Context: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction(MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to ...Context: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction(MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking. Objective: To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI. Design, Setting, and Patients: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock(SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock(mean[SD] age at randomization, 66[11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years(median for survivors, 6 years). Main Outcome Measures: All-cause mortality during long-term follow-up. Results: The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years(13.1%and 13.2%, respectively; hazard ratio[HR], 0.74; 95%confidence interval[CI], 0.57-0.97; log-rank P=.03). At 6 years, overall survival rates were 32.8%and 19.6%in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed(HR, 0.59; 95%CI, 0.36-0.95; P=.03). The 6-year survival rates for the hospital survivors were 62.4%vs 44.4%for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3%vs 14.3%and, for the 1-year survivors, 8.0%vs 10.7%. There was no significant interaction between any subgroup and treatment effect. Conclusions: In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2%absolute and a 67%relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.展开更多
Background -Percutaneous aortic valve implantation by an antegrade transvenous approach has been described but is problematic. Retrograde prosthetic aortic valve implantation via the femoral artery has potential advan...Background -Percutaneous aortic valve implantation by an antegrade transvenous approach has been described but is problematic. Retrograde prosthetic aortic valve implantation via the femoral artery has potential advantages. Percutaneous prosthetic aortic valve implantation via the femoral arterial approach is described and the initial experience reported. Methods and Results -The valve prosthesis is constructed from a stainless steel stent with an attached trileaflet equine pericardial valve and a fabric cuff. After routine aortic balloon valvuloplasty, a 22F or 24F sheath is advanced from the femoral artery to the aorta. A steerable, deflectable catheter facilitates manipulation of the prosthesis around the aortic arch and through the stenotic valve. Rapid ventricular pacing is used to reduce cardiac output while the delivery balloon is inflated to deploy the prosthesis within the annulus. Percutaneous aortic prosthetic valve implantation was attempted in 18 patients(aged 81±6 years) in whom surgical risk was deemed excessive because of comorbidities. Iliac arterial injury, seen in the first 2 patients, did not recur after improvement in screening and access site management. Implantation was successful in 14 patients. After successful implantation, the aortic valve area increased from 0.6±0.2 to 1.6±0.4 cm2. There were no intraprocedural deaths. At follow-up of 75±55 days, 16 patients(89%) remained alive. Conclusions -This initial experience suggests that percutaneous transarterial aortic valve implantation is feasible in selected high-risk patients with satisfactory short-term outcomes.展开更多
Background -Mitral annuloplasty is the most common surgical procedure performed for ischemic mitral regurgitation(MR). Surgical mitral annuloplasty is limited by morbidity, mortality, and MR recurrence. We evaluated t...Background -Mitral annuloplasty is the most common surgical procedure performed for ischemic mitral regurgitation(MR). Surgical mitral annuloplasty is limited by morbidity, mortality, and MR recurrence. We evaluated the safety and feasibility of a transvenous catheter-delivered implantable device to provide a percutaneous alternative to surgical mitral annuloplasty. Methods and Results -Five patients with chronic ischemic MR underwent percutaneous transvenous implantation of an annuloplasty device in the coronary sinus. Implantation was successful in 4 patients. Baseline MR in the entire group was grade 3.0±0.7 and was reduced to grade 1.6±1.1 at the last postimplantation visit when the device was intact or the last postprocedural visit in the patient in whom the device was not successfully implanted. Separation of the bridge section of the device occurred in 3 of 4 implanted devices and was detected at 28 to 81 days after implantation. There were no postprocedural device-related complications. Conclusions -Percutaneous implantation of a device intended to remodel the mitral annulus is feasible. Initial experience suggests a possible favorable effect on MR. Percutaneous transvenous mitral annuloplasty warrants further evaluation as a less invasive alternative to surgical annuloplasty.展开更多
文摘Context: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction(MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking. Objective: To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI. Design, Setting, and Patients: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock(SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock(mean[SD] age at randomization, 66[11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years(median for survivors, 6 years). Main Outcome Measures: All-cause mortality during long-term follow-up. Results: The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years(13.1%and 13.2%, respectively; hazard ratio[HR], 0.74; 95%confidence interval[CI], 0.57-0.97; log-rank P=.03). At 6 years, overall survival rates were 32.8%and 19.6%in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed(HR, 0.59; 95%CI, 0.36-0.95; P=.03). The 6-year survival rates for the hospital survivors were 62.4%vs 44.4%for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3%vs 14.3%and, for the 1-year survivors, 8.0%vs 10.7%. There was no significant interaction between any subgroup and treatment effect. Conclusions: In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2%absolute and a 67%relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.
文摘Background -Percutaneous aortic valve implantation by an antegrade transvenous approach has been described but is problematic. Retrograde prosthetic aortic valve implantation via the femoral artery has potential advantages. Percutaneous prosthetic aortic valve implantation via the femoral arterial approach is described and the initial experience reported. Methods and Results -The valve prosthesis is constructed from a stainless steel stent with an attached trileaflet equine pericardial valve and a fabric cuff. After routine aortic balloon valvuloplasty, a 22F or 24F sheath is advanced from the femoral artery to the aorta. A steerable, deflectable catheter facilitates manipulation of the prosthesis around the aortic arch and through the stenotic valve. Rapid ventricular pacing is used to reduce cardiac output while the delivery balloon is inflated to deploy the prosthesis within the annulus. Percutaneous aortic prosthetic valve implantation was attempted in 18 patients(aged 81±6 years) in whom surgical risk was deemed excessive because of comorbidities. Iliac arterial injury, seen in the first 2 patients, did not recur after improvement in screening and access site management. Implantation was successful in 14 patients. After successful implantation, the aortic valve area increased from 0.6±0.2 to 1.6±0.4 cm2. There were no intraprocedural deaths. At follow-up of 75±55 days, 16 patients(89%) remained alive. Conclusions -This initial experience suggests that percutaneous transarterial aortic valve implantation is feasible in selected high-risk patients with satisfactory short-term outcomes.
文摘Background -Mitral annuloplasty is the most common surgical procedure performed for ischemic mitral regurgitation(MR). Surgical mitral annuloplasty is limited by morbidity, mortality, and MR recurrence. We evaluated the safety and feasibility of a transvenous catheter-delivered implantable device to provide a percutaneous alternative to surgical mitral annuloplasty. Methods and Results -Five patients with chronic ischemic MR underwent percutaneous transvenous implantation of an annuloplasty device in the coronary sinus. Implantation was successful in 4 patients. Baseline MR in the entire group was grade 3.0±0.7 and was reduced to grade 1.6±1.1 at the last postimplantation visit when the device was intact or the last postprocedural visit in the patient in whom the device was not successfully implanted. Separation of the bridge section of the device occurred in 3 of 4 implanted devices and was detected at 28 to 81 days after implantation. There were no postprocedural device-related complications. Conclusions -Percutaneous implantation of a device intended to remodel the mitral annulus is feasible. Initial experience suggests a possible favorable effect on MR. Percutaneous transvenous mitral annuloplasty warrants further evaluation as a less invasive alternative to surgical annuloplasty.
