Nigel Jepson - Academia.edu (original) (raw)

Papers by Nigel Jepson

Research paper thumbnail of Hyperbaric oxygen therapy for acute coronary syndrome

Cochrane Database of Systematic Reviews, Jul 19, 2004

The aim of this review is to assess the evidence for the effects of adjunctive HBOT in the treatm... more The aim of this review is to assess the evidence for the effects of adjunctive HBOT in the treatment of acute coronary syndrome. We will compare treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differ significantly between studies, this will be clearly stated and the implications discussed. All comparisons will be made using an intention to treat analysis. Efficacy will be estimated from randomised trial comparisons but no attempt will be made to evaluate the likely effectiveness that might be achieved in routine clinical practice.

Research paper thumbnail of Association of hypertension with mortality in patients hospitalised with COVID-19

Open Heart

ObjectiveTo assess whether hypertension is an independent risk factor for mortality among patient... more ObjectiveTo assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension.MethodThis observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs.Results546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, p<0.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13 to 6.53, p=0.026), chronic kidney diseas...

Research paper thumbnail of 3D Printing for Cardiovascular Applications: From End-to-End Processes to Emerging Developments

Annals of Biomedical Engineering, 2021

3D printing as a means of fabrication has seen increasing applications in medicine in the last de... more 3D printing as a means of fabrication has seen increasing applications in medicine in the last decade, becoming invaluable for cardiovascular applications. This rapidly developing technology has had a significant impact on cardiovascular research, its clinical translation and education. It has expanded our understanding of the cardiovascular system resulting in better devices, tools and consequently improved patient outcomes. This review discusses the latest developments and future directions of generating medical replicas (‘phantoms’) for use in the cardiovascular field, detailing the end-to-end process from medical imaging to capture structures of interest, to production and use of 3D printed models. We provide comparisons of available imaging modalities and overview of segmentation and post-processing techniques to process images for printing, detailed exploration of latest 3D printing methods and materials, and a comprehensive, up-to-date review of milestone applications and the...

Research paper thumbnail of Two-year outcomes of a bioresorbable everolimus-eluting scaffold using a strategy of meticulous lesion preparation and routine post-dilation : the Australian ESHC-BVS registry

Aims: The Absorb bioresorbable vascular scaffold (BVS) was the first commercially available coron... more Aims: The Absorb bioresorbable vascular scaffold (BVS) was the first commercially available coronary stent to provide vessel scaffolding of a temporary nature following percutaneous coronary intervention. While results in clinical trials have varied, outcomes using a BVS-specific implantation strategy have not been well studied. We report two-year real-world data on the Absorb BVS implanted following meticulous lesion preparation and with a strategy of routine post-dilation. Methods and results: Absorb BVS implantation was attempted in 152 lesions in 100 patients at two Sydney hospitals as part of the prospective ESHC-BVS registry. Lesions treated included complex lesions reflective of real-world practice with lesion length being >20 mm in 24%, and 16% featuring moderate/ severe calcification. In total, type C lesions made up 37% of all lesions treated. A BVS-dedicated implantation strategy was utilised encompassing meticulous lesion preparation and routine post-dilation. Predila...

Research paper thumbnail of Radial vs Femoral Access for Coronary Angiography and Intervention in the Elderly (>75) - A Meta-Analysis

Heart, Lung and Circulation, 2016

Research paper thumbnail of Bioresorbable scaffold—the holy grail of percutaneous coronary intervention: fact or myth?

Journal of Thoracic Disease, 2016

Research paper thumbnail of Letter to the Editor: CSANZ Consensus Guidelines for Interventional Cardiology Services Delivery During COVID-19 Pandemic in Australia and New Zealand

Heart, Lung and Circulation, 2020

Research paper thumbnail of SOLACE AU Registry: Interim results at 30 days of the Edwards SAPIEN XT ™ Transcatheter Heart Valve in intermediate risk patients with severe aortic stenosis in Australia

Heart, Lung and Circulation, 2015

Research paper thumbnail of Australian multi-centre experience with bioresorbable vascular scaffolds in “real-world” coronary disease - twelve-month outcomes

Heart, Lung and Circulation, 2015

Background: We report our recent experience with balloon aortic valvuloplasty (BAV) including ind... more Background: We report our recent experience with balloon aortic valvuloplasty (BAV) including indications, procedural data, complications and 30-day mortality. Methods: Forty consecutive adult patients with severe symptomatic AS underwent 44 retrograde femoral BAV procedures from August 2012 to March 2014. Indications for BAV included: palliation of symptoms (81%); bridge to TAVI (11%);

Research paper thumbnail of Routine debulking rotational atherectomy preparation before drug eluting balloons for the management of in-stent restenosis

Heart, Lung and Circulation, 2015

may be a useful tool in identifying those high-risk patients who need aggressive therapy.

Research paper thumbnail of Mediastinal haematoma complicating percutaneous coronary intervention via the radial artery

Heart, Lung and Circulation, 2015

complication and highlights the need for caution with use of hydrophilic wires. The case also dem... more complication and highlights the need for caution with use of hydrophilic wires. The case also demonstrates an important differential diagnosis of chest pain following cardiac catheterisation by the radial route.

Research paper thumbnail of Very Late Stent Thrombosis 11 Years after Implantation of a Drug-Eluting Stent

Texas Heart Institute Journal, 2015

Very late stent thrombosis is an infrequent yet potentially fatal complication associated with dr... more Very late stent thrombosis is an infrequent yet potentially fatal complication associated with drug-eluting stents. We report the case of an 88-year-old man who sustained an ST-segment-elevation myocardial infarction 11 years after initial sirolimus-eluting stent implantation. Optical coherence tomograms of the lesion showed that the focal incomplete endothelialization of the stent struts was the likely cause; neointimal formation, neoatherosclerosis, and late stent malapposition might also have contributed. To our knowledge, this is the longest reported intervening period between stent insertion and the development of an acute coronary event secondary to very late stent thrombosis. The associated prognostic and therapeutic implications are considerable, because they illuminate the uncertainties surrounding the optimal duration of antiplatelet therapy in patients who have drug-eluting stents. Clinicians face challenges in treating these patients, particularly when competing medical demands necessitate the discontinuation of antiplatelet therapy. In addition to the patient's case, we discuss factors that can contribute to very late stent thrombosis.

Research paper thumbnail of Prognostic Significance of Peri-procedural Myocardial Infarction in the Era of High Sensitivity Troponin: A Validation of the Joint ACCF/AHA/ESC/WHF Universal Definition of Type 4a Myocardial Infarction with High Sensitivity Troponin T

Heart, Lung and Circulation, 2015

This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural my... more This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural myocardial infarction (PMI) with high sensitivity troponin T (hsTnT). Methods A retrospective cohort study encompassing patients admitted to our institution between May 2012 and April 2013 was performed. Results 630 patients underwent percutaneous coronary interventions during the study period. Among them, 459 patients met the inclusion criteria and were eligible for analyses. 76.9% of these patients were male, while the mean age was 68.6. PMI was observed in 4.3% of the patients based on the Universal Definition. The predictors of PMI were chronic kidney disease (OR: 3.0, p=0.026), family history of cardiovascular disease (OR: 2.7, p=0.043) and use of IIb/IIIa inhibitors (OR 4.2, p=0.01). MACE was reported in 4.4% of the patients at 12 months, and was significantly and independently associated with PMI (OR 7.3, p=0.003) in a multivariate model which accounted for lesion complexity, patients' baseline clinical information, dual-antiplatelet status at follow-up and various procedural characteristics. The post-procedural hsTnT was much higher in those who suffered MACE than those who did not (156 v.s. 43 ng/L, p<0.001).

Research paper thumbnail of Patent Foramen Ovale Influences the Presentation of Decompression Illness in SCUBA Divers

Heart, Lung and Circulation, 2015

Research paper thumbnail of Recruited Collateral Channels Are Not Responsible for Ischemic Preconditioning During Single Vessel Angioplasty

Journal of the American College of Cardiology, 1998

Research paper thumbnail of TCT-403 Percutaneous Ultrasound-Guided Thrombin Injection as a Safe and Efficacious Primary Treatment of Iatrogenic Femoral Pseudoaneurysms for the Interventional Cardiologist

Journal of the American College of Cardiology, 2012

Background: Silent cerebral embolization,detected at transcranial Doppler (TCD) monitoring as mic... more Background: Silent cerebral embolization,detected at transcranial Doppler (TCD) monitoring as microembolic signals (MES), is common during diagnostic coronary angiography (DCA). MES rate depends on degree of intravascular catheter manipulation. When using Judkins catheters, right transradial approach (RTA) showed higher rate of MES compared to left transradial and transfemoral, as a consequence of higher rate of catheter exchanges due to difficult navigation and manipulation through tortuous innominate arteries. Microembolization is more common in the right cerebral emisphere, according to origin of right common carotid artery from innominate artery. A single catheter fitting both coronaries (Optitorque Tiger, Terumo,Japan) is available and could reduce the embolization rate. Our aim was to compare cerebral embolization of single (SC) vs double catheters (DC) strategy during DCA performed through RTA. Methods: 19 patients with suspected coronary artery disease were submitted to DCA via RTA after randomization to single (Optitorque Tiger,nϭ9) or double (Judkins Left and Right,nϭ10) catheter strategy, with contemporaneous bilateral TCD monitoring to detect a 50% reduction of MES. Results: Less catheters were employed in SC compared to DC group (1.1ϩ/Ϫ0.3 vs 2.1ϩ/Ϫ0.3,pϽ0.0001) with similar procedural success rate (88% vs 90%,pϭ0.9). MES were detected in all patients, with a significant lower rate in SC group (median 30, interquartile range (IQR) 16-45, vs 57,IQR 54-69,pϽ0.0001), especially during catheters exchange (19,IQR 11-25 vs 41,IQR 27-49,pϭ0.003), whereas no difference was detected during contrast injections (5,IQR 1-13 vs 9,IQR 5-17,pϭ0.24) and coronary ostia engagement (2,IQR 1-6 vs 8,IQR 1-11,pϭ0.15). A strong negative correlation exists among number of MES and SC strategy (Spearman's ϭϪ0.78, pϽ0.0001); at multivariate linear regression analysis the use of a single catheter reduced incidence of MES of 50% (BϭϪ30,std errorϭ7,betaϭϪ0.7,tϭϪ4,95% IC Ϫ46/Ϫ15, pϭ0.001, costantϭ61). Conclusions: RIsk of silent brain injury during DCA is strongly related to number of catheters employed. A specifically designed diagnostic catheter for both coronary arteries via RTA reduced dramatically this embolic risk.

Research paper thumbnail of TCT-425 Real-World Experience with Absorb(tm) Bioresorbable Scaffold Technology - Early Australian Registry Results

Journal of the American College of Cardiology, 2013

Background: Bioresorbable vascular scaffolds have been available on the European market since Nov... more Background: Bioresorbable vascular scaffolds have been available on the European market since November 2011. The first experience in a real-world setting is being documented in the ASSURE registry (NCT01583608). The registry aims to investigate the safety, efficacy and performance of the everolimus-eluting, bioresorbable vascular scaffold (BVS, ABSORBÔ, Abbott Vascular Inc., Santa Clara, CA) over a period of 3 years. Methods: Consecutive patients with de novo native coronary artery disease were treated with BVS at 6 German centers and included in the prospective, observational registry. Acute and 6-months outcomes of equal weight were device success, procedural success, cardiac death, myocardial infarction, ischemia driven target lesion revascularization and target vessel failure or revascularization. Angiographic parameters were assessed at baseline and post procedure. Results: A total of 183 patients (63.5 AE 9.3 years, 79.8% male) were enrolled from April 2012 to March 2013 and 198 lesions were treated. Eligibility criteria for ABSORB A/B would have been met in 16% and for ABSORB EXTEND in 70% of the patients. Acute device success was achieved in 194 (98%) lesions and acute procedural success in all patients. No cardiac death or myocardial infarction occurred and no target lesion revascularization was necessary during hospital stay. Median lesion length was 14.5 mm (5-84 mm) with 85 (42.9%) lesions > 20 mm. 31 (15.7%) lesions were moderately or heavily calcified, 6 (3%) lesions were tightly angulated and 6 (3%) lesions involved a side branch ! 2 mm in diameter. Diameter stenosis was 77.9% at baseline and 4.8% post PCI on average. In 11 (5.6%) lesions diameter of stenosis was ! 99%. The reference vessel diameter of 32 (16.2%) lesions was 2.5 mm. In 30 (15.2%) lesions > 1 BVS was implanted and in 11 patients > 1 target vessel was treated. Bailout with a drug eluting stent was necessary in 3 (1.5%) lesions. Conclusions: Acute results for safety, efficacy and performance of BVS for de novo coronary artery disease in all day clinical practice are promising. Angiographic core lab results will be obtained by June 2013 and clinical 6-months results by September 2013. TCT-422 Malapposition is observed more frequently and to a greater degree in fibrocalcific plaques during bioresorbable vascular scaffold implantation

Research paper thumbnail of Pexelizumab for Acute ST-Elevation Myocardial Infarction in Patients Undergoing Primary Percutaneous Coronary Intervention

JAMA, 2007

CUTE ST-ELEVATION MYOCARdial infarction (STEMI) constitutes a major public health problem, not on... more CUTE ST-ELEVATION MYOCARdial infarction (STEMI) constitutes a major public health problem, not only in western countries but increasingly in developing countries. 1 In the United States, there are estimated to be more than half a million STEMI events annually and these have provided strong impetus for efforts to improve both the process whereby care is delivered and the treatment elements administered. 2 Although reperfusion with primary percutaneous transluminal coronary intervention (PCI) is highly effective, especially if delivered promptly in an expert facility, it is now appreciated that not all PCIs adequately restore myocardial or tissue perfusion. 3 Reperfusion achieved through primary PCI and coronary stenting may be associated with distal coronary embolization, endothelial dysfunction, and impaired ventricular function. 4 A concomitant inflammatory reaction, participating in the accompanying reperfusion injury may mediate apoptosis in the periinfarction area and unfavorable left ventricular remodeling. 5 Poor tissue perfusion and the intensity of the inflammatory response are related to subsequent mortality. 4,6 Complement is known to be both activated and a potential mediator of these processes, and activation of the terminal components of the complement cascade leads to cleavage of the C5 component: this in turn results in formation of both C5a, a potent anaphylatoxin and proinflammatory substance, and C5b-9 or the membrane attack complex (MAC), which causes vesiculation of platelets and endothelial cells, formation of prothrombotic microparticles, and activation of leu-kocytes and endothelial cells. Hence, inhibition of C5 constitutes an attractive therapeutic target. 7 For editorial comment see p 91.

Research paper thumbnail of Initial experience with the balloon expandable Edwards-SAPIEN Transcatheter Heart Valve in Australia and New Zealand: The SOURCE ANZ registry: Outcomes at 30days and one year

International Journal of Cardiology, 2014

Background: We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edw... more Background: We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edwards SAPIEN ™ Transcatheter Heart Valve (THV) in the Australian and New Zealand (ANZ) clinical environment. Methods: This single arm registry of select patients treated in eight centres, represent the initial experience within ANZ with the balloon expandable Edwards SAPIEN THV delivered by transfemoral (TF) and transapical (TA) access. Results: The total enrolment for the study was 132 patients, 63 patients treated by TF, 56 by TA, and 2 patients were withdrawn from the study. The mean ages: 83.7 (TF) and 81.7 (TA), female: 34.3% (TF) and 61.3% (TA), logistic EuroSCORE: 26.8% (TF) and 28.8% (TA), and with procedural success (successful implant without conversion to surgery or death): 92.4% (TF) and 87.1% (TA) (p = 0.32). Outcomes were not significantly different between TF and TA implants. These included one year mortality of 13.6% (TF) and 21.7% (TA) (p = 0.24), MACCE: 16.7% (TF) and 28.3% (TA) (p = 0.12), pacemaker: 4.6% (TF) and 8.3% (TA) (p = 0.39), and VARC major vascular complication of 4.6% (TF) and 5.0% (TA) (p = 0.91). Conclusion: TAVI in the ANZ clinical environment has demonstrated excellent outcomes for both the TA and TF approaches in highly selected patients. These results are consistent with those demonstrated in European, Canadian registries and the pivotal US clinical trials. ACTRN12611001026910.

Research paper thumbnail of Early Australian Experience With AbsorbTM Bioresorbable Scaffold Technology in “Real-World” Coronary Disease

Heart, Lung and Circulation, 2013

Background: National Heart Foundation (NHF) ACS guidelines recommend the use of high sensitivity ... more Background: National Heart Foundation (NHF) ACS guidelines recommend the use of high sensitivity troponin assay (hsTrop). Two thousand and eleven addendum recommends a change in delta value () for hsTrop to 50%. Introduction of hsTrop assay at Box Hill Hospital, 30% was used as the cut off. However, this was changed to 50% six months later. Aim: To determine the clinical impact of 30-50% change for patients presenting with chest pain. Method: We retrospectively collected data from patients >18 years presenting with chest or abdominal pain and had hsTrop between January and March 2012. Results: We analysed 671 patients. 288 (43%) patients who had a STEMI or lacked serial hsTrop values, on dialysis or trauma-related were excluded. Remaining patients were followed up. Out of 383 patients, 148 (39%) with serial hsTrop had at least one abnormal troponin (>14 ng/ml). Thirteen (3.4%) fell within 30-50%. Ten had clinical indications suggestive of ACS and regardless of their hsTrop results went on to have cardiac investigations and management. Three patients with non-cardiac diagnosis had no further tests. At follow up (mean ± SD: 409 ± 13 days), these patients have not had any cardiac events. Conclusion: Our data supports the safety of NHF recommendation for change to 50%. This change affected only 3.4% of the patients and we did not miss any cardiac events. Our clinical decision to investigate 10 of the 13 patients who had <50% underscores the importance of not relying solely on hsTrop assay to diagnose ACS as emphasised in the NHF recommendations.

Research paper thumbnail of Hyperbaric oxygen therapy for acute coronary syndrome

Cochrane Database of Systematic Reviews, Jul 19, 2004

The aim of this review is to assess the evidence for the effects of adjunctive HBOT in the treatm... more The aim of this review is to assess the evidence for the effects of adjunctive HBOT in the treatment of acute coronary syndrome. We will compare treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differ significantly between studies, this will be clearly stated and the implications discussed. All comparisons will be made using an intention to treat analysis. Efficacy will be estimated from randomised trial comparisons but no attempt will be made to evaluate the likely effectiveness that might be achieved in routine clinical practice.

Research paper thumbnail of Association of hypertension with mortality in patients hospitalised with COVID-19

Open Heart

ObjectiveTo assess whether hypertension is an independent risk factor for mortality among patient... more ObjectiveTo assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension.MethodThis observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs.Results546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, p<0.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13 to 6.53, p=0.026), chronic kidney diseas...

Research paper thumbnail of 3D Printing for Cardiovascular Applications: From End-to-End Processes to Emerging Developments

Annals of Biomedical Engineering, 2021

3D printing as a means of fabrication has seen increasing applications in medicine in the last de... more 3D printing as a means of fabrication has seen increasing applications in medicine in the last decade, becoming invaluable for cardiovascular applications. This rapidly developing technology has had a significant impact on cardiovascular research, its clinical translation and education. It has expanded our understanding of the cardiovascular system resulting in better devices, tools and consequently improved patient outcomes. This review discusses the latest developments and future directions of generating medical replicas (‘phantoms’) for use in the cardiovascular field, detailing the end-to-end process from medical imaging to capture structures of interest, to production and use of 3D printed models. We provide comparisons of available imaging modalities and overview of segmentation and post-processing techniques to process images for printing, detailed exploration of latest 3D printing methods and materials, and a comprehensive, up-to-date review of milestone applications and the...

Research paper thumbnail of Two-year outcomes of a bioresorbable everolimus-eluting scaffold using a strategy of meticulous lesion preparation and routine post-dilation : the Australian ESHC-BVS registry

Aims: The Absorb bioresorbable vascular scaffold (BVS) was the first commercially available coron... more Aims: The Absorb bioresorbable vascular scaffold (BVS) was the first commercially available coronary stent to provide vessel scaffolding of a temporary nature following percutaneous coronary intervention. While results in clinical trials have varied, outcomes using a BVS-specific implantation strategy have not been well studied. We report two-year real-world data on the Absorb BVS implanted following meticulous lesion preparation and with a strategy of routine post-dilation. Methods and results: Absorb BVS implantation was attempted in 152 lesions in 100 patients at two Sydney hospitals as part of the prospective ESHC-BVS registry. Lesions treated included complex lesions reflective of real-world practice with lesion length being >20 mm in 24%, and 16% featuring moderate/ severe calcification. In total, type C lesions made up 37% of all lesions treated. A BVS-dedicated implantation strategy was utilised encompassing meticulous lesion preparation and routine post-dilation. Predila...

Research paper thumbnail of Radial vs Femoral Access for Coronary Angiography and Intervention in the Elderly (>75) - A Meta-Analysis

Heart, Lung and Circulation, 2016

Research paper thumbnail of Bioresorbable scaffold—the holy grail of percutaneous coronary intervention: fact or myth?

Journal of Thoracic Disease, 2016

Research paper thumbnail of Letter to the Editor: CSANZ Consensus Guidelines for Interventional Cardiology Services Delivery During COVID-19 Pandemic in Australia and New Zealand

Heart, Lung and Circulation, 2020

Research paper thumbnail of SOLACE AU Registry: Interim results at 30 days of the Edwards SAPIEN XT ™ Transcatheter Heart Valve in intermediate risk patients with severe aortic stenosis in Australia

Heart, Lung and Circulation, 2015

Research paper thumbnail of Australian multi-centre experience with bioresorbable vascular scaffolds in “real-world” coronary disease - twelve-month outcomes

Heart, Lung and Circulation, 2015

Background: We report our recent experience with balloon aortic valvuloplasty (BAV) including ind... more Background: We report our recent experience with balloon aortic valvuloplasty (BAV) including indications, procedural data, complications and 30-day mortality. Methods: Forty consecutive adult patients with severe symptomatic AS underwent 44 retrograde femoral BAV procedures from August 2012 to March 2014. Indications for BAV included: palliation of symptoms (81%); bridge to TAVI (11%);

Research paper thumbnail of Routine debulking rotational atherectomy preparation before drug eluting balloons for the management of in-stent restenosis

Heart, Lung and Circulation, 2015

may be a useful tool in identifying those high-risk patients who need aggressive therapy.

Research paper thumbnail of Mediastinal haematoma complicating percutaneous coronary intervention via the radial artery

Heart, Lung and Circulation, 2015

complication and highlights the need for caution with use of hydrophilic wires. The case also dem... more complication and highlights the need for caution with use of hydrophilic wires. The case also demonstrates an important differential diagnosis of chest pain following cardiac catheterisation by the radial route.

Research paper thumbnail of Very Late Stent Thrombosis 11 Years after Implantation of a Drug-Eluting Stent

Texas Heart Institute Journal, 2015

Very late stent thrombosis is an infrequent yet potentially fatal complication associated with dr... more Very late stent thrombosis is an infrequent yet potentially fatal complication associated with drug-eluting stents. We report the case of an 88-year-old man who sustained an ST-segment-elevation myocardial infarction 11 years after initial sirolimus-eluting stent implantation. Optical coherence tomograms of the lesion showed that the focal incomplete endothelialization of the stent struts was the likely cause; neointimal formation, neoatherosclerosis, and late stent malapposition might also have contributed. To our knowledge, this is the longest reported intervening period between stent insertion and the development of an acute coronary event secondary to very late stent thrombosis. The associated prognostic and therapeutic implications are considerable, because they illuminate the uncertainties surrounding the optimal duration of antiplatelet therapy in patients who have drug-eluting stents. Clinicians face challenges in treating these patients, particularly when competing medical demands necessitate the discontinuation of antiplatelet therapy. In addition to the patient's case, we discuss factors that can contribute to very late stent thrombosis.

Research paper thumbnail of Prognostic Significance of Peri-procedural Myocardial Infarction in the Era of High Sensitivity Troponin: A Validation of the Joint ACCF/AHA/ESC/WHF Universal Definition of Type 4a Myocardial Infarction with High Sensitivity Troponin T

Heart, Lung and Circulation, 2015

This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural my... more This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural myocardial infarction (PMI) with high sensitivity troponin T (hsTnT). Methods A retrospective cohort study encompassing patients admitted to our institution between May 2012 and April 2013 was performed. Results 630 patients underwent percutaneous coronary interventions during the study period. Among them, 459 patients met the inclusion criteria and were eligible for analyses. 76.9% of these patients were male, while the mean age was 68.6. PMI was observed in 4.3% of the patients based on the Universal Definition. The predictors of PMI were chronic kidney disease (OR: 3.0, p=0.026), family history of cardiovascular disease (OR: 2.7, p=0.043) and use of IIb/IIIa inhibitors (OR 4.2, p=0.01). MACE was reported in 4.4% of the patients at 12 months, and was significantly and independently associated with PMI (OR 7.3, p=0.003) in a multivariate model which accounted for lesion complexity, patients' baseline clinical information, dual-antiplatelet status at follow-up and various procedural characteristics. The post-procedural hsTnT was much higher in those who suffered MACE than those who did not (156 v.s. 43 ng/L, p<0.001).

Research paper thumbnail of Patent Foramen Ovale Influences the Presentation of Decompression Illness in SCUBA Divers

Heart, Lung and Circulation, 2015

Research paper thumbnail of Recruited Collateral Channels Are Not Responsible for Ischemic Preconditioning During Single Vessel Angioplasty

Journal of the American College of Cardiology, 1998

Research paper thumbnail of TCT-403 Percutaneous Ultrasound-Guided Thrombin Injection as a Safe and Efficacious Primary Treatment of Iatrogenic Femoral Pseudoaneurysms for the Interventional Cardiologist

Journal of the American College of Cardiology, 2012

Background: Silent cerebral embolization,detected at transcranial Doppler (TCD) monitoring as mic... more Background: Silent cerebral embolization,detected at transcranial Doppler (TCD) monitoring as microembolic signals (MES), is common during diagnostic coronary angiography (DCA). MES rate depends on degree of intravascular catheter manipulation. When using Judkins catheters, right transradial approach (RTA) showed higher rate of MES compared to left transradial and transfemoral, as a consequence of higher rate of catheter exchanges due to difficult navigation and manipulation through tortuous innominate arteries. Microembolization is more common in the right cerebral emisphere, according to origin of right common carotid artery from innominate artery. A single catheter fitting both coronaries (Optitorque Tiger, Terumo,Japan) is available and could reduce the embolization rate. Our aim was to compare cerebral embolization of single (SC) vs double catheters (DC) strategy during DCA performed through RTA. Methods: 19 patients with suspected coronary artery disease were submitted to DCA via RTA after randomization to single (Optitorque Tiger,nϭ9) or double (Judkins Left and Right,nϭ10) catheter strategy, with contemporaneous bilateral TCD monitoring to detect a 50% reduction of MES. Results: Less catheters were employed in SC compared to DC group (1.1ϩ/Ϫ0.3 vs 2.1ϩ/Ϫ0.3,pϽ0.0001) with similar procedural success rate (88% vs 90%,pϭ0.9). MES were detected in all patients, with a significant lower rate in SC group (median 30, interquartile range (IQR) 16-45, vs 57,IQR 54-69,pϽ0.0001), especially during catheters exchange (19,IQR 11-25 vs 41,IQR 27-49,pϭ0.003), whereas no difference was detected during contrast injections (5,IQR 1-13 vs 9,IQR 5-17,pϭ0.24) and coronary ostia engagement (2,IQR 1-6 vs 8,IQR 1-11,pϭ0.15). A strong negative correlation exists among number of MES and SC strategy (Spearman's ϭϪ0.78, pϽ0.0001); at multivariate linear regression analysis the use of a single catheter reduced incidence of MES of 50% (BϭϪ30,std errorϭ7,betaϭϪ0.7,tϭϪ4,95% IC Ϫ46/Ϫ15, pϭ0.001, costantϭ61). Conclusions: RIsk of silent brain injury during DCA is strongly related to number of catheters employed. A specifically designed diagnostic catheter for both coronary arteries via RTA reduced dramatically this embolic risk.

Research paper thumbnail of TCT-425 Real-World Experience with Absorb(tm) Bioresorbable Scaffold Technology - Early Australian Registry Results

Journal of the American College of Cardiology, 2013

Background: Bioresorbable vascular scaffolds have been available on the European market since Nov... more Background: Bioresorbable vascular scaffolds have been available on the European market since November 2011. The first experience in a real-world setting is being documented in the ASSURE registry (NCT01583608). The registry aims to investigate the safety, efficacy and performance of the everolimus-eluting, bioresorbable vascular scaffold (BVS, ABSORBÔ, Abbott Vascular Inc., Santa Clara, CA) over a period of 3 years. Methods: Consecutive patients with de novo native coronary artery disease were treated with BVS at 6 German centers and included in the prospective, observational registry. Acute and 6-months outcomes of equal weight were device success, procedural success, cardiac death, myocardial infarction, ischemia driven target lesion revascularization and target vessel failure or revascularization. Angiographic parameters were assessed at baseline and post procedure. Results: A total of 183 patients (63.5 AE 9.3 years, 79.8% male) were enrolled from April 2012 to March 2013 and 198 lesions were treated. Eligibility criteria for ABSORB A/B would have been met in 16% and for ABSORB EXTEND in 70% of the patients. Acute device success was achieved in 194 (98%) lesions and acute procedural success in all patients. No cardiac death or myocardial infarction occurred and no target lesion revascularization was necessary during hospital stay. Median lesion length was 14.5 mm (5-84 mm) with 85 (42.9%) lesions > 20 mm. 31 (15.7%) lesions were moderately or heavily calcified, 6 (3%) lesions were tightly angulated and 6 (3%) lesions involved a side branch ! 2 mm in diameter. Diameter stenosis was 77.9% at baseline and 4.8% post PCI on average. In 11 (5.6%) lesions diameter of stenosis was ! 99%. The reference vessel diameter of 32 (16.2%) lesions was 2.5 mm. In 30 (15.2%) lesions > 1 BVS was implanted and in 11 patients > 1 target vessel was treated. Bailout with a drug eluting stent was necessary in 3 (1.5%) lesions. Conclusions: Acute results for safety, efficacy and performance of BVS for de novo coronary artery disease in all day clinical practice are promising. Angiographic core lab results will be obtained by June 2013 and clinical 6-months results by September 2013. TCT-422 Malapposition is observed more frequently and to a greater degree in fibrocalcific plaques during bioresorbable vascular scaffold implantation

Research paper thumbnail of Pexelizumab for Acute ST-Elevation Myocardial Infarction in Patients Undergoing Primary Percutaneous Coronary Intervention

JAMA, 2007

CUTE ST-ELEVATION MYOCARdial infarction (STEMI) constitutes a major public health problem, not on... more CUTE ST-ELEVATION MYOCARdial infarction (STEMI) constitutes a major public health problem, not only in western countries but increasingly in developing countries. 1 In the United States, there are estimated to be more than half a million STEMI events annually and these have provided strong impetus for efforts to improve both the process whereby care is delivered and the treatment elements administered. 2 Although reperfusion with primary percutaneous transluminal coronary intervention (PCI) is highly effective, especially if delivered promptly in an expert facility, it is now appreciated that not all PCIs adequately restore myocardial or tissue perfusion. 3 Reperfusion achieved through primary PCI and coronary stenting may be associated with distal coronary embolization, endothelial dysfunction, and impaired ventricular function. 4 A concomitant inflammatory reaction, participating in the accompanying reperfusion injury may mediate apoptosis in the periinfarction area and unfavorable left ventricular remodeling. 5 Poor tissue perfusion and the intensity of the inflammatory response are related to subsequent mortality. 4,6 Complement is known to be both activated and a potential mediator of these processes, and activation of the terminal components of the complement cascade leads to cleavage of the C5 component: this in turn results in formation of both C5a, a potent anaphylatoxin and proinflammatory substance, and C5b-9 or the membrane attack complex (MAC), which causes vesiculation of platelets and endothelial cells, formation of prothrombotic microparticles, and activation of leu-kocytes and endothelial cells. Hence, inhibition of C5 constitutes an attractive therapeutic target. 7 For editorial comment see p 91.

Research paper thumbnail of Initial experience with the balloon expandable Edwards-SAPIEN Transcatheter Heart Valve in Australia and New Zealand: The SOURCE ANZ registry: Outcomes at 30days and one year

International Journal of Cardiology, 2014

Background: We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edw... more Background: We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edwards SAPIEN ™ Transcatheter Heart Valve (THV) in the Australian and New Zealand (ANZ) clinical environment. Methods: This single arm registry of select patients treated in eight centres, represent the initial experience within ANZ with the balloon expandable Edwards SAPIEN THV delivered by transfemoral (TF) and transapical (TA) access. Results: The total enrolment for the study was 132 patients, 63 patients treated by TF, 56 by TA, and 2 patients were withdrawn from the study. The mean ages: 83.7 (TF) and 81.7 (TA), female: 34.3% (TF) and 61.3% (TA), logistic EuroSCORE: 26.8% (TF) and 28.8% (TA), and with procedural success (successful implant without conversion to surgery or death): 92.4% (TF) and 87.1% (TA) (p = 0.32). Outcomes were not significantly different between TF and TA implants. These included one year mortality of 13.6% (TF) and 21.7% (TA) (p = 0.24), MACCE: 16.7% (TF) and 28.3% (TA) (p = 0.12), pacemaker: 4.6% (TF) and 8.3% (TA) (p = 0.39), and VARC major vascular complication of 4.6% (TF) and 5.0% (TA) (p = 0.91). Conclusion: TAVI in the ANZ clinical environment has demonstrated excellent outcomes for both the TA and TF approaches in highly selected patients. These results are consistent with those demonstrated in European, Canadian registries and the pivotal US clinical trials. ACTRN12611001026910.

Research paper thumbnail of Early Australian Experience With AbsorbTM Bioresorbable Scaffold Technology in “Real-World” Coronary Disease

Heart, Lung and Circulation, 2013

Background: National Heart Foundation (NHF) ACS guidelines recommend the use of high sensitivity ... more Background: National Heart Foundation (NHF) ACS guidelines recommend the use of high sensitivity troponin assay (hsTrop). Two thousand and eleven addendum recommends a change in delta value () for hsTrop to 50%. Introduction of hsTrop assay at Box Hill Hospital, 30% was used as the cut off. However, this was changed to 50% six months later. Aim: To determine the clinical impact of 30-50% change for patients presenting with chest pain. Method: We retrospectively collected data from patients >18 years presenting with chest or abdominal pain and had hsTrop between January and March 2012. Results: We analysed 671 patients. 288 (43%) patients who had a STEMI or lacked serial hsTrop values, on dialysis or trauma-related were excluded. Remaining patients were followed up. Out of 383 patients, 148 (39%) with serial hsTrop had at least one abnormal troponin (>14 ng/ml). Thirteen (3.4%) fell within 30-50%. Ten had clinical indications suggestive of ACS and regardless of their hsTrop results went on to have cardiac investigations and management. Three patients with non-cardiac diagnosis had no further tests. At follow up (mean ± SD: 409 ± 13 days), these patients have not had any cardiac events. Conclusion: Our data supports the safety of NHF recommendation for change to 50%. This change affected only 3.4% of the patients and we did not miss any cardiac events. Our clinical decision to investigate 10 of the 13 patients who had <50% underscores the importance of not relying solely on hsTrop assay to diagnose ACS as emphasised in the NHF recommendations.