A persistent patent foramen ovale produces an intermittent intra-atrial right-to-left shunt and occurs in approximately 25% of the general population. Although the vast majority of people with patent foramen ovale are asymptomatic, a patent foramen ovale is believed to act as a pathway for chemicals or thrombus that can result in a variety of clinical manifestations, including stroke, migraine headache, decompression sickness, high-altitude pulmonary edema, and platypnea-orthodeoxia syndrome. The optimal management of patients with patent foramen ovale who experience cryptogenic stroke is unclear. Percutaneous closure appears to have a low risk profile and has been considered in high-risk patients who are not candidates for randomized clinical trials. Randomized clinical trials that are underway should help define the best management of patent foramen ovale, as well as the true safety and efficacy of percutaneous closure devices.

Objectives

We sought to compare percutaneous coronary intervention (PCI) with bare-metal stents (BMS) and drug-eluting stents (DES) for cardiac allograft vasculopathy (CAV).

Background

Cardiac allograft vasculopathy is a rapidly progressive form of atherosclerosis and is one of the main limitations to long-term survival after orthotopic heart transplantation. Percutaneous coronary intervention has been used as a palliative treatment option for CAV but is associated with worse clinical outcomes and greater rate of restenosis compared with PCI of native coronary arteries.

Methods

Between 1995 and 2007, data on 82 consecutive heart transplant patients who underwent PCI with BMS and DES at the University of California at Los Angeles Medical Center were retrospectively analyzed.

Results

A total of 82 lesions were treated with 98 BMS and 76 lesions were treated with 80 DES. Follow-up angiography was performed on 57 of 82 lesions (70%) treated with BMS and 58 of 76 (76%) treated with DES (p = 0.7) at a mean follow-up of 9.5 +/- 5.5 months for BMS and 12.6 +/- 8.2 months for DES (p = 0.02). Compared with BMS, DES was associated with a lower binary restenosis rate (12% vs. 30%, p = 0.02), lower percent diameter stenosis (24 +/- 20 vs. 34 +/- 36, p = 0.06), and less late lumen loss (0.24 +/- 0.75 mm vs. 0.82 +/- 1.03 mm, p = 0.01). No angiographic stent thrombosis was observed with DES.

Conclusions

When compared with BMS, PCI with DES was safe and reduced the rate of angiographic restenosis in patients with CAV. A randomized clinical trial comparing BMS versus DES with longer follow-up is needed to identify the optimal long-term revascularization strategy in patients with CAV.

Patients with myocardial infarction (MI) who have out-of-hospital cardiac arrest and cardiogenic shock have a high mortality rate. Although intra-aortic balloon counterpulsation is frequently used in patients with cardiogenic shock, it does not provide complete hemodynamic support. We report 2 cases in which extracorporeal membrane oxygenation was instituted emergently in the cardiac catheterization laboratory in patients with MI and cardiac arrest who underwent percutaneous coronary intervention and who were hemodynamically unstable despite inotropic agents and intraaortic balloon counterpulsation.

Objectives

To assess the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in orthotopic heart transplantation (OHT) patients with unprotected left main coronary artery (ULMCA) disease.

Background

Accelerated transplant coronary artery disease occurs in 50% of patients at 5 years and is the major cause of death following OHT. The optimal treatment for ULMCA disease in OHT patients is unknown.

Methods

From April 2003 to December 2006, five OHT patients with ULMCA disease underwent PCI with DES at the University of California, Los Angeles, Medical Center.

Results

Technical success was achieved in all five patients. At a median follow-up of 518 days (range 124-990 days), all five patients were alive and free from death, myocardial infarction, and target vessel revascularization. No binary restenosis was present in four patients who underwent surveillance angiography. One patient underwent repeat OHT for progressive left ventricular dysfunction.

Conclusions

In OHT patients, ULMCA PCI with DES is feasible with an excellent technical success rate and is a reasonably palliative treatment option for this difficult patient population.

Background

Patients with elevated white blood cell (WBC) counts who undergo percutaneous coronary intervention (PCI) are at increased risk for short- and long-term mortality as well as major adverse cardiac events (MACE). We assessed the relationship between elevated WBC counts and clinical events in patients who underwent PCI with drug-eluting stents (DES).

Methods

Our retrospective study includes 878 consecutive patients who underwent both elective and emergent PCI with DES at the UCLA Medical Center. The cohort was divided into tertiles based upon the presenting WBC count: 2.8-6.3 x 109 cells/L (tertile 1 [T1]), 6.4-8.7 x 109 cells/L (tertile 2 [T2]), > or = 8.8 x 109 cells/L (tertile 3 [T3]).

Results

Survival at 1 year was significantly different between all three tertiles, and was poorest in patients with WBC counts in T3 (93.9%-T1, 98.4%-T2, 87.3%-T3; p < 0.0001), while T2 had the highest survival rate at 1 year. Age, chronic renal insufficiency, chronic obstructive pulmonary disease, low WBC count in T1, elevated WBC count in T3 and presentation with myocardial infarction were identified as multivariable predictors for survival at 1 year.

Conclusion

Both elevated and low WBC counts are associated with increased mortality and MACE at 1 year following PCI with DES. WBC count is an independent predictor of survival in patients who undergo PCI with DES implantation.

Objective

This meta-analysis was performed to assess the efficacy and safety of bivalirudin compared with unfractionated heparin or enoxaparin plus glycoprotein (GP) IIb/IIIa inhibitors in patients undergoing percutaneous coronary intervention (PCI).

Background

Pharmacotherapy for patients undergoing PCI includes bivalirudin, heparin, and GP IIb/IIIa inhibitors. We sought to compare ischemic and bleeding outcomes with bivalirudin versus heparin plus GP IIb/IIIa inhibitors in patients undergoing PCI.

Methods

A literature search was conducted to identify fully published randomized trials that compared bivalirudin with heparin plus GP IIb/IIIa inhibitors in patients undergoing PCI.

Results

A total of 19,772 patients in 5 clinical trials were included in the analysis (9785 patients received bivalirudin and 9987 patients received heparin plus GP IIb/IIIa inhibitors during PCI). Anticoagulation with bivalirudin, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in no difference in major adverse cardiovascular events (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.96 to 1.19), death (OR 0.93, 95% CI 0.72 to 1.21), or urgent revascularization (OR 1.06, 95% CI 0.86 to 1.30). There is a trend towards a higher risk of myocardial infarction (OR 1.12, 95% CI 0.99 to 1.28) but a significantly lower risk of TIMI major bleeding with bivalirudin (OR 0.55, 95% CI 0.44 to 0.69).

Conclusion

In patients who undergo PCI, anticoagulation with bivalirudin as compared with unfractionated heparin or enoxaparin plus GP IIb/IIIa inhibitors results in similar ischemic adverse events but a reduction in major bleeding.

Background

Age is an important predictor of mortality after percutaneous coronary intervention (PCI). The safety and efficacy of PCI with drug-eluting stents (DES) in nonagenarians have not been extensively studied.

Methods

A retrospective analysis of 889 consecutive patients identified 28 (3.1%) nonagenarians who underwent PCI with DES from May 2003 to December 2005 at our institution.

Results

The mean age was 92 +/- 2 years, 39% were male, and 4% were diabetic. Sirolimus-eluting stents were used in 79%. A mean of 1.5 +/- 0.9 stents/patient were implanted with a total stent length of 31 +/- 20 mm. Twenty-nine percent presented with unstable angina and 39% with myocardial infarction. The angiographic success rate obtained was 100%. The 30-day mortality rate was 21%. The 6 patients who died within 30 days included 3 patients who had cardiogenic shock and one patient with critical aortic stenosis who died due to complications during percutaneous aortic valvuloplasty. The cumulative survival rate for all nonagenarians at 1 year and 3 years was (68 +/- 9)% and (61 +/- 9)%. When the four patients who were in extremis on presentation were excluded, there were no in-hospital deaths, the 30-day mortality was 8%, and the 1 year and 3 year survival rate was (79 +/- 8)% and (71 +/- 9)% for the nonagenarians. No patient had definite stent thrombosis.

Conclusions

The majority of the nonagenarians who underwent PCI with DES presented with acute coronary syndrome. Percutaneous coronary intervention with DES was safe in nonagenarians as there were no in-hospital deaths and acceptable 3-year survival rates when patients who were in extremis on presentation were excluded. The high-risk profile of these patients and the expected attrition of nonagenarians may contribute to their mortality rates.