Info

Time Interval:

aMI symptoms—angioplasty. bShock—angioplasty.

RP, reperfusion; MVD; Multivessel disease.

Time Interval:

aMI symptoms—angioplasty. bShock—angioplasty.

RP, reperfusion; MVD; Multivessel disease.

reported by Himbert et al. (220) demonstrated a mortality of 81% in patients with a successful procedure. However, a more contemporary report of 66 consecutive patients reported by Antoniucci and colleagues (228) demonstrated a procedure success rate of 94% and a hospital mortality of 26% with early shock (within 1 h of admission) undergoing stent (47%) supported angioplasty.

In the SHOCK registry, patients who underwent angioplasty had a lower hospital mortality rate than medically treated patients (46.4 vs 78%, p < 0.001). The mortality rate did correlate with reperfusion efficacy (33% with TIMI grade 3 flow, 50% with TIMI grade 2 flow, and 86% with TIMI 0-1 grade flow) (223).

Modern Advances in Transluminal Revascularization

Stents have ascended to a predominant role in transluminal revascularization. Although the impact was delayed by early concerns regarding implantation of stents in the thrombotic mileau of an acute infarct artery, stenting evolved from a bailout procedure to routine application to patients undergoing primary catheter-based reperfusion. Randomized trials comparing primary stenting with angioplasty in acute infarction have consistently demonstrated a reduction in recurrent ischemia and reinfarction (210). However, in the Stent Primary Angioplasty in Myocardial Infarction (Stent-PAMI) trial, the final TIMI 3 flow rate was lower in the stent group (93 vs 89%, p = 0.0006) with a trend for a higher 6-mo mortality (4.3 vs 2.8%, p = 0.06) (235). These limitations were not seen in the Controlled Abciximab and Device to Lower-Late Angioplasty Complications (CADILLAC) trial with an overall significant reduction in 6 mo Major Adverse Cardiac Events (MACE) in the stent group (10.4 vs 18.4%,p < 0.001) and no evidence of reduced TIMI grade 3 flow or survival with stent implantation (236).

In cardiogenic shock, initial utilization of stent support after balloon angioplasty for suboptimal results or complications (dissection) has enhanced reperfusion success (228,237). Several reports suggest that this improved efficacy may translate into a survival benefit (238-241). In the SHOCK trial, stent use was associated with improved procedure success in the early revascularization group (92 vs 76%, p = 0.045) and success was correlated with reduced 30-d mortality (38 vs 79%,p = 0.003) (242).

Glycoprotein IIb/IIIa inhibitors have been clearly established as important adjuncts for transluminal revascularization principally by reducing ischemic events (243). However, the use of IIb/IIIa inhibition with catheter-based reperfusion therapy for acute ST-elevation infarction remains controversial (244). Trial data are somewhat discordant in regards to the advantage of the addition of abciximab over primary stenting alone (236,245). Analysis of two prospective databases of patients with cardiogenic shock determined a benefit for patients undergoing primary angioplasty and a synergistic advantage with the use of stents (241,246).

Although directional and transluminal extraction atherectomy devices have been utilized as primary reperfusion modalities in acute myocardial infarction, superiority over balloon angioplasty and stenting has not been demonstrated (247,248). However, extensive thrombus burden may be present in some infarct arteries (particularly large [>4.0 mm] right coronary arteries) and result in reduced procedure success, the no reflow phenomenon, and decreased survival (224). Recently, successful thrombus removal utilizing the AngioJet rheolytic thrombectomy device has been reported during acute infarction and in the setting of cardiogenic shock (249,250). Future investigation of this and other thrombectomy devices may validate the effectiveness of this approach.

Table 6

Coronary Artery Bypass Surgery and Cardiogenic Shock

Table 6

Coronary Artery Bypass Surgery and Cardiogenic Shock

Series reference

Was this article helpful?

0 0
Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

Get My Free Ebook


Post a comment