 University of Arizona, Tucson, Arizona, United States; 2Univ of Arizona, Tucson, Arizona, United States BACKGROUND Prompt identification of ST-elevation myocardial infarction (STEMI) on ECG is critical as early reperfusion can be lifesaving. The ACCF/AHA guidelines established that ST elevation (STE) must be present in at least 2 contiguous leads to qualify for a diagnosis of STEMI. STE in aVR, co-existent with multi-lead ST depression (STD), was endorsed as a sign for left main (LM) or proximal LAD occlusion. Previous studies have described the association of multivessel disease with STD in the inferolateral leads with reciprocal STE in aVR. We sought to investigate the incidence of an acutely occluded vessel (i.e. STEMI) versus severe multi-vessel CAD without a total occlusion (i.e. NSTEMI) in patients (pts) presenting with STE-aVR. METHODS STEMI activations between January 2014 and November 2016 were identified by retrospective chart review. Patients with admission ECG showing STE-aVR co-existent with multi-lead STD were enrolled. All ECGs and coronary angiograms were blindly analyzed by experienced cardiologists. Patients’ demographics, presenting complaint, labs, hospital course, and in-hospital mortality were collected. Descriptive analysis was performed using STATA 12.0. RESULTS Among 604 STEMI activations, 66 pts (11%) were identified with STE-aVR. Of those, 24 (36%) presented with cardiac arrest, and 53 (80%) underwent emergent coronary angiography. Culprit coronary occlusion was identified in only 5 pts (9%). Thirty-four pts (64%) were found to have severe diffuse CAD but with distal TIMI 3 flow and 19 pts (36%) had mild or no disease. It was unclear whether the occlusion was acute or chronic in 3 pts. STE-aVR was associated with 32% inhospital mortality, compared to only 6.2% in a 190 randomly sampled STEMIs in the same study period(p<0.001). CONCLUSION STE-aVR was associated with acutely thrombotic coronary occlusion in only 9% of pts. These patients had a five-fold higher in-hospital mortality compared to the overall STEMI population. Majority had severe diffuse disease with extensive comorbidities and prior PCI or CABG. Urgent cardiology evaluation is warranted but routine STEMI activation based on this ECG finding alone should be reconsidered in pts presenting with critical illness. CATEGORIES CORONARY: Acute Coronary Syndromes TCT-389 Does well-developed coronary collateral circulation have an influence on myocardial viability in late presentation myocardial infarction? Alejandro Gutierrez-Barrios,1 Dolores Cañadas,2 Enrique Diaz-Retamino,3 German Calle Perez,4 Rafael Vázquez-García1 1 Hospital Puerta del Mar, Cádiz, Spain; 2Hospital de Jerez, Jerez de la
collateral quality decay
Collateral quality decay
Collateral quality improvement
LVEF B
LVEF 4M
LVEDV B
LVEDV
(%)
(%)
p-value
(ml)
4M (ml)
p-value
41.1
45.5
0.022*
232.4
208 [171-
0.845*
[29.8-
[35.3-
[189-265]
252]
47.3]
55.0]
21.4 [7.6-
36.2
21.4]
[27.9-
0.180
ˇ
CATEGORIES STRUCTURAL: Valvular Disease: Aortic
Table 1. CMR measurements at baseline (B) and 4 month (4m) follow-up in patients with and without
312.1[305-
271.8
312]
[193-359]
190 [166-
205 [169-
247]
245]
0.180
ˇ
cardiogenic shock and high log.ES. Indication for TAVR in these patients (high log.ES and cardiogenic shock) needs to be intensively discussed before the procedure specifically for each patient. Patients with lower log.ES seem to have a low 30-day mortality. High device success shows that the procedure in this very sick patient population is feasible and safe. Overall, echocardiographic LVEF and hemodynamic CO and SV improved directly after TAVR despite very sick patients with severe reduced LV function.
B159
47.8] No collateral quality change
OUTCOMES AFTER PRIMARY PCI - II
43.4
45.1
[32.6-
[37.6-
51.1]
52.3]
0.006#
0.063#
ˇ
*n¼18, n¼2, #n¼67
Abstract nos: 387 - 391 TCT-387 Collateral quality decay several days after primary PCI: a novel observation from the EXPLORE trial. Ivo M. van Dongen,1 Joelle Elias,2 K. Gert van Houwelingen,3 Pierfrancesco Agostoni,4 Bimmer EPM Claessen,1 Loes P. Hoebers,1 Dagmar Ouweneel,5 Rene van der Schaaf,6 Jan Tijssen,7 Jose PS Henriques1 1 Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 2Academic Medical Centre (AMC) - University of Amsterdam, Amsterdam, Netherlands; 3Thoraxcentrum Twente, MST Enschede, Enschede, Netherlands; 4Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands; 5Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 6OLVG, Amsterdam, Netherlands; 7AMC, Naarden, Netherlands BACKGROUND Collaterals towards a concomitant CTO are associated with improved outcome.In the EXPLORE trial, a novel observation was encountered: a decrease in collateral quality to the CTO right before CTO PCI. We have assessed the impact of this on functional and clinical outcome. METHODS All angiograms were corelab analyzed.Well-developed (Rentrop grade 2-3) and poorly-developed (grade 0-1) collaterals were identified.LVF was measured with CMR.Long-term follow-up (median 3.9 years) was collected prospectively. RESULTS Before CTO PCI, a decay in collateral quality compared to primary PCI was observed in 34 of patients randomized to CTO PCI, and in 4 patients an increase was seen.CMR outcomes are shown in table 1.KM curves of MACE and all-cause death are shown in figure 1.
CONCLUSION An unique notion was made in the EXPLORE trial: 23.1% of patients with well-developed collaterals to the CTO during STEMI PCI show quality decay of the collateralization within one week.This is associated with a modest difference in cardiac function and long-term outcomes (mainly MACE) compared to patients without any change in collateral quality, which could suggest that the capability to improve quality of collaterals to a CTO during STEMI may have a protective role.However, this should be further investigated in a larger CTO population. CATEGORIES CORONARY: PCI Outcomes TCT-388 Does ST Segment Elevation in Lead aVR Correlate with Left Main Occlusion? Ahmed Harhash,1 Sridhar Reddy,1 Jennifer Huang-Tsang,1 Balaji Natarajan,1 Mahesh Balakrishnan,1 Ranjith Shetty,1 Mathew Hutchinson,1 Karl Kern2 1 University of Arizona, Tucson, Arizona, United States; 2Univ of Arizona, Tucson, Arizona, United States BACKGROUND Prompt identification of ST-elevation myocardial infarction (STEMI) on ECG is critical as early reperfusion can be lifesaving. The ACCF/AHA guidelines established that ST elevation (STE) must be present in at least 2 contiguous leads to qualify for a diagnosis of STEMI. STE in aVR, co-existent with multi-lead ST depression (STD), was endorsed as a sign for left main (LM) or proximal LAD occlusion. Previous studies have described the association of multivessel disease with STD in the inferolateral leads with reciprocal STE in aVR. We sought to investigate the incidence of an acutely occluded vessel (i.e. STEMI) versus severe multi-vessel CAD without a total occlusion (i.e. NSTEMI) in patients (pts) presenting with STE-aVR. METHODS STEMI activations between January 2014 and November 2016 were identified by retrospective chart review. Patients with admission ECG showing STE-aVR co-existent with multi-lead STD were enrolled. All ECGs and coronary angiograms were blindly analyzed by experienced cardiologists. Patients’ demographics, presenting complaint, labs, hospital course, and in-hospital mortality were collected. Descriptive analysis was performed using STATA 12.0. RESULTS Among 604 STEMI activations, 66 pts (11%) were identified with STE-aVR. Of those, 24 (36%) presented with cardiac arrest, and 53 (80%) underwent emergent coronary angiography. Culprit coronary occlusion was identified in only 5 pts (9%). Thirty-four pts (64%) were found to have severe diffuse CAD but with distal TIMI 3 flow and 19 pts (36%) had mild or no disease. It was unclear whether the occlusion was acute or chronic in 3 pts. STE-aVR was associated with 32% inhospital mortality, compared to only 6.2% in a 190 randomly sampled STEMIs in the same study period(p<0.001). CONCLUSION STE-aVR was associated with acutely thrombotic coronary occlusion in only 9% of pts. These patients had a five-fold higher in-hospital mortality compared to the overall STEMI population. Majority had severe diffuse disease with extensive comorbidities and prior PCI or CABG. Urgent cardiology evaluation is warranted but routine STEMI activation based on this ECG finding alone should be reconsidered in pts presenting with critical illness. CATEGORIES CORONARY: Acute Coronary Syndromes TCT-389 Does well-developed coronary collateral circulation have an influence on myocardial viability in late presentation myocardial infarction? Alejandro Gutierrez-Barrios,1 Dolores Cañadas,2 Enrique Diaz-Retamino,3 German Calle Perez,4 Rafael Vázquez-García1 1 Hospital Puerta del Mar, Cádiz, Spain; 2Hospital de Jerez, Jerez de la