Vol 108. No 2. July 15. 2003
`ISSN 0009-7322
`Circulation.
`v.108, no. 2 (July 15 2003)
`DUP -General Collection
`W1 Cl743
`2003-08-12 07:12:54
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`Heart ff
`American
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`Circulation
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`f JO N J o V R N A I. o F T II E A )I E I( I CA N H EA K 'f" A S S U C I A
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`Volume 108 • Number 2
`July 15, 2003
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`Electronic Pages
`Circulation
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`Cardiology Patient Page
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`Shortness of Breath
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`Biykem Bozk1111,
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`Images in Cardiovascular Medicine
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`Penetrating Atherosclerotic Ulcer of the Aortic Arch
`MD MD; Albert SchtJ111ig, MD; Riidiger Lange, MD; Peter Andrdssy, Christian Firschke, MD; Marek Orban,
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`In Memoriam
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`Management: CarcgiYcr
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`Heart Failure
`MD; Sharon A. Hunt, MD . . . . . . . . . . .
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`Brief Rapid Communication
`Novel Mechanism
`Drug Block:
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`Underlying
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`Drug Actions
`Antiarrhythmic
`MD, PhD; Dan M. Roden, MD . . . . . . . . . .
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`Clinical Investigation and Reports
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`Ef'licacy and Safety of Tenectcplasc in Combination With the Low-Molccular-Weii:ht Heparin Enoxaparin
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`or Unfraclionatcd Heparin in the Prehospit.il Setting: The Assessment of the Safely and Efficacy nf a New
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`Thrombolytic Hcgimen (ASSENT)-3 PLUS Randomized Tri.ii in Acute Myocardial Infarction
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`L Wa/fr11ti11, MD. PhD: !'. Goldstein, MD, PhD; P. \V. Armstrong, MD; C.ll. Granger,
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`MD: A.A.J. Adgey, MD;
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`MD; B. liw/al,/, MD. PhD: M. Miildjiin•i, 11.R. Amtz. MD. PhD; K. Bogaerts, MSc:; T. Dwwy.Y,
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`Origin Arc Cells of Noncardiac in Illood of m1d Endothelial l Progenitor Cells Arc Dccrcasccl
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`Enriched in Transplant Atherosclerosis of Cardiac Allograft Patients With Vasculopathy
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`Inflammation Modifies the Effects of a Reduced-Fat Low-Cholesterol Diet on Lipids: Results From the
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`Trial
`DASH-Sodium
`Thomas P. Erlinger, MD, MPH; Edgar R. Miller Ill, MD, PhD; Jeanne Charleston, RN;
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`J. Appel. MD, MPH . . . . . . .
`Lawrence
`150
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`Intake of n-3 and n-6 Fatty Acids in Relation
`to Inflammatory
`Among US Men
`Markers
`Dietary
`Habitual
`and Women
`ScD; Goklum S. Horamisligil,
`MD, PhD; Nader Rifai, PhD;
`MD, MPH; Susan E. Ha11ki11so11,
`Tobias Pischon,
`MD. DrPH; Eric fl. Rimm, ScD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
`C. Willett,
`Waller
`155
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`Plasma Concentration of C-Reactivc Protein and the Calcul.1ted Framingham Coronary Heart Disease
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`Risk Score
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`Michelle A. Albert, MD, MPH; Robert J. Glynn, PhD; Paul M Ridker, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . .
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`C-Reacti,•e Protein, Carotid Intima-Mcdia Thickness, and Incidence of lschemic Stroke in the Elderly:
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`The Cardiovascular Health Study
`Jie J. Cao, MD, MPH; Clum Thach, PhD, Teri A. Manolio, MD, PhD; Bruce M. Psaty, MD, PhD,
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`Lewis H. Ku/fer, MD, DrPH; Paulo H.M. Chaves, MD, PhD; Joseph F. Polak, MD. MPH;
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`Kim Sutton-Tyrrell, PhD; David M. Herri11;:1011, MD, MHS; Thomas R. Price, MD;
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`Mary Cushman, MD, MSc . . . . . . . . . . . .
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`Mechanical
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`on Myocardial Repcrfusion
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`MD, Giovanni MD; Marco De Carlo, Ugo Limbruno, MD, PhD; Andrea Micheli,
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`Amoroso, MD, PhD;
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`MD, PhD; Vita11to11io Di Bello, MD; Amw Sonia Petronio,
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`Roberta Rossini, MD; Cmerina Palagi.
`MD;
`MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
`Mario Mariani,
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`Gabriella Fmuanini, MD;
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`Prevention of Distal Embolization During Primary Angioplasty: Safety, Feasibility, and Impact
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`Preoperative Thallium Scanning, SclcctiYe Coronary Rcvascularization, and Long-Term After
`Survival
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`Major Vascular Surgery
`Giora Landesberg, MD, DSc; Morris Mosseri, MD; Ye/111da
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`G. Wolf. MD, Moshe Bocher, MD;
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`MD: Haim A1111er, MD: Charles
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`Alon Basevitch, MD: Ehud Rudis. MD: Uzi lzhar,
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`Weis.mum,
`MD;
`Yacov Berlatzky,
`MD . . . . . .
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`Care and Outcomes of Patients Newly llospilnlizcd for Hcnrt Fuilure in the Community Treated hy
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`Cardiologists Compared With Other Specialists
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`Jo11!f, MD; Yanyan Con,:. MSc; Peter I'. Liu. MD; PC't<'
`r C. Austin, PhD; Douglas
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`Philip
`S. Lee, MD;
`Jack V.
`Tu, MD. PhD . . . .
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`Proarrhythmic Effect of Pacemaker Stimulation in Patients With Implanted Cardiovcrlcr-Delibrillators
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`Ewald Himmrich. MD; 0/il'C'r /'rzihilll', M/J; Chri.�1ia11 Zellerhoff. MD; Andreas Liebrich, MD;
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`RN; fla/Jmwule No.wclw, M/J; K/11m !111dn·as, M/J; Oirk N,,!J,di11!f,
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`0111o!fbehi11,
`MD;
`MD . . . . . . . . . . . .
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`Jurgen Meyer,
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`Basic Science Reports
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`Cyclooxygenase-2 in Human amt ExtJcrimental lschcmic l'rolifcrativc Rctinopathy
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`F.Sen11/a11/J, MD, /'hD; F. Valt111u111c•sh, MSc; A. Vazquez-Te/lo, /'!,/); A.M. El-A.m,r, MD, /'Ill);
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`D.Chccchi11, MSc; S. /Jrau/t, MSc; F. Gobeil, l'hD; M.11. /Jea11clw111p, MSc:; II. Mwaikmnho, /JSc:;
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`MD, PhD; D.R. Varma, MD, f't,D; I'. Lac/wpd/C', /'h/J; II. 011/f, J'h/J;
`Y. Courtois, PhD; K. Gchoes,
`F.Behar-Cohen,
`MD. PhD: S. Chemtob.
`MD, PhD
`19H G
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`Impaired
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`Arteriogenic Response to Acute Hindlimh lschcmia in CD4-Knockonl Mice
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`Ki1111airt!, Eugenio Stabile. MD: Mary Susa11 Burnett. PhD: Craig Watkin.�. Ml): Timothy Ml);
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`Bachis, PhD; Andrea la Sala. PhD; Jo11atha11 M. Miller, MS; Marie Slum. MD; Step/"'" H. Epstein. MD;
`Alessio
`Shmuel Fuchs, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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`Diabetes Undermines Estro�cn Control of lnducihlc Nitric Oxide Synthase Function in Rut Aortic Smooth
`Muscle Cells Through Overexpression
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`of Estrogen Receptor-fl
`Adriana
`PltD; Chiara /Jole,:o, f'/,D,
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`Maggi, PhD; Andrea Cig11arella, PhD; Alessia Brusaclel/i,
`Christian
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`Pinna, PhD; Lina Puglisi, PhD . . . . . . . . . . .
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`Ultrasound Imaging of Acute Cardiac Transplant Rejection With Microhuhhles T:1rJ,:ekd to lntcrcellul:1r
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`Adhesion Molecule-J
`M. Csikari, /JS: ;\/exander l. Klilwnov, Pl,D;
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`Gregory E.R. Weller, PhD; Erxio11g Lu, MD; Melissa
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`David Fischer, BS; William R. Wag11er, PhD; Flordeliza S. Villanueva, MD . . . . . . . . . . . . . . . . .
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`/J1·Adrcncrgic
`Receptor
`Blockade
`Attenuates
`Angiotensin
`II-Mediated
`Catecholamine
`Release
`Into the
`Cardiac Interstit
`ium in Mitra! Regurgitation
`Jose Tal/aj,
`Wei, PhD; Gerald H. Hcmkes. DVM, PhD; Merrilee
`Holland,
`DVM;
`MD; Chih-Cha11g
`Patricia Rynders, DVM; A. Ray Dillon,
`DVM; Jeffrey
`L. Ardell, PhD; J.
`Andrew Armour,
`MD, PhD;
`Pamela A. Lucchesi, PhD; Louis J. De/1'/ta/ia, MD . . .
`Reentrant Circuits
`in the Canine Atriovcntricular
`Node During Atrial
`and Ventricular
`Echoes:
`Elcctrophysiological and Histological
`Correlation
`Peter Loh, MD; Siew Yen Ho. PhD; Tokuhiro
`Kmvara,
`MD; Richard
`N. W. Hauer, MD;
`Michie/ J. Janse,
`MD; Jacques
`M.T. de Bakker,
`Breithardt,
`PhD
`MD, PhD; Giinter
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`. . . 231
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`Review: Current
`Perspective
`Therapeutic Potential
`for Cardiovascular
`ase 5 Inhibition
`Disease
`of Phosphodiester
`Thorsten Reffelmcmn, MD; Robert
`A. Khmer, MD, PhD .
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`. . . . . . . .239
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`Images in Cardiovascular
`Medicine
`Pulmonary Artery:
`a Rock and a Hard Place
`Stuck Between
`Frank Grothues. MD; Tobias Welte,
`Huth, MD; Helmut U. Klein,
`MD; Christo!
`MD, FESC
`
`245
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`Annotated Table of Contents
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`AIO
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`Classified Advertising
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`The cover figure
`is from the image in this issue by Firschke
`et al. Figure
`I. Contrast-enhanced CT
`scan of
`the aortic
`arch.
`Seep e14.
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`Mechanical Prevention of Distal Embolization During
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`Primary Angioplasty
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`Safety, Feasibility, and Impact on Myocardial Reperfusion
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`Ugo Limbruno, MD, PhD; Andrea Micheli, MD; Marco De Carlo, MD; Giovanni Amoroso, MD, PhD;
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`Roberta Rossini, MD; Caterina Palagi, MD, PhD; Vitantonio Di Bello, MD; Anna Sonia Petronio, MD;
`
`
`
`Gabriella Fontanini, MD; Mario Mariani, MD
`
`by (PCI) may be limited intervention coronary percutaneous Background-Effective myocardial reperfusion after primary
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`distal embolization. We tested the safety, feasibility, and efficacy of the FilterWire-Ex (FW), a djstal embolic protection
`
`
`
`device, as an adjunct to primary PCJ.
`were compared with PCT with FW protection primary Methods and Results-Fifty-three consecutive patients undergoing
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`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::t:::14 versus 31::t:::19;
`
`
`
`and higher occurrence of grade 3 myocardial blush (66% versus 36%; P=0.006) and early ST-segment
`P=0.005)
`
`
`
`
`
`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 in1provement at 30 days in left ventricular
`
`
`
`
`wall motion score index (-0.30::t:::0.19 versus -0.18::t:::0.26; P=0.008) and ejection fraction (+7::t:::4% versus +4±7%;
`P=0.012).
`use during primary PCT is feasible and safe. Distal embolization prevention appears to exert a beneficial
`
`
`
`
`
`Co11clusions-FW
`
`
`
`
`
`
`
`effect on markers of myocardial reperfusion and on left ventricular function improvement at 30 days. (Circulation.
`2003;108:171-176.)
`
`
`
`Key Words:
`
`
`
`
`
`myocardial infarction • angioplasty • embolism • reperfusion
`
`We here report on the safery and feasibility of the adjunc­
`
`
`igns of microvascular hypoperfusion after successful
`
`S
`
`
`
`
`prin1ary percutaneous coronary intervention (PCI) have
`
`
`tive use of the FW during primary PCI performed on native
`
`
`been observed in up to 80% of cases according to the marker
`
`
`
`
`coronary arteries for acute myocardial infarction. The impact
`
`
`used to assess effective reperfusion, such as angiographic
`
`
`
`of FW ust! on myocardial rnpt!rfusion was compared with a
`
`
`
`
`myocardial blush, resolution of ST-segment elevation, or
`
`
`case-matched control group.
`
`
`myocardial contrast echocardiography.
`6 This occurrence,
`
`
`named "no-reflow," is associated with poorer functional
`Methods
`
`
`recovery and adverse outcome.
`7 Distal embolization of
`
`Patient Population
`
`
`
`thrombus/plaque components during primary PCI may play a
`Fifty-three consecutive patient!: with acute myocaniial infarction
`
`
`
`&-10;
`
`
`
`
`crucial role in limiting effective myocardial reperfusion
`
`
`
`
`were included in the study and subjected to primary PCI with the FW
`
`
`thus, it can be hypothesized that mechanical prevention of
`
`
`
`
`
`after written consent was obtained. The inclusion criteria were as
`
`
`
`
`djstal embolization might prevent no-reflow during primary
`
`
`
`follows: (I) presentation within 6 hours from symptom onset;
`(2)
`
`
`chest pain lasting >30 minutes and resistan
`t to intravenous nitrates;
`
`PCI.
`
`
`
`
`(3)::=0,2-m V ST-segment elevation in at least 2 contiguous leads on
`
`
`
`The FilterWire-EX (FW) is a 0.014-inch guidewire that
`
`
`
`a 12-lead ECG; (4) infarct-related native artery with a reference
`
`
`
`incorporates a nonoccluding polyurethane porous membrane
`
`
`lumen diameter >3.0 mm and with a Thrombolysis In Myocardial
`
`
`
`filter (80·µ.m pores) in the shape of a windsock to allow
`
`
`Infarction trial (TIMO flow grade <3. Although FW use is recom­
`
`
`
`
`
`retention and removal of embolized particles. The filter can
`
`
`
`mended for coronary diameters ranging from 3.5 to 5.5 mm, the
`
`
`
`
`inclusion criterion was extended to vessels >3.0 mm because
`
`
`
`
`be delivered and retrieved through a 3.9F monorail sheath.
`
`1-
`
`
`
`From the Cardiac and Thoracic Department (U.L.. A.M .. M.D.C., G.A .. R.R .. C.P., V.D.B., A.S.P .. M.M.) and Department of Oncology. Transplants
`
`
`
`Correspondence to Ugo Limbruno, MD, Cardiac and Thoracic Department, Cisanello Hospital, Via Paradisa 2. 56124. Pisa. Italy. E-mail
`
`
`
`
`
`
`
`
`
`Received February 14, 2003; revision received April 10, 2003; accepted April 11, 2003.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`and New Technologies in Medicine (G.F.), University of Pisa. Italy.
`
`
`
`
`ulimbru@tin.it
`
`© 2003 American Heart Association. Inc.
`
`Circulnlion is available at http://www.circulationaha.org 001: 10.116Wl.Cffi.0000079223.4742I.78
`
`171
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`172 Circulatum July 15, 2003
`
`unpublished data from the manufacturer·s laboratory indicate nearly
`
`
`
`
`ECG, Echocardiographic, and Laboratory Data
`
`
`
`
`
`
`complete distal protection in vessels 3.0 to 3.5 mm in diameter (data
`
`
`
`
`Preintervention and postintervention 12-lead ECGs were analyzed as
`
`
`
`Corp). The exclusion criteria were signif­
`
`on file, Boston Scientific
`
`
`
`a single group by a blinded observer (A.M.). The total ST-segment
`
`
`
`
`icant left main coronary disease, cardiogenic shock at admission, or
`
`
`elevation (LSTe) was calculated in each ECG from leads exploring
`
`
`
`thrombolytic therapy. The local Institutional Ethics Committee
`
`
`
`
`of !STe after previously.•� Resolution the infarct area as described
`
`approved the study protocol.
`
`
`
`PC! was defined as >70% reduction of the initial value.
`
`
`
`Analysis of 20 echocardiograms, performed before and 30 days
`
`
`
`after PCI, was performed by 2 investigators blinded to the treatment
`Primary PCI With Distal Protection
`
`
`
`
`(C.P. and V.D.B.). The left ventricular (LV) wall motion score index
`
`
`
`Interventions were performed by 2 high-volume operators (U.L.,
`
`
`
`
`
`(WMSI). end-diastolic volume, end-systolic volume, and ejection
`
`
`
`
`
`A.S.P.). Before intervention, patients received standard medical
`
`
`
`
`fraction (L VEF) were calculated by standard methods. Creatine
`
`
`
`
`therapy consisting of 7500 IU of unfractionated heparin, 500 mg of
`
`
`
`kinase (CK) and CK-MB were assessed every 8 hours during the first
`
`
`
`aspirin. and /3-blockers if not contraindicated. Administration of
`
`day and then daily until discharge.
`
`
`
`glycoprotein ITb/TTTa inhibitors was at the discretion of the treating
`
`
`
`
`physician. During intervention, the activated cloning time was
`Study End Points
`
`
`
`
`maintained between 250 and 300 seconds. Poststenting therapy
`The primary end points of the present study were the feasibility and
`
`
`
`
`
`
`
`
`
`consisted of aspirin and clopidogrel at standard dosages. Primary
`safety of arljunctive
`
`
`w;e of the FW <luring primary PCI. Seconrlary
`
`
`PCI was performed with 6F radial access unless contraindicated.
`
`
`
`end points were the markers of effective reperfusion (!STe resolu­
`
`
`
`
`stent placement without restrictions, and treatment of the infarct­
`
`
`
`tion, myocardial blush grade, and cTFC). Other secondary end points
`
`
`
`
`related anery only. The initial auempt to cross the target lesion was
`
`were peak CK and CK-MB release, change in LVEF and WMSI at
`
`
`performed with the FW guidewire tip. The device was advanced
`
`
`
`30 days compared with admission, and incidence of major adverse
`
`
`
`
`beyond the target lesion proximally to any important bifurcation. ln
`
`
`
`cardiac events, including death, reinfarction, and need for target
`
`
`
`patients with persistent TIMJ grade O flow, the filler was deployed
`
`
`vessel revascularization at 30 days.
`
`
`2.0 to 3.0 cm beyond the occlusion and repositioned if necessary
`
`
`after prcdilation with a 1.5-mm balloon. After satisfactory stcnt
`
`
`
`
`deployment, the FW was reinserted into its sheath and retrieved. In
`
`Statistical Analysis
`Data are expressed as mean±SD for continuous variables and as
`
`
`
`
`
`
`
`case of FW inability to cross the target lesion, a second attempt was
`
`
`
`
`
`absolute and relative frequencies for categorical variables. Student's
`
`
`
`made with a traditional guidewire as a "buddy'' wire and, if
`
`
`unpaired t test or Mann-Whitney U test was used to compare
`
`
`
`necessary, by predilation with a 1.5-mm balloon. In case of FW
`
`
`
`
`
`
`continuous variables between groups. Student's paired t test was
`
`
`
`
`
`delivery failure within 10 minutes, routine PCI was performed, and
`
`
`used to assess changes from baseline to 30 days. Categorical
`
`
`
`
`an intention-to-treat criterion was applied. Successful coronary
`
`
`
`exact test, as variables were compared by x2 test or Fisher's
`
`
`
`
`intervention was defined as residual stenosis <20% with TIMI flow
`
`
`
`
`appropriate. Independent predictors of the occurrence of !STe
`grade 2:2.
`
`
`
`resolution and of grade 3 myocardial blush were identified by
`
`
`
`
`
`entering all variables associated with a probability value <0.10 at
`Histopathologic Analysis
`
`
`
`
`
`
`univariate analysis into a logistic regression analysis. Probability
`The last consecutive 13 deployed devices were placed in I 0% neutral
`
`
`
`
`
`
`
`
`values <0.05 were considered to be statistically significant (NCSS
`
`
`
`
`buffered formalin. The filter content was teased away and processed
`2000 Software).
`
`
`
`for histological analysis. The formalin in the test tube was also
`
`
`
`
`filtered and processed. Tissue samples were dehydrated in graded
`
`
`
`
`
`series of alcohol and embedded in paraffin. Serial histological
`
`
`
`sections at 5-µm intervals were cut and stained with hematoxylin­
`
`
`
`eosin or Alcian blue for examination with a light microscope.
`
`Primary PCI
`
`
`
`Morphometric analysis of the size and number of particles was
`Correct FW delivery was achieved in 47 patients (89%). In 7
`
`
`
`
`
`
`performed with a micrometric grid. If the number of particles
`
`
`
`
`patients (15%), FW delivery, initially unsuccessful, was
`
`
`
`
`exceeded 20 per slide, only the largest 20 particles were analyzed.
`
`
`achieved after insertion of a "buddy" wire to reduce vessel
`
`
`tortuosity; in 4 of these patients, predilation with a l.5-mm
`Matched Comparison
`
`
`
`
`
`balloon was also necessary. Blinded positioning of the FW
`To compare markers of effective reperfusion of FW patients (FW
`
`
`
`
`
`
`
`
`group). a case-matched comrol group of 53 patients undergoing
`
`
`
`because of persistent TIMI grade O flow occurred in 7 cases
`
`
`
`
`
`
`primary PCI without distal protection (PC] group) was selected from
`
`
`
`( 15%); filter repositioning after predilation was necessary in
`
`
`
`
`
`our database. Matching was performed through an automatic query
`
`
`
`
`2 of these cases. Safe retrieval of the filter was obtained in all
`
`
`
`
`
`on the database. blinded to procedural and clinical outcomes. The
`
`
`
`cases. Coronary dissections attributable to FW delivery were
`
`
`
`
`database was reviewed sequentially in a chronologically inverse
`not observed.
`
`
`
`
`
`order; for each FW patient, the first patient in the database satisfying
`
`
`
`
`the matching parameters and fulfilling the inclusion/exclusion crite­
`After retrieval of the device, direct visual inspection of the
`
`
`
`
`
`
`ria was chosen. The matching parameters in order of sequential
`
`
`
`
`
`filter yielded macroscopic particles in 16 patients (34% ),
`
`
`
`
`
`selection were as follows: (I) infarct-related artery; (2) pre-PCI TIMI
`
`
`including 7 of the 13 patients in whom histopathologic
`
`
`flow grade; (3) gender; and (4) age ±4 years.
`
`
`
`
`analysis was performed (Figures I and 2). Temporary reduc­
`
`
`
`tion in coronary flow during FW deployment was observed in
`Angiographic Analysis
`14 cases (30%), followed by TIMI grade 3 flow restoration
`
`
`
`The angiograms were re-read as a single group by 3 experienced
`
`after FW retrieval in all cases.
`
`
`
`
`observers (G.A., R.R., and M.D.C.). Preprocedure and postprocedure
`
`
`
`
`angiograms, the object of analysis, were spliced from the rest of the
`In 4 cases (9% ), a "kissing" FW technique was performed
`
`
`
`
`procedure to blind the investigators to the use of the FW. Quantita­
`
`
`
`
`at bifurcations located just beyond the target lesion and with
`
`
`
`
`tive coronary angiography parameters, TTMT flow grade, corrected
`
`
`both branches >3.0 mm in lumen diameter; procedural
`
`
`
`
`TIMI frame count (cTFC), and myocardial blush were measured as
`
`
`
`success was obtained with balloon angioplasty alone in 2
`
`described previously.4,11-13 With regard 10 cTFC, the number of
`
`
`
`
`
`
`cases, whereas provisional stenting, after removal of one of
`
`
`
`frames was multiplied by 30 and divided by 12.5 to report a cine
`
`
`frame count in accordance with standard methods.
`
`
`
`the devices, was necessary in 2 cases. In 9 patients ( 19% ), a
`
`Feasibility and Safety of FW Use During
`
`Results
`
`Page 6
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`

`
`Limbruno et al
`
`Embolic Protection in Primary Angioplasty 173
`
`Figure 3. A, Fresh thrombus; groups of polymorphonuclear cells
`
`
`
`Figure 1. A, Angiographic view of FW deployed during PC! of
`
`
`
`
`
`
`
`infiltrate fibrin net (magnification X40). 8, Necrotic area is visual­
`
`
`
`
`ized (arrows) within thrombotic fragment (magnification x20). C,
`
`
`
`Filling defect (arrow) is
`
`
`
`
`acutely occluded right coronary artery.
`
`
`
`
`visible in filter. 8, Same case, magnified view of retrieved filter
`
`
`
`Cellular clusters (arrows), including polymorphonucleates, sur­
`with red embolus.
`
`
`
`
`rounded by necrosis (magnification X20). D, Focal positivity for
`
`
`
`Alcian blue stain indicating presence of mucopolysaccharides
`
`(magnification x 10).
`branch 2.5 to 3.0 mm in diameter was left unprotected
`
`
`
`
`because of its contiguity to the target lesion.
`
`the presence of ongoing thrombus organization and/or plaque
`
`
`
`
`
`
`
`
`remnants (Figures 3B and 3C). Particles with mucopolysac­
`Histopathologic Analysis
`
`
`
`charidic amorphous extracellular matrix, which stained pos­
`
`
`
`
`
`Pa11icles were recovered in 13 of 13 devices, and their
`
`
`
`itive with Alcian blue, were observed in 5 patients (38%),
`
`number ranged from 7 to 118 per filter ( mean 45 ±40).
`
`
`which also supports the presence of plaque components
`
`
`
`Distribution of particle major axis dimensions was as follows:
`
`
`
`within the embolized material (Figure 30). Foam cells,
`22% <80 µm, 30% 80 to 120 µm, 16% 120 to 250 µm, 15%
`
`
`
`smooth muscle cells, cholesterol clefts, and calcifications
`
`250 to 500 µm, and 17% >500 µm. The majority of particles
`
`
`
`
`were composed of platelets, red cells, and fibrin, which led to
`were not observed.
`
`
`
`classification as fresh t.hromhus (Figure 3A). Cellularit
`y was
`
`
`
`widely variable, often including polymorphonuclear cells
`Matched Comparison of Procedural Results
`
`
`
`
`
`
`Table I compares the baseline clinical and angiographic
`
`
`
`(Figures 3A and 3C). In 7 patients ( 54%), a necrotic core was
`
`
`
`
`observed in the context of a fibrin network, which suggests
`
`
`characteristics of the 2 study groups. LSTe and WMSI mean
`
`
`
`
`values at admission were slightly, although not significantly,
`
`
`
`higher in the PCI group (P=0.054 and P=0.069). Use of
`
`
`
`
`glycoprotein Ub/IITa inhibitors was significantly less frequent
`in the FW group (P<0.001).
`Procedural results in the 2 groups are presented in Table 2.
`
`
`
`
`
`
`The needle-to-balloon time was slightly but significantly
`
`
`longer in the FW group (P<0.00 I). After PCI, TIMI flow less
`
`than grade 3, myocardial blush less than grade 3, angio­
`
`
`
`graphic signs of distal embolization, and lack of lSTe
`
`
`
`resolution were significantly more frequent in the PCI group,
`
`
`
`which also showed higher cTFC values (P=0.005). Peale CK
`
`
`
`
`and CK-MB release values were significantly higher in the
`PCI group.
`Univariate and multivariate analysis indicated that FW use
`
`
`
`
`
`
`was the only independent predictor of LSTe resolution
`
`
`(P=0.003, OR 0.18, 95% CI 0.06 to 0.56) and of myocardial
`
`blush grade 3 after PCI (P=0.01, OR 0.33, 95% CI 0.13 to
`
`
`
`0.81) among the following variables: gender, age, infarct
`
`
`
`
`
`location, diabetes, previous myocardial infarction, preinfarc­
`Figure 2. A, Angiographic view of FW deployed during PC! of
`
`
`
`
`
`
`tion angina, glycoprotein TTb/Ula inhibitor use, coronary
`
`
`
`
`
`
`acutely occluded left anterior descending artery. Filling defect
`
`
`dimensions, pain onset-to-PC! time, needle-to-balloon time,
`
`
`
`
`(arrow) is visible in filter. B, Same case, magnified view of
`basal ISTe, basal WMSI, and basal L YEF ( Table 3).
`
`
`
`retrieved filter with yellow-white embolus.
`
`Page 7
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`

`174 Circulatum July 15, 2003
`
`
`
`TABLE 1. Clinical and Angiographic Characteristics at Admission in Patients in
`
`
`
`
`
`
`the FW and PCI Groups
`
`PCl FW
`
`
`(n;53) (n;53) p Failed FW (n;6)
`
`60±11 61±11 0.645 64±7
`Age, y
`
`
`Gender, male/female, n
`44/9 44/9 1.000 6/0
`
`
`31 (58) 28 (53) 0.696 5(83)
`Smoking history, n (%)
`
`Diabetes, n (%)
`6 (11) 9 (17) 0.408 1 (17)
`n (%) 7 (13) 9 (17) 0.592 2(33)
`
`
`Previous myocardial infarction,
`25 (47) 20 (38) 0.438 2(50)
`
`
`Preinfarction angina, n (%)
`n (%) 21 (40) 25 (47) 0.557 4 (67)
`Multivessel coronary disease,
`
`
`
`Systolic blood pressure, mm:Hg 116±28 111 ±26 0.404 113±28
`85±22 82±21 0.429 85±31
`Heart rate, bpm
`
`
`
`LVEF, %
`
`45±8 43±6 0.201 42±5
`
`1.62±0.25 1.72±0.29 0.069 1.75±0.37
`
`LV WSMI
`11±5 13±5 0.054 14±4
`
`
`Total ST-segment elevation, mV
`n (%) 34 (64) 16 (30) <0.001 1 (17)
`Glycoprotein llb/llla inhibitor,
`
`
`
`
`Infarct-related coronary artery, n (%)
`Left anterior descending 23 (43) 23 (43) 1.000 3 (50)
`
`Left circumflex
`8 (15) 8 (15) 1.000 2(33)
`
`Right
`
`22 (41) 22 (41) 1.000 1 (17)
`
`mm 3.41 ±0.42 3.43±0.43 0.748 3.32±0.28
`Proximal reference diameter,
`
`
`0.12±0.22 0.213 0.03±0.08
`
`
`Minimal lumen diameter, mm 0.16±0.24
`95±7 97±7 0.179 99±2
`
`
`
`
`Diameter stenosis, %
`
`TIMI flow gr