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Cardiogenic shock remains associated with unacceptably high mortality, but recent improvements with early revascularization, continued support with pharmacologic agents, and use of an intra-aortic balloon pump have led to improvements in the rate of mortality. Timely intervention with cardiac surgery in patients with mechanical complications, 3-vessel disease, and left main disease is beneficial. Continued research and ever-improving understanding of this once deadly condition have helped further in improving prognosis. Cutting-edge technologies, such as myocyte cell implantation and the use of a cooling system, will help in pushing the boundaries farther., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The field of myocardial regeneration (angiogenesis and myogenesis) might prove to play an important role in the future management of cardiovascular disease. Stem cells are currently undergoing testing in Phase I and Phase II clinical trials. Methods of delivery will affect the outcome of such therapies, perhaps significantly. This document provides suggested guidance in 4 methods of delivery: endocardial, intracoronary, coronary sinus, and epicardial., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial demonstrated that bivalirudin monotherapy significantly reduces major bleeding compared with heparin (unfractionated or enoxaparin) or bivalirudin plus a glycoprotein IIb/IIIa inhibitor in acute coronary syndromes. Whether vascular closure devices (VCD) impact these results is unknown. Therefore, this study sought to determine whether VCD impact major access site bleeding (ASB) in patients with acute coronary syndromes undergoing early invasive management by the femoral approach., Methods and Results: Major ASB in ACUITY was defined as ASB requiring interventional or surgical correction, hematoma > or =5 cm at the access site, retroperitoneal bleeding, or hemoglobin drop > or =3 g/dL with ecchymosis or hematoma <5 cm, oozing blood, or prolonged bleeding (>30 minutes) at the access site. Stepwise logistical regression was performed to identify the independent determinants of ASB. Of 11 621 patients undergoing angiography with or without percutaneous coronary intervention by the femoral approach, 4307 (37.1%) received a VCD and 7314 (62.9%) did not. Rates of major ASB were lower with VCD compared with no VCD (2.5% versus 3.3%, relative risk, 0.76; 95% CI, 0.61 to 0.94; P=0.01) and were lowest in patients treated with bivalirudin monotherapy and a VCD (0.7%). Stepwise logistic regression revealed that a VCD (odds ratio, 0.78; 95% CI, 0.61 to 0.99; P=0.04) and bivalirudin monotherapy (odds ratio, 0.35; 95% CI, 0.25 to 0.49; P<0.0001) were both independent determinates of freedom from major ASB., Conclusions: In patients with acute coronary syndromes undergoing an early invasive management strategy by the femoral approach, the use of a VCD, bivalirudin monotherapy, or both minimizes rates of major ASB. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00093158.

A number of bifurcation lesion classification schemes exist in which capital letters or Roman numerals categorize various types of bifurcation lesions. Unfortunately, these classification schemes are confusing and difficult to remember because of the lack of association between the numbers or letters and various anatomic abnormalities of bifurcation lesions. Recently, the Medina classification was proposed as a simpler, easier-to-remember scheme that labels bifurcation lesions by plaque involvement in 3 anatomic segments (proximal main segment, distal segment of main branch, and side branch). However, this classification also has limitations because it doesn't include important descriptive features of bifurcation lesions that could be important in determining optimum stent treatment strategy. The Movahed classification overcomes these limitations by including bifurcation angle and proximal vessel size in its scheme. The impact of these various classification schemes on stent treatment strategies and more recent clinical trial results is discussed.

Background: Little has been reported regarding the utility or outcomes of femoral venous vascular closure using arterial suture closure devices. We describe results using a pre-closure approach with a 6 French (Fr) Perclose Closer S device in patients who underwent antegrade aortic valvuloplasty using 14 Fr percutaneous femoral venous access catheters., Methods: Forty-five patients underwent antegrade aortic valvuloplasty and suture-mediated closure with a 6 Fr Perclose device. A 6 Fr Closer S suture device was preloaded into the femoral vein after 6 Fr sheath access, prior to insertion of a 14 Fr venous sheath. Upon completion of the procedure, the 14 Fr femoral venous sheath was removed through the existing sutures., Results: Of 45 patients (mean age 82.4 years; 17 males), immediate hemostasis was achieved with percutaneous suture closure in 43 (95.6%). Only 2 failures occurred which were subsequently successfully treated with manual compression. No late access site bleeding occurred from sutured sites. In all other patients, hemostasis using a 6 Fr Perclose suture-mediated device was successful and immediate. There was no need for transfusion, no clinical venous thrombosis, and no infections occurred at the access site. Two hospital deaths were documented from causes unrelated to suture-mediated closure., Conclusions: In conjunction with 14-Fr size percutaneous sheaths during antegrade aortic valvuloplasty, percutaneous suturemediated closure is a highly effective method for achieving hemostasis. This has simplified postprocedural management in terms of early mobilization and diminished late access site bleeding.

Background: Early studies suggested that morbidity and mortality after percutaneous coronary intervention (PCI) were greater for women than men. However, in recent reports, sex-related differences in short-term outcome have decreased as outcomes among women have improved., Objective: The aim of the study was to evaluate the effect of sex on long-term mortality among a large cohort of patients undergoing PCI in the contemporary era., Methods: Three hospitals in New York City contributed prospectively defined data elements on 4284 consecutive patients undergoing PCI in 1998 to 1999. All-cause mortality at a mean follow-up of 3 years was the primary end point., Results: Of the 4284 patients, 1331 (31%) were women. Women were significantly older than men (mean age 67 vs 62 years, P < .001) and less often white (72% vs 80%, P < .001). Hypertension (78% vs 66%, P < .001) and diabetes (36% vs 22%, P < .001) were more prevalent in women. Prior cardiac surgery (14% vs 19%, P = .001) and previous myocardial infarction (MI) (33% vs 36%, P = .08) were less common among women. Presentation with unstable angina was more frequent in women (45% vs 41%, P = .034), whereas presentation with acute MI did not differ by sex. Congestive heart failure developed more commonly among women (7.1% vs 4.1%, P < .001). The extent of coronary disease (1-, 2-, or 3-vessel disease) did not differ between women and men. Mean ejection fraction was 52% in women and 50% in men (P < .001). Stents were placed in 77% of both groups. Procedural success was 97% for both women and men. Inhospital adverse outcomes including death, post-PCI MI, emergency bypass surgery, abrupt closure, and stent thrombosis were uncommon and not different between groups. Mortality at 3 years was 10% for women and 8.9% for men (P = .197). However, using Cox proportional hazards analysis to adjust for comorbidities and possible confounders, female sex was associated with a significant independent reduction in the hazard of long-term mortality (hazard ratio 0.78, 95% CI 0.620-0.969, P = .02)., Conclusions: Despite more high-risk characteristics, female sex conferred a long-term survival advantage after PCI.

Background: In the SHOCK trial, the group of patients aged >or=75 years did not appear to derive the mortality benefit from early revascularization (ERV) versus initial medical stabilization (IMS) that was seen in patients aged <75 years. We sought to determine the reason for this finding by examining the baseline characteristics and outcomes of the 2 treatment groups by age., Methods: Patients with cardiogenic shock (CS) secondary to left ventricular (LV) failure were randomized to ERV within 6 hours or to a period of IMS. We compared the characteristics by treatment group of patients aged >or=75 years and of their younger counterparts., Results: Of the 56 enrolled patients aged >or=75 years, those assigned to ERV had lower LV ejection fraction at baseline than IMS-assigned patients (27.5% +/- 12.7% vs 35.6% +/- 11.6%, P = .051). In the elderly ERV and IMS groups, 54.2% and 31.3%, respectively, were women ( P = .105) and 62.5% and 40.6%, respectively, had an anterior infarction (P = .177). The 30-day mortality rate in the ERV group was 75.0% in patients aged >or=75 years and 41.4% in those aged <75 years. In the IMS group, 30-day mortality was 53.1% for those aged >or=75 years, similar to the 56.8% for patients aged <75 years., Conclusions: Overall, the elderly randomized to ERV did not have better survival than elderly IMS patients. Despite the strong association of age and death post-CS, elderly patients assigned to IMS had a 30-day mortality rate similar to that of IMS patients aged <75 years, suggesting that this was a lower-risk group with more favorable baseline characteristics. The lack of apparent benefit from ERV in elderly patients in the SHOCK trial may thus be due to differences in important baseline characteristics, specifically LV function, and play of chance arising from the small sample size. Therefore, the SHOCK trial overall finding of a 12-month survival benefit for ERV should be viewed as applicable to all patients, including those >or=75 years of age, with acute myocardial infarction complicated by CS.

Background: Percutaneous coronary rotational atherectomy (PCRA) is a potent stimulus of platelet activation and aggregation in vivo. For this reason, many patients undergoing PCRA are treated with platelet glycoprotein (GP) IIb/IIIa inhibitors. However, there is limited data regarding the ability of GP IIb/IIIa inhibitors to reduce ischemic complications of PCRA and no data regarding their effect on long-term survival., Methods: Data on 1138 consecutive patients undergoing PCRA in 5 hospitals in 1998-1999 were pooled and analyzed. Long-term survival was available for all 530 patients treated in 3 of the hospitals., Results and Conclusions: GP IIb/IIIa inhibitors were administered to 315 of 1138 (28%) PCRA patients. There was no difference in age, gender or race among patients treated with and without GP IIb/IIIa antagonists. The prevalence of hypertension, diabetes, renal insufficiency and peripheral vascular disease did not differ between groups. Unstable angina was more common among patients treated with GP IIb/IIIa inhibitors (45% vs. 38%, P = 0.036) Patients treated with GP IIb/IIIa inhibitors had lower ejection fractions (50% vs. 55%, P < 0.001) and more 3-vessel coronary disease (24% vs. 16%, P = 0.002). Angiographic success was over 99% in both groups (P = NS). The frequency of major adverse cardiovascular events (MACE) was slightly greater in GP IIb/IIIa inhibitor treated patients (3.8% vs. 2.2%, P = 0.126). At a mean follow-up of 3 years, mortality was 13.3% in the GP IIb/IIIa treated patients and 12% in the untreated patients (P = 0.224). On Cox proportional hazards analysis, treatment with a GP IIb/IIIa inhibitor was not significantly associated with increased survival (Hazard Ratio, 0.81, 95% Confidence Interval, 0.631-1.039, P = 0.098). These data do not indicate a significant association between GP IIb/IIIa inhibitor treatment during PCRA and MACE or survival., Condensed Abstract: There is limited data regarding the ability of GP IIb/IIIa inhibitors to reduce ischemic complications of percutaneous coronary rotational atherectomy (PCRA) and no data regarding their effect on long-term survival. These data do not indicate a significant association between GP IIb/IIIa inhibitor treatment during PCRA and MACE or survival.

The use of angiogenic factors to effect therapeutic angiogenesis may be an attractive treatment modality for a substantial number of patients who have diffuse coronary artery disease and who are not candidates for traditional revascularization procedures. Delivery of angiogenic factors as a protein or gene encoding for the respective protein product has been shown to induce angiogenesis in numerous animal models, and expression of a functioning product has been demonstrated. Various early clinical trials of therapeutic angiogenesis have shown reduction in anginal symptoms and increases in exercise time, as well as objective evidence of improved perfusion, left ventricular function and angiographic appearance following such angiogenic treatments., (Copyright 2004 S. Karger AG, Basel)

Both sealing and suturing closure devices have been shown to shorten hemostasis time, reduce the discomfort of manual or mechanical compression, and allow for earlier ambulation after cardiac catheterization and percutaneous coronary interventions without increasing vascular complications compared with conventional compression techniques. Several studies now report a reduction in vascular complications for percutaneous coronary intervention patients treated with closure devices compared with manual compression with pronounced benefit seen in patients receiving glycoprotein IIb/IIIa receptor inhibitors. Adoption of a simple predeployment femoral angiogram is now standard practice for use of a closure device. In an attempt to develop devices that are safer and more "user friendly," considerable modifications and improvements have been made in newer generation devices. Ultimately, the acceptance of femoral closure devices will depend on which device provides a simple approach with reliable hemostasis and a cost that can justify their incorporation into routine practice.