Assali, A

338 Pages·2010·3.04 MB·English

1550263
Analysis and Prediction of Percutaneous Intervention Cost Using a Complexity Score
Bental, T; Assali, A; Vaknin-Assa, H; Lev, E; Shor, N; Kornowski, R
Cardiology Dept. Rabin medical Center, Petach Tikva, Israel
Background: There is a large variability of the costs of percutaneous coronary interventions
(PCI). Catheterization laboratories have to account these costs to the hospital management.
Methods: We sought to devise a scoring system in order to analyze and possibly predict the
costs of PCI's. Using a custom made program, we collected data regarding the technical
complexity of PCI's in patients undergoing PCI at our institution between 1/1/2009 and
31/10/2009. The complexity elements were STEMI, Non-STEMI, chronic total occlusion (CTO),
bifurcation, Multivessel PCI, Long lesions, PCI in SVG, heavy calcification, Left main, general
difficulty and use of intracoronary imaging. Using univariate and multivariate analysis we
defined the contribution of these elements and their combinations to the actual cost of the
procedures. A scoring system was devised, defining 4 levels of complexity. Results: Data was
based on the analysis of 1071 PCI's. 29.04% were in complexity group A, with a mean cost of
6115 NIS and comprising 17.1% of the total expenditure, 19.8% were in complexity group B,
with a mean cost of 8449 NIS and comprising 16.1% of the total expenditure, 17.8% in group
C, with a mean cost of 10672 NIS and comprising 18.3% of the total expenditure and 33.3% in
group D , with a mean cost of 15083 NIS, comprising 48.5% of the total expenditure.
Figures: distribution of the complexity groups; mean cost by complexity group

Conclusions: About 70% of the procedures performed at our center involve at least one
technical complexity, 33% of them being very complex, with a high cost per procedure. This
data should be considered when evaluating the running costs of a cardiac catheterization
laboratory.
1550408
Unprotected Left Main Stenting: An Israeli Perspective.
Fefer, P1; Segev, A1; Elian, D1; Yonash, M1; Har Zahav, Y1; Agranat, O1; Rath, S2; Guetta, V2
1Sheba Medical Center, Ramat Gan, Israel; 2Heart Center, Sheba Medical Center, Ramat Gan,
Israel
Background: The most recent ACC/AHA guidelines focused update has for the first time
endorsed PCI as an alternative to CABG surgery in suitable patients with unprotected left main
coronary artery disease (ULMCA).
Aim: To describe the practice and outcomes of a contemporary Israeli cohort of consecutive
patients undergoing PCI to ULMCA over a five years period.
Results: Stenting of ULMCA was performed in 74 patients: 73% were male; average age was
73±12 (range 40-95 years); 34% were ≥ 80 years and 30% were < 65 years. Past medical
history included: Hypertension in 73%; diabetes in 48%; active malignancy in 12%; and severe
COPD in 7%. CAD was known in 36% of patients. Half the patients presented with UAP/NSTEMI;
26% with stable coronary disease; and 12% with STEMI. Nine patients (12%) had no LM
disease but underwent LM stenting following treatment of adjacent LAD or LCx disease. Isolated
LM stenosis or LM and 1 vessel disease was found in 14% and 22% respectively, whereas 64%
had mutivessel disease. Stenosis involved the ostium or body of the LM in 2/3 of the patients
and was distal in 1/3. Drug eluting stents were implanted in 54%. IVUS guidance was used in 2
patients and glycoprotein IIbIIIa antagonists were used in 26% of procedures. IABP was used in
6 patients (all were in cardiogenic shock). There was one procedure related death in a severely
ill and inoperable patient. Routine angiographic follow-up was performed in patients under 80
years. Others underwent nuclear imaging. Angiographic follow-up was available for 44 patients.
In-stent restenosis (>50% narrowing) was present in 7 patients (9%): One underwent POBA
alone, 4 underwent repeat stenting (all DES) and 2 were referred for CABG surgery.
Conclusion: Angioplasty of ULM as performed at our centre results in favourable clinical and
angiographic results. Adverse outcomes do not seem to be related to ULMCA treatment itself but
rather to the patients' high-risk profile.
1550415
An Early Experience with the MGuard Stent: A Promising Device to Prevent Distal
Embolization
Varshitzky, B1; Boguslavsky, L2; Loncar, S2; Danenberg, H2; Admon, D2; Nassar, H2; Lotan, C2
1Hadasaah, Jerusalem, Israel; 2Hadassah, Jerusalem, Israel
Background:
Lesions containing large mass of thrombus or atheroma, as in degenerated SVG and in patients
with ACS, are at high risk for distal embolization.
Methods:
Early angiographic analysis and long-term clinical outcomes were evaluated in 38 patients who
underwent MGuard stent implantation between 11/2008 –11/2009 in Hadassah University
Hospital. Patients with bifurcation and calcified lesions were excluded.
Results:
Consecutive patients were treated by MGuard system in native arteries (Group A, n= 26), and
to vein grafts (Group B, n= 12). Clinical indications were: STEMI (n=17), NSEMI and Unstable
AP (n=12) and elective (n=9).
Procedural success was achieved in all patients. Final TIMI III flow was documented in 22(86%)
pts from group A and in 12(92%) patients from group B. There were no cases of instent
thrombosis, procedure related MI or mortality during hospitalization.
Clinical follow-up at a mean of 5 ±2.3 months revealed a mortality rate 2.6%, restenosis 8%,
2.6% rate of TLR due to restenosis, and rehospitalization rate of 16%.
Group A (n=26) Group B (n=12)
Indication STEMI ALL 15 (58%) 2 (17%)
Primary PCI 12 (46%) 1 (8%)
NSTEMI and Unstable AP 7 (27%) 5 (42%)
Ellective 4 (15%) 5 (42%)
Procedural TIMI before 0 11 (42%) 1 (8%)
I 5 (19%) 2 (17%)
II 7 (27%) 7 (58%)
III 3 (12%) 2 (17%)
TIMI final 0 - I 0 0
II 4 (15%) 1 (8%)
III 22 (86%) 12 (92%)
Side branches arising from culprit 29
Side branch closure 5 (17%)
Ostial side branches compromise 8 (28%)
Follow up Mortality 0 1 (8%)
Coronary angio follow-up 5 (19%) 3 (25%)
Restenosis rate 2 (8%) 1 (8%)
TLR 1 (4%) 0

Conclusion: Use of the MGuard stent for treatment of patients with a large thrombus/atheroma
lesion achieves very high success rates with relatively low distal embolization rate, and is
associated with good medium-term clinical result.
1550499
Early Revascularization in Elderly Patients ≥80 years-Old Presenting with Acute
Myocardial Infarction and Cardiogenic Shock
Danon, A; Lewis, B; Halon, D; Khader, N; Flugelman, M; Rubinshtein, R; Zisman, K; Wolff, R;
Merdler, A; Goldstein, J; Jaffe, R
Carmel Medical Center, Haifa, Israel
Background: The benefit of early revascularization in cardiogenic shock is well established.
However, the efficacy of an invasive strategy in shock pts ≥80 years-old is controversial.
Methods: We retrospectively identified 35 pts ≥80 years-old with cardiogenic shock due to acute
MI in whom a primary coronary intervention strategy was implemented. Clinical characteristics
and survival were analyzed. Results: Mean age was 85±3 (range 80-97) years. Mean symptom-
to-admission and door-to-balloon times were 319±343 (range 46-1540) and 126±76 (range 30-
448) minutes, respectively. Eighteen (51%) had anterior infarction, 13 (37%) were
mechanically ventilated, 24 (69%) received intra-aortic balloon pump and 11 (31%) needed a
temporary pacing. Mean SYNTAX and TIMI STEMI risk scores were 28±16 (range 5.0-58.5) and
10.7±1.5 (range 8-14) points, respectively. Overall, 2 patients died before revascularization, 27
underwent PCI, 4 underwent emergency CABG and 2 were treated medically following
diagnostic angiography. Mortality rates were 14% during the first day, 48% in-hospital, 51% at
30 days and 60% at 1 year. In univariate analysis, anterior infarction predicted increased
mortality (p=0.018), whereas the RCA as culprit vessel was associated with lower mortality
(p=0.005). Increased TIMI STEMI risk score predicted mortality (p=0.002) but SYNTAX score
did not. Interestingly age, symptom-to-admission and door-to-balloon times did not predict
outcome. Conclusion: Cardiogenic shock complicating acute MI in pts ≥80 years-old carries a
high mortality rate. Following early urgent revascularization half the pts were alive at 1 month
and 40% at 1 year. Policy regarding health care resource allocation for intervention and
intensive cardiac care in these patients should be made at an institutional and societal level.
Age (years): (Mean±SD) 85±3
Female sex: n (%) 14 (40)
Diabetes: n (%) 7 (20)
STEMI: n (%) 32 (91)
NSTEMI: n (%) 3 (9)
Time from symptoms to admission (minutes): (mean±SD) 319 ± 343
Time from Door to balloon (minutes): (mean±SD) 126 ± 76
Cardiopulmonary rescusitation: n (%) 9 (26)
Intra-aortic balloon counterpulsation: n (%) 24 (69)
Temporary pacing: n (%) 11 (31)
SYNTAX score: (mean±SD) 28±16
TIMI RISK score: (mean±SD) 10.7±1.5
PCI: n (%) 27 (77)
CABG: n (%) 4 (11)
24 hour mortality: n (%) 5 (14)
In-hospital mortality: n (%) 17 (49)
30-day mortality: n (%) 18 (51)
1550899
When it is Hazardous to Utilize an Internal Mammary Artery for Coronary
Revascularization in Patients with Severe Peripheral Vascular Disease!
Ben-Dor, I; Waksman, R; Satler, L; Pichard, A
Washington Hospital Center, Washington DC, USA
Background: The use of the internal mammary arteries for coronary revascularization has
become the standard of care in coronary artery bypass grafting (CABG). However, in patients
with aortoiliac disease, the internal mammary arteries may become a major collateral route to
the lower extremities. This study aimed to characterize the clinical and angiographic
characteristics of patients with collateralization from the internal mammary artery to the iliac
artery.
Methods: We have collected 15 cases of patients admitted for diagnostic coronary angiography
in whom we observed collateral flow from one or both internal mammary arteries to an occluded
or stenotic iliac artery.
Results: The mean age was 63.2 ± 11.2 years; 8 were men (53.3%). Coronary angiography
was done as a peri-operative evaluation for peripheral vascular surgery in 3 patients (20%) and
was done because of cardiac symptoms or a positive thallium scan in 2 (80%). The finding that
the mammary artery collateralized the iliac artery led to major treatment changes in all patients
7 (46.6%) who required CABG. In 5 patients (33%), use of one or both internal mammary
artery(ies) for coronary grafts was avoided. In one patient, CABG was deferred and in another
patient, percutaneous intervention in both iliac arteries preceded CABG using both mammary
arteries. There was no incidence of post-operative acute lower extremity ischemia.
Conclusions: Selective angiographic visualization of the internal mammary artery is an essential
part of the pre-operative evaluation in patients with severe peripheral vascular disease
undergoing CABG.
1550948
Contrast Induced Nephropathy Post Percutaneous Coronary Intervention: What is the
Right Definition?
Jabara, R1; Gadesam, R2; Pendyala, L2; Chronos, N2; King, S2; Manoukian, S3
1Hadassah University Hospital, Jerusalem, Israel; 2Saint Joseph's Hospital, Atlanta, USA; 3Sarah
Cannon Research Institute, Nashville, TN, USA
Background: Several definitions have been used to assess rates of contrast-induced
nephropathy (CIN) in patients undergoing percutaneous coronary intervention (PCI). Whether
the definition influences observed rates of CIN is unclear.
Objectives: The Oxilan Registry was the first prospective analysis of the efficacy and safety of
ioxilan (low-osmolar and low-viscosity contrast medium), including rates of CIN assessed by
multiple definitions, in PCI.
Methods: From July 2006 to June 2007, consecutive patients undergoing PCI using ioxilan were
enrolled. Serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) were assessed
at baseline and 3 to 5 days after PCI. CIN was defined by 1 of 4 definitions: (1) absolute
increase in SCr ≥0.5 mg/dl over baseline, (2) relative decrease in eGFR and ≥25% from
baseline, (3) relative increase in SCr ≥25% over baseline, and (4) a composite of the preceding
3 definitions.
Results: Of 400 patients (age 62 ± 11 years), 19% were women, 37% were diabetic, 22% were
anemic, and 8% had a history of congestive heart failure. Baseline SCr was 1.12 ± 0.3 mg/dl
and 24% had an eGFR <60 ml/min. CIN rates were 3.3% (SCr increase ≥0.5 mg/dl), 7.6%
(eGFR decrease ≥25%), 10.2% (SCr increase ≥25%), and 10.5% (composite). Hospitalization
was prolonged in 3.4% of patients with CIN and none required dialysis. There were no deaths or
severe allergic reactions. Non¨CST-elevation myocardial infarction and repeat revascularization
each occurred in 0.8%.
Conclusions: In this unselected population undergoing PCI, CIN ranged in frequency from 3.3%
to 10.5% depending on the definition used and was not associated with in-hospital mortality or
substantial morbidity, such as dialysis. The wide variation in CIN and its lack of association with
adverse outcomes underscore the need for a standardized, clinically relevant definition.
1548477
Myocardial gap junction channel protein, connexin-43, most likely modulates
susceptibility of the heart to lethal arrhythmias.
Tribulova, N1; Bacova, B2; Radosinska, J1; Knezl, V3; Lin, H4; Imanaga, I4; Okruhlicova, L1;
Slezak, J1
1Institute for Heart Research, Bratislava, Slovakia; 2Institute for Heart Rsearch, Bratislava,
Slovakia; 3Institute of Exper.Pharmacology, Bratislava, Slovakia; 4Fukuoka University, Fukuoka,
Japan
Functional electrical and metabolic cell-to-cell communication via gap junction connexin (Cx)
channels ensures myocardial synchronisation while defects in Cx expression and/or distribution
are thought to be arrhythmogenic facilitating occurrence of lethal arrhythmias. We examined
topology and expression of myocardial Cx43 as well as susceptibility of the isolated working
heart to ventricular fibrillation (VF) in hypertensive, hyperthyroid and diabetic (type 1) rats and
diabetic rats treated with thyroid hormone and compared to healthy rats. All diseased hearts
exhibited myocardial Cx43 remodelling that was most pronounced in hypertensive rats. Total
Cx43 and its phosphorylated forms were significantly decreased in hypertensive and
hyperthyroid while increased in diabetic rat hearts comparing to controls. However, treatment of
diabetic rats with thyroid hormone suppressed both expression and phosphorylation of Cx43.
Hypertensive and hyperthyroid rats were much prone to develop VF compared to healthy
controls unlike diabetic rats that were much less. However, treatment of diabetic rats with
thyroid hormone increased their vulnerability to VF. These findings indicate that Cx43 is most
likely involved in modulation of cardiac susceptibility to malignant arrhythmias, i.e. up-
regulation of Cx43 is associated with decrease while down-regulation with increased
vulnerability. Further studies are needed to examine whether currently used cardio-protective
drugs exhibiting antiarrhythmic potential (statins, ACEI, sartans) affect Cx43 expression and/or
distribution.
1549879
Insulin-resistant diabetic rats benefit from omega-3 fatty acids supplementation due
to up-regulation of connexin-43.
Radosinska, J1; Bacova, B2; Dosenko, V3; Lin, H4; Imanaga, I5; Tribulova, N2
1Comenius University Faculty of Medicine, Bratislava, Slovakia; 2Institute for Heart Research,
Bratislava, Slovakia; 3Bogomoletz Institute of Physiology, Kyiv, Ukraine; 4Fukuoka University
Medical school, Fukuoka, Japan; 5Fukuoka University School of Medicine, Fukuoka, Japan
Goal of this study was to investigate whether myocardial transcript and protein expression of
connexin-43 (Cx43), which ensures direct cell-to-cell communication, are altered in insulin-
resistant diabetic rats and whether they may benefit from omega-3 fatty acids supplementation.
Experiments were conducted on spontaneously diabetic rats and age-matched healthy rats.
They were divided into un-treated and treated for 2-month with omega-3 FA (200mg/kg/day).
Biometrical and biochemical parameters were registered. Left ventricular heart tissues were
used for determination of Cx43 mRNA and protein expression as well as for protein kinase C
(PKC) expression and myocardial ultrastructure examination. Blood glucose, cholesterol and
triglycerides were increased in diabetic rats and significantly reduced due to treatment with
omega-3 FA while body and heart weights were not affected. Myocardial Cx43 mRNA level was
higher in diabetic than non-diabetic rats and omega-3 FA caused its marked increase in both
groups. Ratio of phosphorylated to non-phosphorylated form of Cx43 protein was lower in
diabetic versus healthy rats and enhanced upon omega-3 FA that was associated with increased
expression of PKC epsilon. Moreover, subcellular integrity of cardiomyocytes and their junctions
was improved due to omega-3 FA treatment. It is concluded that rats with type-2 diabetes
benefit from omega-3 FA supplementation because of suppression a risk markers for CVD and
particularly due to up-regulation of myocardial connexin-43 and preservation of ultrastructure.
Consequently, it may improve heart function and decrease susceptibility to malignant
arrhythmias.
1549882
Chronic and acute antiarrhythmic aeffects of atorvastatin and omega-3 fatty acids
documented in rats suffering from hypertriglyceridemia (HTG).
Bacova, B1; Knezl, V2; Radosinska, J3; Barancik, M1; Karas, S4; Tribulova, N1
1Institute for Heart Research, Bratislava, Slovakia; 2Institute of Pharmacology, Bratislava,
Slovakia; 3Comenius University Faculty of Medicine, Bratislava, Slovakia; 4Institue of
Measuremet, Bratislava, Slovakia
Atorvastatin (Ato) and omega-3 FA exhibit antiarrhythmic effects in clinic but underlying
mechanisms are not elucidated yet. This study was aimed to examine whether these compounds
exert antiarrhythmic effects upon chronic and acute administration and whether intercellular
connexin (Cx) channels, which ensure electrical coupling and myocardial synchronisation, are
implicated. Experiments were conducted on VF prone HTG rats that were treated with Ato
(0.5mg/kg/day) and omega-3 FA (400mg/kg/day) for 2mth. VF inducibility was tested on
isolated working heart preparation using electrical stimulation. In acute experiments the hearts
were perfused with 1.5, 7, 15 µmol atorvastatin and omega-3 FA,i.e. EPA and DHA during 10
min prior el. stimulation. Prolonged application of Ato and omega-3 FA was accompanied by
reduction of plasma triglycerides and resulted in significant increase of stimulation threshold for
VF to 40+0.2 mA and 45+0.2 mA vs 15+0.1 mA. HTG rats were characterized by abnormal
elevation of phsosphorylated forms of Cx43 compared to healthy rat hearts, while omega-3 FA
and atorvastatin significantly decreased it. Acute application of Ato, EPA and DHA reduced VF
incidence to 33%, 71.4% and 80% in male and to 60%, 75% and 60% in female rats. Bolus of
either EPA or DHA (150 µmol) administered directly to fibrillating heart defibrillated it. It is
concluded that chronic administration of atorvastatin and omega-3 FA resulted in antiarrhythmic
effects that were associated with beneficial Cx43 alterations. It is very likely that modulation of
connexin-43 channels function is implicated in acute effects. Findings point out the role of
intercellular communication in pleitropic effects of statins and non-pharmacological approaches
in prevention of malignant arrhythmias.
1550224
Systemic Administration of 5-Azacythidine Improves Cardiac Remodeling and Infarct
Vascularization after Myocardial Infarction in Rat
Azab, M; Landa-Rouben, N; Holbova, R; Nagler, A; Leor, J
Sheba Medical Center, Tel-Aviv University, Tel-Hashomer 52621, Ramat Gan, Israel
BACKGROUND: Attempts have been made to induce transdifferentiation of fibroblasts to
cardiomyocyte-like cells with 5-azacythidine (5-Aza). These attempts have been successful in
some aspects in vitro. 5-Aza is a general demethylating agent, leading to unmasking of genes
that are not expressed due to promoter hypermethylation. We tested the hypothesis that
systemic administration of 5-Aza could convert infarct fibroblasts in situ and improve remodeling
and function after myocardial infarction (MI) in rat.
METHODS & RESULTS: The optimal dose and safety of 5-Aza administration was determined in
a pilot study in normal rats. Subsequently, 29 rats were subjected to permanent left anterior
descending coronary artery occlusion and anterior MI. Seven days after MI rats were
randomized to 7-day treatment with 5-Aza (50 mg/m2/d, n=15) or saline (n=14). Cardiac
remodeling and function were assessed by echocardiography before and 30 days after initiation
of treatment. Total RNA was extracted from the scar tissue and remote myocardium to
determine spatial gene profile by DNA array analysis 30 days after MI. Serial echocardiography
studies showed that systemic administration of 5-Aza attenuated left ventricular systolic and
diastolic dilatation compared with controls (p<0.05). Moreover, 5-Aza treatment improved the
number of vessels in the scar tissue (p=0.008). Immunostaining of scar tissue revealed positive
staining for the myogenic transcriptional factor MyoD in 4 of the 11 animals treated with 5-Aza
vs. 0 of 9 in control hearts (p=0.09). Gene expression analysis in the infarct and remote
myocardium revealed upregulation of genes associated with regeneration and repair in 5-Aza
treated animals.
CONCLUSIONS: Our study suggests, for the first time, that administration of 5-Aza after MI can
improve left ventricular remodeling and infarct vascularization in rat. Our findings suggest a new
strategy for infarct repair and regeneration by reprogramming fibroblasts in situ.