Biomedical subjects
Publications and source records attributed to Anna Sonia Petronio.
Explore the source record for details and available documents.
BACKGROUND: Restenosis after coronary stenting is mainly caused by intimal hyperplasia. Both experimental and clinical studies suggest that statins may be able to inhibit intimal hyperplasia and, therefore, in-stent restenosis (ISR), by mechanisms beyond lipid lowering. METHODS: In a 12-month study, we randomized 71 normocholesterolemic patients to 20 mg simvastatin or no treatment, 2 weeks before elective coronary stenting. Patients were evaluated by quantitative coronary angiography and intravascular ultrasound, immediately after the index procedure and at the 12-month catheterization. RESULTS: Binary ISR was present in 15% and in 18% of simvastatin-treated patients and controls, respectively (P = NS). Intimal hyperplasia did not differ significantly between the 2 groups (3.6 +/- 1.8 vs 3.8 +/- 2.3 mm3/mm, 34% +/- 15% vs 35% +/- 23% for simvastatin vs controls, P = NS). However, persistent plaque decreased with simvastatin but increased in controls (-4.0 +/- 4.0 vs +1.6 +/- 3.8 mm3/mm, -14% +/- 10% vs +6% +/- 12%, P < .05). The same behavior was shown by intermediate plaques at nonstented sites (-2.5 +/- 3.0 vs +1.0 +/- 3.0 mm3/mm, -10% +/- 8% vs +9% +/- 9%, P < .05). Major adverse events at 12 months were present in 11% and 24% of simvastatin-treated patients and controls, respectively (P = .20). CONCLUSIONS: In normocholesterolemic patients undergoing coronary stenting, simvastatin does not prevent intimal hyperplasia or ISR, but it promotes atherosclerotic regression both at stented and at nonstented sites.
BACKGROUND: Distal embolization during primary percutaneous coronary interventions (PCIs) may affect myocardial reperfusion. We evaluated the prevalence and features of embolization during primary PCI and its relationship with clinical and angiographic variables. METHODS: Forty-six consecutive patients with acute myocardial infarction underwent primary PCI with a filter-based distal protection device. Histopathologic analysis was performed on retrieved embolic fragments, assessing the presence and relative amount of fibrin, necrosis, lipid droplets, collagen, mucopolysaccharides, and leukocytes, as well as the total debris volume. Such variables were related to baseline clinical and angiographic variables. RESULTS: Embolic material was recovered in 41 (89%) of 46 cases, with a mean total debris volume of 1.2 +/- 2.2 mm3. Prevalent histopathologic patterns were organized thrombus (47%), fresh thrombus (29%), and plaque fragments (24%). At multivariate analysis, none of the baseline clinical variables considered significantly predicted the total debris volume. Among angiographic variables, angiographic signs of high thrombus burden (cut-off coronary occlusion pattern or large intracoronary minus image) independently predicted the total debris volume at multivariate analysis (odds ratio 15.8, P < .005). Compared with its nonuse, abciximab did not affect the total number and the mean total volume of embolized material (15 +/- 16 vs 10 +/- 8 fragments, 1.5 +/- 2.5 vs 1.0 +/- 1.9 mm3, respectively, for both P > .20), or its qualitative composition. CONCLUSIONS: Distal embolization occurs in most patients during primary PCI and mainly consists of plaque fragments and partially organized thrombi, which are likely to be scarcely responsive to antiplatelet drugs. Baseline angiographic signs of a high thrombus burden are the only significant predictors of the extent of distal embolization.
BACKGROUND: Invasive coronary procedures are increasing in number and complexity over time. This trend translates in an increased need for economical and human resources, among which is nurse staffing the most affected. AIMS: To identify possible predictors of nurse workload, during and after diagnostic and interventional procedures. METHODS: Two hundred and sixty consecutive patients were included: 52 and 208 patients underwent femoral and radial access, respectively. Nurse workload was calculated with a self-developed model. RESULTS: Cathlab nurse workload was 103 [63--156] min. Independent predictors of increased Cathlab nurse workload were: femoral access, failed radial access and cross-over, interventional procedures, procedural time, urgent procedures. Cathlab nurse workload was 174 [134--218] and 86 [58--126] min, for femoral and radial access, respectively (p<0.001). Among the overall population, 174/260 patients (44 females, mean age 66+/-11 years) were hospitalised at our Center after the procedure. Fifty-six and 118 patients had femoral and radial access, respectively. Ward nurse workload was 457 [226--954] min. Independent predictors of increased Ward nurse workload were: access-site complication, length of in-hospital stay, admission to CCU, interventional procedures. Ward nurse workload was 386 [226--652] and 720 [314--1375] min, respectively for radial and femoral access (p<0.001). CONCLUSIONS: A systematic radial access is an effective strategy for reducing nurse workload, both during, by simplifying nurse tasks in the CathLab, and after coronary invasive procedures, by preventing access-site complications, shortening in-hospital stays, and reducing admissions to CCU.
Accelerated coronary artery disease remains the limiting factor in the long-term survival of heart transplant (HT) recipients and occurs in approximately 50% of patients by 5 years after transplantation. Sequelae of graft arteriosclerosis include congestive heart failure (due to acute or chronic ischemia), graft loss, and death. Unfortunately, as a consequence of cardiac denervation, symptoms are often atypical or completely absent, and thus presentation with an acute coronary syndrome is extremely uncommon. We describe the case of an HT recipient with a typical clinical picture of an acute myocardial infarction (MI), who presented to our hospital 2 hours after the onset of symptoms and was successfully treated with primary percutaneous transluminal coronary angioplasty (PTCA).
BACKGROUND: Although periprocedural drug therapy has been shown to improve the outcome of percutaneous coronary intervention (PCI), information regarding its use in daily clinical practice is limited. METHODS: We conducted a national survey on periprocedural drug therapy across the spectrum of PCI practice in Italy. Seventy-nine centers (41% of the Italian interventional cath labs) with a fair distribution across the country volunteered to enroll consecutive patients undergoing PCI for any indication from September 15 to 29, 2003. RESULTS: Of the 1517 patients enrolled, 745 (49 %) had stable coronary disease and 772 (51%) acute coronary syndromes (ACS): 457 without and 315 with ST-segment elevation. Stenting was used in 89% of cases. N-acetylcysteine was used in 23% of the patients with preexisting renal dysfunction. Thienopyridine (63% clopidogrel) pretreatment was given in 49 % of the cases and, at logistic regression analysis, was independently associated with prior myocardial infarction (p < 0.001), prior PCI (p = 0.007), stable coronary disease (p = 0.005), and treatment in northern Italy (p < 0.05). Platelet glycoprotein (GP) IIb/IIIa receptor blockers (50% abciximab 50% tirofiban) were used in 22% of the stable patients and 40 % of those with ACS, a proportion increasing to 62 % when PCI was undertaken as an emergency procedure. Off-label use of these drugs was frequent (direct cath lab use of tirofiban in 55% of the cases; bailout use: 16% with abciximab and 26% with tirofiban). At logistic regression analysis, independent predictors of GP IIb/IIIa receptor blocker use were emergency procedure (odds ratio 3.6, 95 % confidence interval 2.6 to 5.0, p < 0.0001) and treatment for an ACS (odds ratio 1.6, 95% confidence interval 1.3 to 2.1, p = 0.0002). An emergency procedure was the only independent predictor for the use of abciximab instead of tirofiban (odds ratio 4.1, 95% confidence interval 2.6 to 6.5, p < 0.0001). Triple periprocedural antiplatelet therapy, including aspirin, a thienopyridine and a GP IIb/IIIa receptor blocker was administered in only 21% of cases. At discharge, all stented patients received aspirin and a thienopyridine. Despite complete procedural success in > 90% of cases, 50% of the patients were discharged on symptomatic anti-ischemic therapy. CONCLUSIONS: A wide gap exists between guideline recommendations and periprocedural drug therapy in PCI, the only exception being full prescription of aspirin and a thienopyridine at discharge after stenting. In patients with ACS, thienopyridine pretreatment is often used as a surrogate for GP IIb/IIIa blockade, whose use rather is associated with emergency procedures. Off-label use of drugs is not uncommon.
Transradial approach in primary and rescue angioplasty may be advantageous with respect to the femoral access due to the lower incidence of vascular complications. Ulnar cannulation has been proposed for elective procedures in patients not suitable for transradial approach. We here report on 13 patients undergoing primary angioplasty performed using the transulnar approach. Ulnar access was finally obtained in 10 patients, sheath insertion time ranged from 2 to 5 min, time from arterial puncture to vessel recanalization ranged from 21 to 36 min. Primary angioplasty was successful in all patients. At 30-day echo color Doppler, all ulnar arteries were patent and with a physiologic pattern of flow. Subcutaneous hemorrhage of the forearm was observed in two patients, whereas hematoma, pseudoaneurysm, thrombus, and arterovenous fistula were not observed. In conclusion, transulnar access may represent an additional option in patients undergoing primary angioplasty when the radial artery access site is not available.
Explore the source record for details and available documents.
BACKGROUND: Strategies for percutaneous coronary intervention are continuously evolving, in order to reduce complications and to warrant better immediate and long-term outcomes. We sought to evaluate the safety, feasibility, and long-term outcomes of a systematic strategy of coronary stenting without predilation (direct stenting) via a transradial approach for single-vessel procedures. METHODS: Stenting was performed with Snapper stent and wide inner-lumen, preformed, guiding catheters; 118 minimally-selected patients (59% of all single-vessel procedures performed at our center during the study period) were enrolled: among them 39% presented for acute coronary syndromes, 28% were under glycoprotein IIb/IIIa inhibitor treatment, and 10% had a poor left ventricular function; 130 lesions were treated (1.1 stents/lesion): 53% were type B2/C, 8% longer than 20 mm, and 16% on bifurcations. RESULTS: The transradial approach was successful in 96% of cases; 7% required predilation. The immediate angiographic and clinical success rates were 100 and 98% respectively. No bleeding complications occurred when the transradial approach was successful. At 6 months, the mortality, major adverse events, recurrent ischemia, and target lesion revascularization rates were 0, 14, 15, and 10% respectively. CONCLUSIONS: A systematic strategy of direct stenting via a transradial approach for single-vessel procedures seems safe, feasible, and efficacious both immediately, and at 6 months of follow-up, even when treating complex lesions and/or high-risk patients.
In the setting of acute myocardial infarction, thrombolytic therapy fails to restore an adequate epicardial flow in a large number of patients. Although an increasing number of patients undergoes a percutaneous coronary intervention (PCI) after failed thrombolysis, this treatment has been poorly investigated. This review focuses particularly on the safety and prognostic impact of glycoprotein (GP) IIb/IIIa receptor inhibitors after failed thrombolysis. GPIIb/IIIa inhibitors have been demonstrated to improve the clinical outcome in patients undergoing primary PCI. However, the increased risk of bleeding with the administration of potent antiplatelet drugs after full-dose thrombolytics has limited the widespread use of GPIIb/IIIa inhibitors during rescue PCI. We recently reported that abciximab treatment during rescue PCI has a beneficial effect on the short-term prognosis, without excess bleeding complications. This result can be achieved by using the radial approach, a low-dose weight-adjusted heparin regimen, and by limiting the use of aortic counterpulsation. In conclusion, in case of thrombolysis failure, patients should be referred to tertiary hospitals where rescue PCI can be performed with expertise.
Explore the source record for details and available documents.
BACKGROUND: Effective myocardial reperfusion after primary percutaneous coronary intervention (PCI) may be limited by distal embolization. We tested the safety, feasibility, and efficacy of the FilterWire-Ex (FW), a distal embolic protection device, as an adjunct to primary PCI. METHODS AND RESULTS: Fifty-three consecutive patients undergoing primary PCI with FW protection were compared with a matched control group treated by primary PCI alone. Successful FW positioning was obtained in 47 patients (89%) without complications. Histological analysis of the content of the last 13 filters showed multiple embolic debris in all cases. FW use was associated with lower postinterventional corrected TIMI frame count (22+/-14 versus 31+/-19; P=0.005) and higher occurrence of grade 3 myocardial blush (66% versus 36%; P=0.006) and early ST-segment elevation resolution (80% versus 54%; P=0.006). At multivariate analysis, FW use was the only independent predictor of early ST-segment elevation resolution and of grade 3 myocardial blush. FW patients showed lower peak creatine kinase-MB release (236+/-172 versus 333+/-219 ng/mL; P=0.013) and greater improvement at 30 days in left ventricular wall motion score index (-0.30+/-0.19 versus -0.18+/-0.26; P=0.008) and ejection fraction (+7+/-4% versus +4+/-7%; P=0.012). CONCLUSIONS: FW use during primary PCI is feasible and safe. Distal embolization prevention appears to exert a beneficial effect on markers of myocardial reperfusion and on left ventricular function improvement at 30 days.
The aim of the study was to evaluate the accuracy of intermittent, harmonic power Doppler (HPD) during intravenous Levovist infusion in identifying myocardial perfusion abnormalities in patients with recent infarction. Fifty-five patients with first acute myocardial infarction, successfully treated by primary PTCA, were studied after 1 month by myocardial contrast echocardiography (MCE), 99mTc tetrofosmin single photon emission computed tomography (SPECT), and low dose dobutamine echocardiography (DE). Scoring myocardial perfusion as normal, moderately, or severely reduced; MCE and SPECT were in agreement in 71% of segments(k = 0.414). Discordance was mainly due to ventricular walls with normal enhancement by MCE and moderate perfusion abnormalities by SPECT. Scoring perfusion as present or absent, the agreement significantly improved up to 86% (k = 0.59). Sensitivity and specificity of HPD for identifying SPECT perfusion defects were 63% and 93%, respectively. The agreement between MCE and SPECT was higher(85%, k = 0.627)in patients with anterior infarction. An improvement in regional contractile function was noted after dobutamine in 79 dysfunctional segments. A normal perfusion or a moderate perfusion defect by MCE were detected in 71 of 79 of these segments, while a severe perfusion defect was observed in 59 of 85 ventricular segments without dobutamine-induced wall-motion improvement. Sensitivity and specificity by HPD in detecting segments with contractile reserve were 90% and 69%, respectively. Thus, intermittent HPD during Levovist infusion allows myocardial perfusion abnormalities to be detected in patients with recent infarction. This method has a limited sensitivity but a high specificity in detecting SPECT perfusion defects, and a good sensitivity but a limited specificity in detecting contractile reserve.
BACKGROUND: Few data are available concerning the effects on clinical outcome and left ventricular function of abciximab administration in patients undergoing rescue percutaneous transluminal coronary angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction. The aim of the study was to investigate such effects. METHODS: Eighty-nine consecutive patients referred to our laboratory from other hospitals for rescue PTCA within 24 hours from the onset of chest pain were prospectively randomized before the procedure to abciximab treatment (44 patients) or placebo (45 patients). No significant differences in baseline characteristics were observed between the 2 groups. Study end points were the occurrence of major adverse cardiac events (MACE) such as death, reinfarction, congestive heart failure, target lesion revascularization, or recurrent ischemia at 30-day and 6-month follow-up and the occurrence of periprocedural bleeding. RESULTS: Mean time from symptom onset to reperfusion was 8.5 +/-5.4 hours; rescue PTCA was successful in 96% of patients. The incidence of major, moderate, and minor bleeding was similar in the 2 groups. At 30-day follow-up, the echocardiographic left ventricular wall motion score index showed a significantly higher improvement in the abciximab group versus the placebo group (P <.001). At 6-month follow-up, the incidence of MACE was 11% in the abciximab group versus 38% in the placebo group (P =.004). Abciximab administration (P =.003) and cardiogenic shock (P =.005) were the only independent predictors of the occurrence of MACE at multivariable analysis. CONCLUSION: Treatment with abciximab during rescue PTCA positively affects clinical outcome at 6-month follow-up without increasing periprocedural bleeding.
BACKGROUND: The aim of this study was to evaluate the risk factors for cardiovascular diseases, clinical presentation and coronary anatomical size differences in women. METHODS: From January 1999 to December 2000, 244 female and 980 male patients were submitted to coronary angioplasty (PTCA). For both groups the following were considered: risk factors for cardiovascular diseases, clinical presentation and angiographic data. The clinically confirmed 6 months restenoses were evaluated. We performed intravascular ultrasound (IVUS) with three-dimensional reconstruction and quantitative coronary angiography (QCA) on the proximal left anterior descending (LAD) coronary artery segments free of significant atherosclerosis in 60 men and 50 women matched for age and clinical characteristics. The arterial and luminal areas were measured by planimetry and corrected for body surface area. We also evaluated the external elastic membrane diameter (EEMd), the minimal lumen diameter (MLD) and the intima-media thickness (IMT). RESULTS: At the time of admission, women were older than men, were shorter, weighed less, and had a smaller body surface area; they had more severe angina, diabetes mellitus and hypercholesterolemia. There was no difference between women and men in the incidence of clinical restenosis at 6 months of follow-up. At IVUS, the mean uncorrected LAD arterial area was smaller in women than in men (12.7 +/- 3 vs 15.9 +/- 3.3 mm2, p < 0.05), as was the mean LAD luminal area (9.9 +/- 3 vs 12.9 +/- 2.7 mm2, p < 0.005). Both the MLD and the EEMd as well as the IMT were smaller in women than in men (MLD 3.3 +/- 0.6 vs 3.9 +/- 0.5 mm, p < 0.05; EEMd 3.7 +/- 0.6 vs 4.2 +/- 0.4 mm, p < 0.005; IMT 0.29 +/- 0.1 vs 0.4 +/- 0.1 mm, p < 0.05). QCA confirmed the IVUS results (MLD 2.9 +/- 0.6 vs 3.5 +/- 0.8 mm, p < 0.05). After correction for body surface area, univariate associations between sex and both the arterial and luminal areas were no longer present. CONCLUSIONS: Women submitted to PTCA were older. The incidence of hypertension, diabetes mellitus and hypercholesterolemia was higher than in men. There was no sex difference in the rate of clinical restenosis at 6 months of follow-up. The LAD artery is smaller in women, independently of body size. This suggests an intrinsic sex effect on coronary dimensions.