Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care** and Thrombosis of the European Society of Cardiology

Radial access use has been growing steadily but, despite encouraging results, still varies greatly among operators, hospitals, countries and continents. Twenty years from its introduction, it was felt that the time had come to develop a common evidence-based view on the technical, clinical and organisational implications of using the radial approach for coronary angiography and interventions. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) has, therefore, appointed a core group of European and non-European experts, including pioneers of radial angioplasty and operators with different practices in vascular access supported by experts nominated by the Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology (ESC). Their goal was to define the role of the radial approach in modern interventional practice and give advice on technique, training needs, and optimal clinical indications.

Comparison of the feasibility and effectiveness of transradial coronary angiography via right versus left radial artery approaches (from the PREVAIL Study)

It remains undefined if transradial coronary angiography from a right or left radial arterial approach differs in real-world practice. To address this issue, we performed a subanalysis of the PREVAIL study. The PREVAIL study was a prospective, multicenter, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures over a 1-month observation period, specifically aimed at assessing the outcomes of radial approach in the contemporary real world. The choice of arterial approach was left to the discretion of the operator. Prespecified end points of this subanalysis were procedural characteristics. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization, 304 with a right radial and 205 with a left radial approach. Procedural success rates were similar between the 2 groups. Compared to the left radial group, the right radial group had longer procedure duration (46 ± 29 vs 33 ± 24 minutes, p <0.0001) and fluoroscopy time (765 ± 787 vs 533 ± 502, p <0.0001). At multivariate analysis, including a parsimonious propensity score for the choice of left radial approach, duration of procedure (beta coefficient 11.38, p <0.001) and total dose-area product (beta coefficient 11.38, p <0.001) were independently associated with the choice of the left radial artery approach. The operator's proficiency in right/left radial approach did not influence study results. In conclusion, right and left radial approaches are feasible and effective to perform percutaneous procedures. In the contemporary real world, however, the left radial route is associated with shorter procedures and lower radiologic exposure than the right radial approach, independently of an operator's proficiency.

Propagation of the Sinus Impulse Into the Koch Triangle and Localization, Timing, and Origin of the Multicomponent Potentials Recorded in This Area

Background—

The presence of a conduction block at the level of the Koch triangle (KT) and the origin of the multicomponent potentials inside this area are controversial issues. We investigated the propagation of the sinus impulse into the KT and the characteristics of multicomponent potentials recorded in that area in patients with and without atrioventricular nodal reentrant tachycardia (AVNRT).

Methods and Results—

Thirty-two patients (16 with AVNRT, 16 without AVNRT) underwent a sinus rhythm electroanatomic mapping of the right atrium (RA). Conduction velocities in the RA and in the KT were evaluated quantitatively on activation maps and qualitatively on isochronal and propagation maps. The presence, location, and timing of different types of multicomponent potentials were evaluated. A mean of 149±44 points were sampled in the RA, whereas a mean of 79±21 points were collected inside the KT. Propagation block at the level of crista terminalis was not found in any patient, whereas slow conduction inside the KT was found in all (median conduction velocity, 122 cm/s [110 to 135 cm/s] outside KT versus 60 cm/s [48 to 75 cm/s] inside KT; P <0.0001). Jackman potentials were identified inside KT in almost all the patients and were invariably found on the line of collision between the wavefronts activating the KT in opposite directions.

Conclusions—

No conduction block was detected inside the KT in patients with and without AVNRT. Conduction slowing was demonstrated during propagation of the sinus impulse inside the KT. The genesis of the Jackman potential may be related to the collision of the wavefronts activating KT in opposite directions.

Recovery of distal coronary flow reserve in LAD and LCx after Y-Graft intervention assessed by transthoracic echocardiography

BACKGROUND

Y- graft (Y-G) is a graft formed by the Left Internal Mammary Artery (LIMA) connected to the Left Anterior Descending Artery (LAD) and by a free Right Internal Mammary Artery (RIMA) connected to LIMA and to a Marginal artery of Left Circumflex Artery (LCx). Aim of the work was to study the flow of this graft during a six months follow-up to assess whether the graft was able to meet the request of all the left coronary circulation, and to assess whether it could be done by evaluation of coronary flow reserve (CFR).

METHODS

In 13 consecutive patients submitted to Y-G (13 men), CFR was measured in distal LAD and in distal LCx from 1 week after , every two months, up to six months after operation (a total of 8 tests for each patient) by means of transthoracic echocardiography (TTE) and Adenosine infusion (140 mcg/kg/min for 3-6 min). A Sequoia 256, Acuson-Siemens, was used. Contrast was used when necessary (Levovist 300 mg/ml solution at a rate of 0,5-1 ml/min). Max coronary flow diastolic velocity post-/pre-test > or =2 was considered normal CFR.

RESULTS

Coronary arteriography revealed patency of both branches of Y-G after six months. Accuracy of TTE was 100% for LAD and 85% for LCx. Feasibility was 100% for LAD and 85% for LCx. CFR improved from baseline in LAD (2.21 +/- 0.5 to 2.6 +/- 0.5, p = 0.03) and in LCx (1.7 +/- 1 to 2.12 +/- 1, p = 0.05). CFR was under normal at baseline in 30% of patients vs 8% after six months in LAD (p = 0.027), and in 69% of patients vs 30% after six months in LCx (p = 0.066).

CONCLUSION

CFR in Y-G is sometimes reduced in both left territories postoperatively but it improves at six months follow-up. A follow-up can be done non-invasively by TTE and CFR evaluation.

Safety of drug eluting stents in patients on chronic anticoagulation using long-term single antiplatelet treatment with clopidogrel

BACKGROUND

Use of triple therapy with aspirin, clopidogrel, and anticoagulants significantly increases bleeding, thus drug eluting stents (DES) are usually avoided in patients requiring anticoagulation. We tested use of DES vs. BMS using a long-term therapy with clopidogrel only and anticoagulants in this group of patients.

METHODS

We enrolled 165 consecutive patients, 79 receiving DES (age 67 +/- 9 years, 84% with atrial fibrillation) and 86 receiving bare metal stents (BMS) (age 70 +/- 11 years, 71% with atrial fibrillation). All patients received aspirin + clopidogrel + oral anticoagulants for 4 weeks, then aspirin was stopped and clopidogrel was continued during the 12-month follow-up. Primary end point was the combined incidence of major adverse coronary events and major bleedings.

RESULTS

Incidence of the primary endpoint was 10.1% in patients with DES and 26.7% in patients with BMS (P = 0.01). There was a large difference in incidence of target vessel revascularization (8.1% for DES, 23.3% for BMS, P = 0.01), whereas incidence of myocardial infarction (3.8% in DES vs. 8.1% in BMS) and major bleeding (1.3% vs. 2.3%, respectively) were not significantly different. There were no cases of stent thrombosis. On multivariate Cox regression analysis, the only factor associated with a reduced risk of the primary endpoint was use of DES (hazard ratio 0.35 with 95% confidence interval 0.14-0.85, P = 0.02).

CONCLUSIONS

Results of our cohort study suggest that use of DES associated with a treatment with clopidogrel only may be safe and significantly reduce the need for new revascularization in patients requiring chronic anticoagulation.

Identifying factors that predict the choice and success rate of radial artery catheterisation in contemporary real world cardiology practice: a sub-analysis of the PREVAIL study data

AIMS

To assess: the reasons behind an operator choosing to perform radial artery catheterisation (RAC) as against femoral arterial catheterisation, and to explore why RAC may fail in the real world.

METHODS AND RESULTS

A pre-determined analysis of PREVAIL study database was performed. Relevant data were collected in a prospective, observational survey of 1,052 consecutive patients undergoing invasive cardiovascular procedures at nine Italian hospitals over a one month observation period. By multivariate analysis, the independent predictors of RAC choice were having the procedure performed: (1) at a high procedural volume centre; and (2) by an operator who performs a high volume of radial procedures; clinical variables played no statistically significant role. RAC failure was predicted independently by (1) a lower operator propensity to use RAC; and (2) the presence of obstructive peripheral artery disease. A 10-fold lower rate of RAC failure was observed among operators who perform RAC for > 85% of their personal caseload than among those who use RAC < 25% of the time (3.8% vs. 33.0%, respectively); by receiver operator characteristic (ROC) analysis, no threshold value for operator RAC volume predicted RAC failure.

CONCLUSIONS

A routine RAC in all-comers is superior to a selective strategy in terms of feasibility and success rate.

[Secondary cardiovascular prevention after acute coronary syndrome in clinical practice]

Secondary prevention after acute coronary syndromes should be aimed at reducing the risk of further adverse cardiovascular events, thereby improving quality of life, and lengthening survival. Despite compelling evidence from large randomized controlled trials, secondary prevention is not fully implemented in most cases after hospitalization for acute coronary syndrome. The Lazio Region (Italy) has about 5.3 million inhabitants (9% of the entire Italian population). Every year about 11 000 patients are admitted for acute coronary syndrome in hospitals of the Lazio Region. Most of these patients receive state-of-the art acute medical and interventional care during hospitalization. However, observational data suggest that after discharge acute coronary syndrome patients are neither properly followed nor receive all evidence-based treatments. This consensus document has been developed by 11 Scientific Societies of Cardiovascular and Internal Medicine in order develop a sustainable and effective clinical approach for secondary cardiovascular prevention after acute coronary syndrome in the local scenario of the Lazio Region. An evidence-based simplified decalogue for secondary cardiovascular prevention is proposed as the cornerstone of clinical intervention, taking into account regional laws and relative shortage of resources. The following appropriate interventions should be consistently applied: smoking cessation, blood pressure control (blood pressure < 130/80 mmHg), optimal lipid management (LDL cholesterol < 80 mmHg), weight and diabetes management, promotion of physical activity and rehabilitation, correct use of antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone system blockers.

The development of an international, common, prospective, cardiology database. Report of the joint G8 Cardio-Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO)--Societé Française de Cardiologie (SFC) database committee

BACKGROUND

Sharing and comparing health data at the international level is made difficult by heterogeneity in real world databases.

AIM

Our primary objective was to field-test the implementation of the first common database developed conjointly by different national cardiological societies.

METHODS

Based upon G8-Cardio feasibility projects, the Italian Society of Hospital Cardiologists and the French Society of Cardiology joined together to standardize a cardiological, patient-oriented database, created by means of consensus agreement for sharing data in a common server. Quantification of standardization was obtained by analysing each dataset according to the possibility of merging corresponding fields. Data merging from national centres was completed in the common server and after proper data integration in the common database; a comparison was performed between French and Italian populations.

RESULTS

Standardization of contents allowed for 89% overall interoperability (merged fields) to be achieved with only 11% divergent fields. All (100%) merged homogeneous data on the first 2717 patients from peripheral centres were selected consecutively from the common database and analysed successfully. Relevant differences between the two populations were outlined.

CONCLUSIONS

The international standardization and sharing/merging of databases is feasible. This model opens the way to important applications in internationally shared health care policies.

Major improvement of percutaneous cardiovascular procedure outcomes with radial artery catheterisation: results from the PREVAIL study

OBJECTIVE

To obtain a "snapshot" view of access-specific percutaneous cardiovascular procedures outcomes in the real world.

DESIGN

Multicentre, prospective study performed over a 30-day period.

SETTING

Nine hospitals with invasive cardiology facilities, reflecting the contemporary state of healthcare.

PATIENTS

Unselected consecutive sample of patients undergoing any percutaneous cardiovascular procedure requiring an arterial access.

INTERVENTIONS

Percutaneous cardiovascular procedures by radial or femoral access

MAIN OUTCOME MEASURES

The primary outcome was the combined incidence of in-hospital (a) major and minor haemorrhages; (b) peri-procedural stroke; and (c) entry-site vascular complications. The secondary outcome was the combined incidence of in-hospital death and myocardial infarction/reinfarction. For analysis purposes, outcomes were allocated to arterial access-determined study arms on an intention-to treat basis. Multivariable analysis adjusted using propensity score was performed to correct for selection bias related to arterial site.

RESULTS

A total of 1052 patients were enrolled: 509 underwent radial access and 543 femoral access. In both groups, 40% underwent a coronary angioplasty. Relative to femoral access, radial access was associated with a lower incidence both of primary (4.2% vs 1.96%, p = 0.03, respectively) and secondary endpoints (3.1% vs 0.6%, p = 0.005, respectively). Multivariate analysis, adjusted for procedural and clinical confounders, confirmed that intention-to-access via the radial route was significantly and independently associated with a decreased risk both of primary (OR 0.37, 95% CI 0.16 to 0.84) and secondary endpoints (OR 0.14, 95% CI 0.03 to 0.62).

CONCLUSIONS

Our study indicates strikingly better outcomes of percutaneous cardiovascular procedures with radial access versus femoral access in contemporary, real-world clinical settings.

Angiographic and clinical outcome of invasively managed patients with thrombosed coronary bare metal or drug-eluting stents: the OPTIMIST study

AIMS

Stent thrombosis (ST) is a major complication of percutaneous coronary interventions (PCIs). An invasive management by re-PCI is the commonly adopted treatment for ST, but data on outcome are limited.

METHODS AND RESULTS

We performed a 2-year multicentre registry enrolling consecutive patients with angiographically confirmed ST undergoing PCI. The primary angiographic endpoint was optimal angiographic reperfusion (TIMI 3 + blush grade 2 or 3). The primary clinical endpoints were death and major adverse coronary and cerebrovascular events (MACCEs) at 6 months. A total of 110 patients underwent 117 urgent PCI during the study. Patients with drug-eluting stent (DES) thrombosis, compared with those with bare metal stent (BMS) thrombosis, exhibited a higher rate of late or very late presentation and of anti-platelet therapy withdrawal. Optimal angiographic reperfusion was obtained in 64% of the patients. Death and MACCE rates at 6 months were 17 and 30%, respectively. Clinical outcome was similar for BMS and DES thrombosis. Very late ST, implantation of stent during PCI for ST, and failure to achieve optimal angiographic reperfusion were the independent predictors of 6-month mortality.

CONCLUSION

DES and BMS thromboses have different clinical features, but a similar poor outcome. Indeed, PCI for ST is associated with a low rate of reperfusion and to a high rate of death and MACCE, calling for action in order to prevent its occurrence and to improve its management.

[Implementation of an emergency clinical pathway for ST-elevation myocardial infarction in the Lazio Region: results of a pilot study]

BACKGROUND

Timely reperfusion therapies (primary angioplasty and pre-hospital thrombolysis) remain a key component in improving the survival of patients with ST-segment elevation myocardial infarction (STEMI). The Lazio Region emergency organization has a complex mixed logistic (the large city of Rome, presence of complex orography), therefore the use of telemedicine technologies by the emergency medical system (EMS) is mandatory. Emergency clinical pathways (ECP) for the management of STEMI patients were designed, focusing on early pre-hospital diagnosis and best appropriate treatment through the ECG transmission and teleconsultation among EMS and cardiologists in coronary care units (CCU).

METHODS

To evaluate the effectiveness of ECP-STEMI in the current practice, a prospective observational cohort study of ambulance-transported patients with cardiovascular symptoms was conducted in a selected area of the Lazio Region during a 6-month period. The implementation of the ECP was carried out by educational activities for the EMS personnel based on the "experiential learning" methods.

RESULTS

From October 2005 to March 2006, 287 patients were enrolled in the study and a pre-hospital ECG was performed in 66% of them. One hundred and fifty-two patients were referred to hospital and only 34 had discharged diagnosis of acute myocardial infarction, of whom 23 were STEMI. In the 34 acute myocardial infarction patients the medium time from "call to the EMS" to "arrival to the hospital" was 41 min (range 29-63 min) and 3 had their ECG telematically transmitted from the ambulance to the CCU. All of these cases were STEMI. Twenty-eight acute myocardial infarctions were discharged alive, 2 were transferred in other hospitals, 4 died. No patients received pre-hospital thrombolysis. Prior to the ECP implementation the ECG for STEMI patients has never been transmitted by EMS to the CCU in the Lazio Region.

CONCLUSIONS

Our study suggests that adherence to ECP improved the appropriateness of STEMI patient referral and treatment in the CCU in the Lazio Region. The EMS personnel, during the study, showed a high interest in the protocol trying to change their current practice. The Regional Administration plans to expand the utilization of ECP to all regional emergency network (EMS and Emergency Departments) and to improve its use.