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Contains fulltext : 233810.pdf (Publisher’s version ) (Closed access) BACKGROUND AND AIMS: The impact of advanced age on the optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary revascularization (PCI) is still greatly debated. Therefore, the aim of the present sub-analysis of the REDUCE trial was to assess the impact of age on the comparison between a short 3 months vs standard 12 months DAPT in ACS patients treated with the COMBO Dual Stent Therapy. METHODS: The REDUCE trial is a prospective, multicenter, investigator-initiated study that randomized ACS patients undergoing PCI with the COMBO drug eluting stent to either 3 or 12 months of DAPT. The study population was divided according to age (

AIMS The LEADERS FREE trial has demonstrated that a polymer-free Biolimus A9-coated stent (BA9-DCS) is superior to a bare metal stent (BMS) for high bleeding risk (HBR) patients when treated with one month of dual antiplatelet therapy (DAPT). This analysis aimed to determine the impact of PCI procedure complexity on the two-year results. METHODS AND RESULTS Six hundred and sixty-seven (667) patients enrolled in the LEADERS FREE (BA9-DCS 346, BMS 321) underwent a complex PCI, defined by one or more of eight characteristics: total stent length ≥60 mm, ≥3 vessels or lesions treated, ≥3 stents implanted, bifurcation lesion treated with ≥2 stents, chronically occluded, restenotic or saphenous vein graft lesion. Patients undergoing complex PCI were older, more often male, and presented with more ACS, diabetes, renal insufficiency, anaemia and multivessel disease. They derived major benefit from DCS over BMS for safety (16.2% vs. 21.7%, HR 0.70 [0.49-0.99], p

BACKGROUND Patients at high risk for bleeding who undergo percutaneous coronary intervention (PCI) often receive bare-metal stents followed by 1 month of dual antiplatelet therapy. We studied a polymer-free and carrier-free drug-coated stent that transfers umirolimus (also known as biolimus A9), a highly lipophilic sirolimus analogue, into the vessel wall over a period of 1 month. METHODS In a randomized, double-blind trial, we compared the drug-coated stent with a very similar bare-metal stent in patients with a high risk of bleeding who underwent PCI. All patients received 1 month of dual antiplatelet therapy. The primary safety end point, tested for both noninferiority and superiority, was a composite of cardiac death, myocardial infarction, or stent thrombosis. The primary efficacy end point was clinically driven target-lesion revascularization. RESULTS We enrolled 2466 patients. At 390 days, the primary safety end point had occurred in 112 patients (9.4%) in the drug-coated–stent group and in 154 patients (12.9%) in the bare-metal–stent group (risk difference, −3.6 percentage points; 95% confi dence interval [CI], −6.1 to −1.0; hazard ratio, 0.71; 95% CI, 0.56 to 0.91; P

Over the past decade, outcomes for patients with acute ST-segment-elevation myocardial infarction (STEMI) have been improving in the developed world - mainly, USA and Europe. This is as a result of an organized revolution in AMI (Acute Myocardial Infarction)-care in general and STEMI-care in

PCI of long diffuse coronary lesions are often challenging. Data regarding usage and real-world outcomes of very long coronary stents are limited. This retrospective study sought to determine the safety, the efficacy of the procedure and 1-year outcome in terms of MACE in patients treated with Ultra

Background: The TAXUS OLYMPIA registry is a prospective, postapproval registry collecting clinical outcomes data on patients receiving the TAXUS Liberte paclitaxel-eluting stent during routine interventional cardiology practice. Methods: Between February and July 2005, 529 patients receiving the TAXUS Liberte stent at 16 centers in the Middle East, South/Central America, and Asia/Pacific regions were enrolled in Phase I of OLYMPIA. The primary end-point was TAXUS Liberte stent-related cardiac events (cardiac death, MI, and revascularization) at 30 days postimplant. Additional clinical assessment was conducted at 6 and 12 months. OLYMPIA phases II and III are in clinical follow-up and will be reported separately. Results: One-year clinical follow-up is available for 98% of patients. Complex patients and lesions were prevalent, including: 50% diabetes mellitus, 49% multivessel disease, 30% multiple stenting, 48% AHA/ACC type B2/C lesions, 19% long lesions (>26 mm), and 40% small vessels (≤2.75 mm). At 1 year, the cardiac event rate was 4.1%, including 1.5% cardiac death, 1.5% MI, and 2.3% target vessel revascularization (TVR). The TAXUS Liberte stent-related cardiac event rate was 3.7% at 1 year. Stent thrombosis (ST) occurred in 1.7% of patients, with three cases occurring >30 days postprocedure. One-year cardiac event rates among complex subpopulations (diabetics 5.0%, multiple stents 3.8%, long lesions 3.1%, and small vessels 2.9%) were comparable to the overall study population. Conclusions: In conclusion, this first report of real-world experience with the TAXUS Liberte stent demonstrates the safety and clinical utility of this stent in the broader spectrum of coronary disease treated in everyday practice.

Background: Rheumatic heart disease remains the most common acquired heart disease in children, especially in developing countries. This study aims to investigate the predictors of immediate procedural success and the immediate and long-term outcomes in patients undergoing percutaneous mitral commissurotomy (PTMC). Methods: A total of 1552 patients with rheumatic mitral stenosis and underwent PTMC from 1989 to 2012 were identified. We divided the group according to Wilkins score as low risk (≤5), intermediate risk (6-8) and high-risk (≥9). Procedural success was defined as mitral valve area greater than 1.0cm2 with a mean gradient of less than 10mmHg. Results: The median age was 36 years old [IQR 28-45]. The majority of patients was female (78.5%) and did not have any other valve involvements (85.0%). Most of cases were elective (99.5%) although 103 patients were pregnant (6.6%) during PTMC. The mitral valve area increased from 0.8cm2 [IQR 0.7-1.0] pre-procedure to 1.5cm2 [IQR 1.3-1.7] post-procedure, with a reduction in the mean pressure gradient of 15mmHg [IQR 12-20] to 4mmhg [IQR 2-6] post-procedure (all p< 0.05). Using logistic regression analysis, no difference was seen in immediate procedural success between increasing age, previous PTMC, emergency cases, New York Heart Association status, balloon size or increasing risk groups (all p>0.05). During the 15-year follow-up, the majority of patients were still alive. Conclusions: PTMC appears to be safe and effective in our population, irrespective of older age, higher NYHA class, higher Wilkins score and previous PTMC with good immediate and long-term outcomes.

Patient initials or identifier number sd ### Relevant clinical history and physical exam A 59 year old female with long standing diabetes and hypertension and history of PCI to ostial Left Main (LM) – Left Anterior Descending artery (LAD) in March 2013. During a subsequent follow up in

Patient initials or identifier number MKI ### Relevant clinical history and physical exam 54 years old / Gentleman Known case of hypertension for the last 10 years. Family history of IHD (older brother had CABG at 50 years of age). Smoker (20 sticks /day) Recent history of unstable angina

1Senior Consultant Cardiologist, National Heart Institute Kuala Lumpur 2Consultant Cardiologist, Subang Jaya Medical Centre, Selangor 3Consultant Cardiologist, Sarawak General Hospital Heart Centre 4Consultant Physician, Hospital Raja Permaisuri Bainun, Ipoh 5Consultant Cardiologist, Subang Jaya Medical Centre, Selangor 6Family Medicine Specialist, Primary Health Clinic Tanglin, Kuala Lumpur 7Consultant Cardiologist, Hospital Pulau Pinang, Penang 8Consultant Cardiologist, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 9Specialist in Internal Medicine, Hospital Kuala Lumpur, Kuala Lumpur 10Consultant Cardiologist, National Heart Institute Kuala Lumpur 11Consultant Cardiologist, University Malaya Medical Centre Kuala Lumpur

Background: Sex differences in acute coronary syndrome (ACS) have been well studied in major registries and clinical trials in Western populations. Limited studies have examined the sex differences in ACS using a large number of Asian women as the subjects.Objectives: The aim was to study the sex differences in ACS using the NCVD-ACS (National Cardiovascular Disease Database—Acute Coronary Syndrome) registry.Methods: We analyzed 13,591 ACS patients, of which 75.8% were men and 24.2% were women, from March 2006 to February 2010. Data were collected on demographic characteristics, risk factors, anthropometrics, treatments, procedures, mortalities, and complications. The results were compared among 3 cohorts of ACS (ST-segment elevation myocardial infarction [STEMI], non–STEMI, and unstable angina).Results: Women were older and more likely to have diabetes, hypertension, previous heart failure, and cerebral vascular accidents than men were. Women were less likely to receive in-hospital administration of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers, and they were less likely to undergo angiography and percutaneous coronary intervention. In STEMI, a significantly lower proportion of women than men received primary percutaneous coronary intervention (6.2% vs. 6.7%, respectively, p = 0.000) and fibrinolysis (64.4% vs. 74.6%, respectively, p = 0.000). In addition, with regard to STEMI, women had a significantly higher unadjusted in-hospital mortality rate than men did (15.0% vs. 8.1%, respectively, p < 0.000). There was no statistically significant in-hospital mortality difference between sexes for non-STEMI and unstable angina. After adjustment for age and other covariates, a multivariate analysis showed no sex differences in the in-hospital mortality in all spectrums of ACS.Conclusions: Our study showed significant sex differences in the demographic characteristics, risk factors, treatments, and outcomes of ACS. More importantly, in ACS patients, we found evidence of suboptimal treatments and interventions in women versus men. Our findings provide an opportunity to narrow the sex gap in the care of women with ACS in Malaysia.HighlightsWe studied the sex differences in acute coronary syndrome in Malaysia using the National Cardiovascular Disease Database—Acute Coronary Syndrome Registry.Demographic data, risk factors, anthropometrics, treatments, procedures, and outcomes were compared between sexes.Women were older, had more comorbidities, and were less likely to receive evidence-based treatment than men were.After adjustment for covariates, a multivariate analysis showed no sex differences in the in-hospital mortality among all spectrums of acute coronary syndromes.We found evidence of suboptimal treatments and interventions in women with acute coronary syndromes.

events included: IABP support (13%), renal replacement therapy (6%), infections (3.6%). No cerebrovascular events or AMI occurred. Median length of hospital stay was 5 days. At discharge, 87% patients had MR 2+. At 1 year months EF was 34.7 10.4% (p1⁄40.002 compared to baseline value). Actuarial survival at 1 year was 89.6 3%. Actuarial freedom from MR 3+ at 1 year was 79.4 4%. At 1 year, MLHFQ improved from 40 15 to 22 16 (p

This study was designed to prospectively evaluate the safety and efficacy of the 38-mm Resolute zotarolimus-eluting stent (R-ZES). Drug-eluting stents with long lengths are needed to ensure coverage of long lesions in some patients. Patients recruited from the RESOLUTE US and RESOLUTE Asia studies were implanted with at least one 38-mm R-ZES. Up to 2 lesions (in separate vessels) could be implanted with length ≤35 mm and a reference vessel diameter of 3.0 to 4.2 mm. The primary end point was 1-year target lesion failure, defined as cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. The 1-year target lesion failure rate using 1 vessel per patient was compared with a performance goal (19%) derived from historical data. There were 223 patients enrolled (n = 269 lesions). The mean age was 60.9 ± 10.9 years, 79% were men, and 38% had diabetes. Target lesion failure rate using a single-vessel analysis was 4.5%, and the upper limit of the 1-sided 95% confidence interval (7.5%) was less than the performance goal of 19%. A secondary analysis using all lesions resulted in a target lesion failure rate of 5.4% (upper limit of 1-sided 95% confidence interval, 8.6%). Baseline characteristics and clinical outcomes were similar between patients with and without diabetes. The rate of probable or definite stent thrombosis was 0.9%. In conclusion, the 38-mm length of the R-ZES was found to be safe and effective with a low rate of target lesion failure and stent thrombosis and no differences in outcomes between patients with and without diabetes.

Asian patients have a uniquely high risk for heart disease compared to other ethnicities. Past drug eluting stent trials have examined mainly populations of European heritage. As a significant proportion of the real world population in the SPIRIT V single arm study is Asian, the study provides insight into how this population responds to stenting with the XIENCE V Everolimus Eluting Coronary Stent (EES).2,700 patients were enrolled at 93 sites in Europe, Asia Pacific and Canada between November 2006 and November 2007. 698 (26%) patients were recruited from Asian sites in India, China, Hong Kong, Malaysia, Singapore and Thailand. De novo coronary artery lesions of all patients were to be treated with up to 4 planned EES. Up to 2 year follow-up, major adverse cardiac events, myocardial infarction and target lesion revascularization rates were lower in the Asian subgroup than in the non-Asian subgroup. These results were mainly driven by better clinical outcomes in the Indian population. All populations showed similar low stent thrombosis rates.These findings demonstrate the safety and efficacy of the EES when used in a real-world Asian population, known to be at higher risk for heart disease.

In the past decade, outcomes for patients with acute ST-segment-elevation myocardial infarction (STEMI) have improved in the developed world as a result of an organized revolution in STEMI-care. Concurrently, the Acute Myocardial Infarction (AMI) burden in the developing world is steadily rising.

Summary Objective The Malaysian NCVD-PCI registry attempts to determine the number and to monitor the outcomes of Percutaneous Coronary Intervention (PCI), based on selected performance indicators. It provides a comprehensive view to determine the level of adherence to existing guidelines, to evaluate the cost-effectiveness of treatment and prevention programs and to facilitate quality improvement activities of the participants. It also aims to stimulate research and to act as a reference for future studies. Methods It was a voluntary, multi-centered, observational, cohort study and included patients of 18 years or above, with coronary artery disease who underwent PCI at eight participating centers in the year 2007. Results A total of 3677 patients underwent 3920 PCI procedures with 6299 stents for 5512 lesions. The mean age of patients was 56.7 ± 10.11 years. The mean BMI was 26.38 ± 4.21 kg/m2, while 80% of all subjects had a BMI above 23 kg/m2. Males constituted 81.2% of the total population and 98.4% of the total population had at least one cardiovascular risk factor. Regarding PCI status, 90.1% were elective cases and 94% of cases had a low TIMI risk index at the beginning of PCI. Femoral approach accounted for 59%, radial approach for 34% and brachial approach for 1% of all cases. The median fluoroscopy time was 15.7 min and the median door-to-balloon time for primary infarct PCI was 93.5 min. The commonest site of lesion was the left anterior descending artery, accounting for 48% of all lesions and 92.8% of all lesions were de novo. The mean lesion length was 24.4 ± 15.18 mm and about 28% of all lesions had high risk characteristics. Drug-eluting stents and bare metal stents were used in 53.6% and 42.5% of cases, respectively. After PCI, 91% of all lesions achieved TIMI grade 3 flow. Regarding pharmacotherapy, 99.5% of all patients received unfractionated heparin, 5% received LMWH prior to intervention, 96% received aspirin and 98% received clopidogrel. Over-all in-hospital mortality and 30 day mortality for the entire cohort was 1.1% and 1.8%, respectively. Conclusion A summary of the first nationwide PCI registry has been presented. The subjects were much younger with a high prevalence of cardiovascular risk factors. The majority of cases (90%) were elective procedures with a low TIMI risk index. Mean door-to-balloon time for primary PCI was higher than the recommended guidelines. There was good prescribing of antiplatelets and heparin. Over-all in-hospital and 30 day mortality were comparable to other registries.

Objective To retrospectively evaluate the 12-month effectiveness of the Endeavor zotarolimus-eluting stent (ZES) in diabetic versus non-diabetic patients enrolled in the E-Five Registry. Design and Setting The E-Five Registry is a prospective, multicentre registry of 8314 patients presenting with symptomatic coronary artery disease treated with the Endeavor (ZES). Patients were treated at 188 centres located in 37 countries across Europe, Latin America and Asia Pacific. Patients There were 2721 (32.7%) patients with diabetes (DM) and among these patients 682 were insulin-treated (ITDM) and 2039 were non-insulin-treated diabetic patients (NITDM). Interventions All enrolled patients received an Endeavor ZES and were followed for 12 months. Main outcome measurements The primary outcome measure was major adverse cardiac event (MACE) at 12 months. Secondary endpoints included target lesion revascularisation (TLR), target vessel revascularisation (TVR), target vessel failure (TVF) and stent thrombosis. Results Compared with non-DM patients, DM patients had higher rates of MACE (9.7% vs 6.4%, p

Background: Rheumatic heart disease remains the most common acquired heart disease in children, especially in developing countries. This study aims to investigate the predictors of immediate proced...

Objective The Malaysian NCVD-ACS (National Cardiovascular Disease Database-Acute Coronary Syndrome) registry attempts to determine the incidence and demographic profile of patients with ACS and to identify high risk group among them. It provides a comprehensive view to assess treatment strategies and adherence to existing guidelines for ACS patients; which can help in future development. It also aims to facilitate research using this database. Methods The study included patients with ST-segment elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) admitted to 11 participating sites in Malaysia from 1st January 2006 to 31st December 2006. The data were analyzed in terms of characteristics, clinical presentation, treatment, in-hospital outcome and 30-day outcome. Results A total of 3422 patients were enrolled, with male to female ratio of 3:1, mean age of 59±12years and mean BMI of 25.8±4.4kg/m 2 . Among total study population, 96% had at least one established cardiovascular risk factor. In STEMI population, 70% received fibrinolytic therapy and 8% proceeded for primary percutaneous coronary intervention (PCI). Mean door-to-needle time for fibrinolytic therapy was 103±143min. Medical management was conducted for 86% of NSTEMI and 91% UA patients, with intervention for 14% and 9% respectively. The overall in-hospital mortality and 30-day mortality were 7% and 8% respectively. Conclusion In our NCVD-ACS registry, when compared with other registries, the subjects were much younger at presentation and had higher prevalence of established cardiovascular risk factors, indicating the importance of primary prevention programme. Majority of the patients were managed medically, with low rates of cardiac interventions, the factor being driven largely by availability of resources. Mean door-to-needle time was much higher than the recommended guidelines, an issue that needs attention. The results indicate many opportunities for improvement of in-hospital and 30-day mortality.

A 10-month-old boy underwent operation to close a large secundum atrial septal defect and multiple muscular ventricular septal defects. Closure of the ventricular septal defects was unsuccessful and led to worsening cardiac failure and inability to wean the patient from mechanical ventilation. Transcatheter closure of the ventricular septal defects using Gianturco coils was undertaken. This technique is an effective alternative for closure of multiple muscular ventricular septal defects in infants and small children.

OBJECTIVE We compared the result of radiofrequency (RF)-assisted valvotomy and balloon dilation with closed surgical valvotomy and Blalock Taussig (BT) shunt as primary treatment in selected patients with pulmonary atresia and intact ventricular septum (PA-IVS). BACKGROUND Patients with PA-IVS who have mild to moderate hypoplasia of the right ventricle (RV) and patent infundiblum have the greatest potential for complete biventricular circulation. The use of RF or laser wires to perforate the atretic valve followed by balloon dilation provides an alternative to surgery. METHODS Between May 1990 and March 1998, 33 selected patients underwent either percutaneous RF valvotomy and balloon dilation (group 1, n = 21; two crossed over to group 2) or surgical valvotomy with concomitant BT shunt (group 2, n = 14). Second RV decompression by balloon dilation or right ventricular outflow tract (RVOT) reconstruction were performed if necessary. Patients who remained cyanosed were subjected to transcatheter trial closure of the interatrial communication. Partial biventricular repair was offered to those with inadequate growth of the RV. RESULTS The primary procedure was successful in 19 patients in group 1. There was one in-hospital death and two late deaths. Of the remaining 16 survivors, 12 achieved complete biventricular circulation, 7 of whom required no further interventions. Two patients required repeat balloon dilation, 1 RVOT reconstruction and 2 transcatheter closure of interatrial communication. Two patients underwent partial biventricular repair. In group 2, there were 3 in-hospital deaths after the primary procedure and 1 patient died four months later. All survivors (n = 10) required a second RV decompression, 8 by balloon dilation and 2 by RVOT reconstruction, after which, two patients died. Of the final 8 survivors, 7 achieved complete biventricular circulation, 5 after coil occlusion of the BT shunt and 2 after closure of interatrial communication. CONCLUSIONS Radiofrequency valvotomy and balloon dilation is more efficacious and safe compared with closed pulmonary valvotomy and BT shunt in selected patients with PA-IVS.