Treatment of Late Thrombosis of Drug-eluting Stent Using a Thrombus Extraction Catheter We report on the case of a 69-year-old patient with late thrombosis of a drug-eluting stent, admitted to hospital with anterior AMI, who was successfully treated using a thrombus extraction catheter (Pronto TM V3). DESCRIPTORS: Stents. Coronary thrombosis. Thrombectomy. RESUMO Relatamos o caso de um paciente de 69 anos com trombose tardia de stent farmacológico, admitido com infarto agudo do miocárdio anterior, tratado com sucesso com o uso de cateter de aspiração de trombos (Pronto TM V3).
Background Major disparities exist between developed and developing countries in Acute Myocardial Infarction (AMI) outcomes. Telemedicine has emerged as a powerful, cost-efficient, and scalable tool for population-based AMI management. We propose efficient telemedicine protocols as frontline AMI strategies for resource-constrained developing countries. Purpose To create a global template of using telemedicine protocols for treating AMI. Methods A hub and spoke strategy was utilized for Latin America Telemedicine Infarct Network (LATIN) to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics and primary care health centers in remote areas were strategically connected with 24/7 primary PCI facilities. Experts at 4 remote sites provided urgent EKG diagnosis and tele-consultation that triggered ambulance dispatch and implementation of standardized AMI protocols. Results 784,947 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With this expanded geographic reach, 8,448 (1.08%) patients were diagnosed with STEMI and 3,911 (46.3%) urgently reperfused, including 3,049 (78%) with Primary PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Major reasons for non-treatment were insurance denials, lack of ICU beds and chest pain >12 hours. Conclusions LATIN demonstrates the feasibility of a population-based and telemedicine guided AMI strategy that can hugely expand access. Telemedicine has important public health implications as a global approach to AMI care in developing countries.
Background The behemoth telemedicine program, Latin America Telemedicine Infarct Network (LATIN) has exponentially grown in 4 countries in Central and South America. It has provided AMI coverage to >100 million patients and it has contributed to transforming AMI care in the continent by its “halo” effect. We continue our meticulous search in evaluating the impact of LATIN and in doing so, we have confronted a sobering reality. Purpose To make continued improvements in population-based AMI management, the continued success of the initiative requires participation from healthcare policy makers, health economists, and payers. Methods LATIN was created as a hub and spoke model to hugely increase access (>100 million population coverage) to quality AMI treatment primarily with short door to balloon time (D2B) PCI. Innovative telemedicine platforms were created and networked at all 350 centers that were located in small clinics and primary health centers in poor sections of the countries (spokes) and at 24/7 PCI capable institutions (hubs). Remote cardiologists, located in 3 central locations, provided immediate EKG diagnosis (time to telemedicine diagnosis, TTD <3.5 minutes) and they provided expert guidance for the entire STEMI process, Door in Door Out (DIDO), and transport times (TT). LATIN performance metrics, under its strict control, and including process metrics at the hubs, spokes, and at the command telemedicine sites, were measured and plotted. The macroeconomic variables of insurance approvals, ambulance structure, and availability of ICU beds were determined and incorporated into performance variables of the LATIN program. Results 784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Over 4 years of operation, the proportion of reperfused STEMI patients has ranged between 41–48% - the major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation. Conclusions Sustained improvements, as a result of stringent QA processes and continuous education, have resulted in reduced D2B, TTD, DIDO, TT, and in overall mortality. However, LATIN remains constrained with a large proportion of patients that are diagnosed but not treated, largely because of payer denials. Although this metric is showing improvement from broad dissemination of LATIN benefits, further gains from LATIN will result mainly from improved reimbursements.
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