Similarities and Differences Between Primary Percutaneous Coronary Intervention and Mechanical Thrombectomy

Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review

Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.

Fabrication of Shape Memory Polymer Endovascular Thrombectomy Device for Treating Ischemic Stroke

Stroke is the second result for death and ischemic stroke constitutes most of all stroke cases. Ischemic stroke takes place when blood clot or embolus blocks cerebral vessel and interrupts blood flow, which often leads to brain damage, permanent disability, or death. There is a 4.5-h (golden hour) treatment window to restore blood flow prior to permanent neurological impairment results. Current stroke treatments consist mechanical system or thrombolytic drug therapy to disrupt or dissolve thrombus. Promising method for stroke treatment is mechanical retrieving of thrombi employing device deployed endovascularly. Advent of smart materials has led to research fabrication of several minimally invasive endovascular devices that take advantage of new materials capabilities. One of these capabilities is shape memory, is capability of material to store temporary form, then activate to primary shape as subjected to stimuli. Shape memory polymers (SMPs) are employed as good materials for thrombectomy device fabrication. Therefore, current review presents thrombectomy device development and fabrication with SMPs. Design, performance, limitations, and in vitro or in vivo clinical results of SMP-based thrombectomy devices are identified. Review also sheds light on SMP's future outlook and recommendations for thrombectomy device application, opening a new era for advanced materials in materials science.

Effectiveness of endovascular treatment for in-hospital stroke vs. community-onset stroke: a propensity score-matched analysis

BACKGROUND

The effectiveness of endovascular treatment for in-hospital stroke remains debatable. We aimed to compare the outcomes between patients with in-hospital stroke and community-onset stroke who received endovascular treatment.

METHODS

This prospective registry-based cohort study included consecutive patients who underwent endovascular treatment from January 2013 to December 2022 and were registered in the Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy study and Yonsei Stroke Cohort. Functional outcomes at day 90, radiological outcomes, and safety outcomes were compared between the in-hospital and community-onset groups using logistic regression and propensity score-matched analysis.

RESULTS

Of 1,219 patients who underwent endovascular treatment, 117 (9.6%) had in-hospital stroke. Patients with in-hospital onset were more likely to have a pre-stroke disability and active cancer than those with community-onset. The interval from the last known well to puncture was shorter in the in-hospital group than in the community-onset group (155 vs. 355 min, p<0.001). No significant differences in successful recanalization or safety outcomes were observed between the groups; however, the in-hospital group exhibited worse functional outcomes and higher mortality at day 90 than the community-onset group (all p<0.05). After propensity score matching including baseline characteristics, functional outcomes after endovascular treatment did not differ between the groups (OR: 1.19, 95% CI 0.78-1.83, p=0.4). Safety outcomes did not significantly differ between the groups.

CONCLUSION

Endovascular treatment is a safe and effective treatment for eligible patients with in-hospital stroke. Our results will help physicians in making decisions when planning treatment and counseling caregivers or patients.

The Effect of Percutaneous Coronary Intervention on QT Dispersion and the Association Between Them: A Systematic Review

Electrocardiography (ECG) parameters are significant in the prognosis of ischemia and other cardiovascular conditions. Reperfusion or revascularization techniques are essential in reestablishing blood flow to ischemic tissues. This study aims to demonstrate the association between percutaneous coronary intervention (PCI), a revascularization technique, and the electrocardiography (ECG) parameter, QT dispersion (QTd). We conducted a systematic review of the association between PCI and QTd through a literature search in three electronic databases, ScienceDirect, PubMed, and Google Scholar, for empirical studies published in English. Review Manager (RevMan) 5.4 (Cochrane Collaboration, Oxford, England) was used for statistical analysis. Of 3,626 studies, 12 articles met the inclusion criteria, enrolling a total of 1,239 patients. After a successful PCI procedure, QTd and corrected QT (QTc) tremendously reduced at various time intervals with statistical significance in most of the studies. There was a clear association between ECG parameters QTd, QTc, and corrected QT dispersion (QTcd), and PCI, in that there is a considerable reduction in these ECG parameters after PCI treatment.

The many roles of urgent catheter interventions: from myocardial infarction to acute stroke and pulmonary embolism

INTRODUCTION

Cardiovascular diseases (CVDs) are the leading cause of cardiovascular mortality and a major contributor to disability worldwide. The prevalence of CVDs is continuously increasing, and from 1990 to 2019, it has doubled. Global cardiovascular mortality has increased from 12.1 million in 1990 to 18.6 million cases in 2019. The development of therapeutic options for these diseases is at the forefront of interest concerning the extensive socio-economic consequences. Modern endovascular transcatheter therapeutic options contribute to the reduction of cardiovascular morbidity and mortality.

AREAS COVERED

The article concentrates on the triad of the most common causes of acute cardiovascular mortality and morbidity - myocardial infarction, ischemic stroke, and pulmonary embolism. Current evidence-based indications, specific interventional techniques, and remaining unsolved issues are reviewed and compared. A personal perspective on the possible implications for the future is provided.

EXPERT OPINION

Primary angioplasty for ST-segment elevation myocardial infarction is a well-established therapeutic option with proven mortality benefits. We suppose that catheter-based interventions for acute stroke will spread quickly from centers of excellence to routine clinical practice. We believe that ongoing research will provide a basis for the expansion of interventional treatment of pulmonary embolism soon.

Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities

Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.

The Heart Brain Team and Patient-Centered Management of Ischemic Stroke

The multifaceted connections between the heart and the brain have been extensively studied at the anatomy, pathophysiology, and clinical levels. Studies have suggested a vital role for both cardiologists and neurologists in the management of various cardiovascular and neurological disorders. However, a true heart-brain team-based approach remained confined to large, specialized centers. In this paper, we review the various intersection areas of cardiology and neurology with regard to ischemic stroke. We focus our discussion on the challenges and opportunity for a heart-team approach to stroke in the context of atrial fibrillation, carotid disease, and patent foramen ovale, and in the setting of strokes complicating transcatheter endovascular interventions.

Interdisciplinary management of acute ischaemic stroke - current evidence on training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention: A step forward

Stroke, a vascular disease of the brain, is the #1 cause of disability and a major cause of death worldwide. Stroke has a major negative impact on the life of stroke-affected individuals, their families and the society. A significant proportion of stroke victims indicate that would have preferred death over their after-stroke quality of life. Mechanical thrombectomy (MT), opening the occluded artery using mechanical aspiration or a thrombus-entrapment device, is a guideline-mandated (class I, level of evidence A) treatment modality in patients with large vessel occlusion stroke. MT clinical benefit magnitude indicates that a universal access to this treatment strategy should be the standard of care. Today there is a substantial geographic variation in MT deliverability, with large-scale disparities in MT implementation. In many countries effective access to MT remains severely limited. In addition, many of the MT-treated patients are treated too late for a good functional outcome because of logistic delays that include transportations to remotely located, scarce, comprehensive stroke centres. Position Paper from the European Society of Cardiology Council on Stroke and European Association for Percutaneous Cardiovascular Interventions on interdisciplinary management of acute ischaemic stroke, developed with the support of the European Board of Neurointervention fills an important gap in systematically enabling interventional cardiologists to support stroke intervention in the geographic areas of unmet needs in particular. We review strengths and weaknesses of the document, and suggest directions for the next steps that are swiftly needed to deliver MT to stroke patients more effectively.

Comparison of QT dispersion in patients with ST elevation acute myocardial infarction (STEMI) before and after treatment by streptokinase versus primary percutaneous coronary intervention (PCI)

Background

QT dispersion (QTD) represents inhomogeneous ventricular repolarization such that an increased QTD may predispose the heart to malignant ventricular arrhythmias (VAs). This study was conducted to compare QTD in patients with ST-elevation myocardial infarction (STEMI) before and after treatment by streptokinase (SK) versus primary percutaneous coronary intervention (PCI).

Methods

The present case–control study was conducted on 185 STEMI patients who received SK (115 cases) or underwent primary PCI (70 cases). QTD and QT corrected dispersion before and 24 h after treatment. Likewise, they were also found to correct fatal arrhythmias (VT and VF) during the first 24 h after admission, and ejection fraction (EF) 24 h after treatment was evaluated.

Results

QTD decreased in the primary PCI group, though no significant difference was seen between the two studied groups (P > 0.05). A significant increase was detected in the EF mean values for the primary PCI-treated patients (P = 0.022). Moreover, there was a significant reduction in QTD of patients with fatal arrhythmias in the primary PCI group (P = 0.022).

Conclusion

An overall QTD reduction in the primary PCI group and a significant decrease in QTD of patients with fatal arrhythmias in the primary PCI group show that this treatment strategy is more efficient than thrombolytic therapy. As an important indicator of proper myocardial function, EF can independently predict improved myocardial function in the primary PCI group.