Background: Conflicting data exist regarding the benefit of urgent coronary angiogram and percutaneous coronary intervention (PCI) after sudden cardiac arrest, particularly in the absence of ST-segment elevation. We hypothesized that the type of lesions treated (stable versus unstable) influences the benefit derived from PCI. Methods: Data were taken between May 2011 and 2014 from a prospective registry enrolling all sudden cardiac arrest in Paris and suburbs (6.7 million inhabitants). Patients undergoing emergent coronary angiogram were included. Decision to perform PCI was left to the discretion of local teams. We assessed the impact of emergent PCI on survival at discharge according to whether the treated lesion was angiographically unstable or stable, and we investigated the predictive factors for unstable coronary lesions. Results: Among 9265 sudden cardiac arrests occurring during the study period, 1078 underwent emergent coronary angiogram (median age: 59.6 years, 78.3% males): 463 (42.9%) had an unstable lesion, 253 (23.5%) only stable lesions, and 362 (33.6%) no significant lesions. Emergent PCI was performed in 478 patients (91.4% of unstable and 21.7% of stable lesions). At discharge, PCI of unstable lesions was associated with twice-higher survival rate compared with untreated unstable lesions (47.9% versus 25.6%, P =0.013), while stable lesions PCI did not improve survival (25.5% versus 26.3%, P =1.00). After adjustment, PCI of unstable coronary lesions was independently associated with improved survival (odds ratio, 2.09 [95% CI, 1.42–3.09], P <0.001), contrary to PCI of stable lesions (odds ratio, 0.92 [95% CI. 0.44–1.87], P =0.824). Angina, initial shockable rhythm, ST-segment elevation, and absence of known coronary artery disease were independent predictors of unstable lesions. Conclusions: Emergent PCI of unstable lesions is associated with improved survival after sudden cardiac arrest, contrary to PCI of stable lesions. Accordingly, early PCI should only be performed in patients with unstable lesions. Four factors (chest pain, ST-elevation, absence of coronary artery disease history, and shockable initial rhythm) could help identify patients with unstable lesions who would, therefore, benefit from emergent coronary angiogram.
SummaryAim: Cryptogenic stroke remains the final diagnosis in 40% of ischemic acute cerebrovascular events. Until now there are no clinical evidences that the percutaneous closure of PFO is able to prevent the recurrence of stroke or transient ischemic attack (TIA). The aim of this study was to evaluate the incidence of recurrence in patients successfully. Treated by percutaneous closure of PFO with different occlude devices by using TDC, TTE and clinical evaluation. Material and Method:From June 2004 to February 2010, 72 PTS, (40 females and 32 males; everage age 46 yrs, range 14-66), admitted with diagnosis of recurrent ischemic neurologic events (58 stroke and 14 TIA)underwent percutaneous closure of PFO. Thirty-one (43%) of the 72 patients had a concomitant history of migraine, 16(52%) of whom with aura. Five different occlude devices were used, with a total amount of 74 implants. All pts were studied during the follow-up by clinical evaluation (Rankin modified scale), TCD and TTE.Results: Successful device deployment is achieved in 100% of pts without any periprocedural major complication. Only in two pts atrial arrhythmia have occurred. All pts was discharged within 3 days in good overall conditions. In all pts a double antiplatelet regimen was adopted. The follow-up was complete in 100% of the cases (median 30, range 3-58 months). At five years, there was no recurrent stroke or TIA, and no new cerebral lesions developed by MRI in those patients with residual shunt. Moreover, in 65 (90%)of them the Rankin scale significantly (P<0.0001) reduced to 0 whereas only in 2 pts score 1 was reached. In 19 (61%) of the 31 pts with concomitant migraine, the intensity and the frequency of the attacks significantly (P<0.0001) decreased over time. At the TCD, 5 pts (7%) resulted positive for microembolic signals but, only 1 of them, was successfully treated for an associate defect. The TTE evaluation showed however an optimal sealing of all the devices without signs of erosion, incomplete closure and thrombus formation around the device. Conclusion:Our experience suggests that percutaneous treatment of PFO is safe and beneficial at the medium term follow-up for secondary prevention since able to prevent the clinical recurrence of acute cerebrovascular events irrespective of the device used.Keywords: Stroke, paradoxical embolism, percutaneous transcatheter.Pollice F, Pollice P, Jacob L. Percutaneous transcatheter closure of patent foramen ovale in patients with paradoxical embolism.
Objective: Diabetics with coronary artery disease face a high risk of adverse events following coronary revascularization. However, recurrence rates of after the first revascularization have never been appraised. The aim of this study was to evaluate recurrent events in diabetics undergoing percutaneous coronary intervention (PCI) in the current era. Material and Method: Authors collected baseline and outcome data of consecutive type-2 diabetics treated with PCI (January 2005-December 2008). End-points of interest were the long-term rates of major adverse cardiac events (MACE: cardiac death, myocardial infarction [MI], percutaneous target vessel revascularization [TVR-PCI], or coronary artery bypass grafting [CABG]), non-TVR PCI, and stent thrombosis. Results: A total of 429 diabetics were included, 191 (44%) insulin-dependent, with drug-eluting stents implanted in 232 (54%). After a median of 38 months, events were as follows: MACE in 167 (38.9%) subjects, cardiac death in 38 (8.8%), MI in 42(9.8%), TVR PCI in 130 (30.3%), CABG in 11 (6.2%), non-TVR PCI in 52 (12.1%), and definite stent thrombosis (2.1%). Among the 129 patients undergoing TVR PCI as first event, as many as 28 (21.7%) underwent a second TVR PCI, 7 (5.4%) underwent a third TVR PCI, and a further 2 (1.5%) underwent a fourth TVR PCI, whereas CABG was performed in 2 (1.5%)and non-TVR PCI in 4 (3.1%). Conclusion: This work, originally reporting on risk of recurrent repeat revascularization events among diabetics treated with PCI, showed that adverse events occur frequently in these patients, but can be managed in most cases safely and successfully by means of repeat PCI only.
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