Primary stent implantation compared with primary balloon angioplasty for acute myocardial infarction: a meta-analysis of randomized clinical trials

Percutaneous coronary interventions (PCIs) are generally performed in adults with ischaemic heart disease, but reports of experience in the paediatric population are relatively limited.

To report indications, interventional techniques and procedural outcomes for PCI in children treated in two French institutions.

Medical records of all children in whom a PCI was attempted in two French tertiary institutions between 1998 and 2015 were systematically reviewed. Diagnostic procedures, including coronary angiograms, were excluded.

A total of 40 PCIs were attempted in 29 patients (median age 6.5 years, range three days to 17.9 years). Nineteen procedures (47.5%) were performed on an emergency basis. A total of 36/40 coronary obstructions were successfully treated, with no immediate residual postintervention stenosis. Initial balloon angioplasty was performed for all lesions, with subsequent stent placement in 23 lesions. There were two periprocedural and five late deaths. After a median follow-up of 12 months (range 1 week to 115 months), freedom from death and reintervention at 36 months were 79% and 60%, respectively. Age < 1 month, emergency procedure and balloon angioplasty without stent implantation were associated with shorter survival.

PCI can be used in the paediatric population in a wide range of anatomical conditions; it may be effective in selected patients, but remains challenging when performed in emergency and/or in neonates.

Le traitement percutané des artères coronaires (TPAC) est généralement réalisé dans la population adulte ayant une cardiopathie ischémique, mais l’expérience rapportée dans la population pédiatrique est limitée.

Rapporter les indications, les techniques interventionnelles et le devenir des procédures de TPAC chez les enfants pris en charge dans deux institutions françaises.

Les dossiers médicaux de l’ensemble des enfants chez qui un TPAC a été tenté dans deux institutions françaises tertiaires entre 1998 et 2015 ont été systématiquement revus. Les procédures diagnostiques incluant des coronarographies ont été exclues.

Un total de 40 TPAC ont été tentés chez 29 enfants (âge médian 6,5 ans, range 3 jours à 17,9 ans). Dix-neuf procédures (47 %) ont été réalisées en urgence. Un total de 36/40 obstructions coronaires ont été traitées avec succès sans sténose immédiate post-interventionnelle. Une angioplastie initiale au ballon a été réalisée sur toutes les lésions, avec mise en place d’un stent pour 23 lésions. Il y eut deux décès periprocéduraux et cinq décès tardifs. Après un suivi médian de 12 mois (une semaine à 115 mois), les survies sans décès et sans ré interventions à 36 mois étaient respectivement de 79 % et 60 %. Un âge < 1 mois, une procédure en urgence et une angioplastie au ballon sans mise en place de stent étaient associés avec une survie diminuée.

Le traitement percutané des artères coronaires peut être utilisé au sein de la population pédiatrique dans une large gamme de conditions anatomiques différentes. Il peut être efficace pour des patients sélectionnés mais reste une procédure difficile lorsqu’elle est réalisée en urgence ou chez les nouveau-nés.

Remarkable strides have been made in the treatment of ischemic heart disease in decades. As the initial loss of cardiomyocytes associated with myocardial infarction serves as an impetus for myocardial remodeling, the ability to replace these cells with healthy counterparts would represent an effective treatment for many forms of cardiovascular disease. The discovery of cardiac stem cells (that can differentiate into multiple lineages) highlighted the possibility for development of cell-based therapeutics to achieve this ultimate goal. Recent research features cardiac stem cell maintenance, proliferation, and differentiation, as well as direct reprogramming of various somatic cells into cardiomyocytes, all within the context of the holy grail of regeneration of the injured heart. Much work remains to be done, but the future looks bright!

Acute myocardial infarction has traditionally been divided into ST elevation or non-ST elevation myocardial infarction; however, therapies are similar between the two, and the overall management of acute myocardial infarction can be reviewed for simplicity. Acute myocardial infarction remains a leading cause of morbidity and mortality worldwide, despite substantial improvements in prognosis over the past decade. The progress is a result of several major trends, including improvements in risk stratification, more widespread use of an invasive strategy, implementation of care delivery systems prioritising immediate revascularisation through percutaneous coronary intervention (or fibrinolysis), advances in antiplatelet agents and anticoagulants, and greater use of secondary prevention strategies such as statins. This seminar discusses the important topics of the pathophysiology, epidemiological trends, and modern management of acute myocardial infarction, focusing on the recent advances in reperfusion strategies and pharmacological treatment approaches.

Even though primary angioplasty restores TIMI 3 flow in more than 90% of STEMI patients, the results in terms of myocardial perfusion are still unsatisfactory in a relatively large proportion of patients. Great interest has been focused in the last years on distal embolization as major determinant of poor reperfusion and clinical outcome after primary angioplasty. The aim of this article is to perform an updated meta-analysis of thrombectomy devices in STEMI patients undergoing primary angioplasty.

The literature was scanned by formal searches of electronic databases (MEDLINE, Pubmed) from January 1990 to December 2010, the scientific session abstracts (from January 1990 to December 2010) and oral presentation and/or expert slide presentations (from January 2002 to December 2010) (on TCT, AHA, ESC, ACC and EuroPCR websites). No language restrictions were enforced.

A total of 21 randomized trials were finally included in the meta-analysis, involving 4514 patients (2270 or 50.3% randomized to thrombectomy and 2244 or 49.7% to standard angioplasty). Overall thrombectomy did not reduce 30-day mortality, with more benefits observed only with manual thrombectomy. No difference was observed in the 30-day reinfarction rate, whereas a trend in higher risk of stroke was observed with thrombectomy (p = 0.06). Manual but not mechanical thrombectomy significantly improved postprocedural TIMI 3 flow, however, both devices significantly improved myocardial reperfusion as evaluated by ST-segment resolution.

By meta-regression analysis a linear relationship was observed between benefits from thrombectomy in ST-segment resolution and in the presence of thrombus at baseline angiography (p = 0.0016).

The present meta-analysis has demonstrated that, among patients with STEMI, manual thrombectomy significantly improved myocardial perfusion, with a trend in short-term mortality benefits, whereas mechanical thrombectomy, despite the benefits in myocardial perfusion, did not impact on short-term survival. However, the benefits in myocardial perfusion were significantly related to prevalence of coronary thrombus. In light of the observed higher risk of stroke, thrombectomy cannot be routinely recommended, but should be used in case of evident intracoronary thrombus. Mechanical thrombectomy devices may be considered as well to further improve reperfusion and facilitate optimal stent implantation, especially in the presence of large thrombus burden.