hirudin and Wounds--Penetrating

The lack of a specific counteragent to bivalirudin may complicate the management of patients with coronary artery (CA) perforation during percutaneous coronary intervention (PCI).. Assess outcomes of patients with CA perforation from three PCI trials comparing intravenous bivalirudin with provisional glycoprotein (GP) IIb/IIIa inhibition versus unfractionated heparin (UFH) plus GP IIb/IIIa.. A pooled analysis of patients treated with PCI in three randomized trials including REPLACE-2, ACUITY, and HORIZONS-AMI.. Among a total of 12,921 patients, CA perforation occurred in 35 patients (0.27%). By multivariable analysis, baseline creatinine clearance was the only independent predictor of CA perforation (per 10 mL/min decrease, odds ratio [95% confidence interval]= 1.28 [1.11, 1.47], P = 0.0007). At 30 days, patients with versus without CA perforation had significantly (all P values < or =0.001) higher rates of 30-day mortality (11.4% vs. 1.0%), myocardial infarction (MI) [Q wave: 22.9% vs. 5.7%; non-Q wave: 17.1% vs. 4.9%], target vessel revascularization (TVR) [20.1% vs. 1.8%], and composite end-point of death/MI/TVR (31.4% vs. 7.8%). Patients assigned to bivalirudin versus UFH plus a GP IIb/IIIa inhibitor had nonsignificantly lower rates of death (0% vs. 18.8%, P = 0.08), similar rates of MI (26.7% vs. 25.0%, P = 0.92), significantly lower rates of TVR (6.7% vs. 37.5%, P = 0.04), and similar rates of the composite end-point of death/MI/TVR (35.5% vs. 26.7%, P = 0.54).. In three PCI trials, treatment of patients experiencing CA perforation with adjunctive antithrombotic therapy of bivalirudin monotherapy was not associated with worse outcomes compared to treatment with UFH plus GP IIb/IIIa inhibitors.

Topics: Aged; Anticoagulants; Chemotherapy, Adjuvant; Coronary Vessels; Drug Therapy, Combination; Female; Fibrinolytic Agents; Heparin; Hirudins; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Peptide Fragments; Platelet Glycoprotein GPIIb-IIIa Complex; Recombinant Proteins; Survival Rate; Treatment Outcome; Wounds, Penetrating

Successful management of acute cardiac tamponade secondary to coronary artery perforation during percutaneous coronary intervention (PCI) includes sealing off the site of perforation and pericardiocentesis. We report two cases of acute cardiac tamponade during PCI associated with the administration of bivalirudin, in which attempts at percutaneous pericardiocentesis failed, due to the present of thrombus, rather blood, in the pericardium.

Topics: Acute Disease; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Cardiac Tamponade; Coronary Artery Disease; Coronary Vessels; Female; Heart Injuries; Hemostatic Techniques; Hirudins; Humans; Male; Middle Aged; Peptide Fragments; Pericardiectomy; Pericardiocentesis; Recombinant Proteins; Stents; Sternotomy; Thrombosis; Treatment Failure; Ultrasonography; Wounds, Penetrating

Topics: Angioplasty, Balloon, Coronary; Coronary Vessels; Fibrinolytic Agents; Heparin; Hirudins; Humans; Meta-Analysis as Topic; Peptide Fragments; Recombinant Proteins; Risk Assessment; Wounds, Penetrating

The objective of this study is to analyze the clinical outcomes and treatment strategies of coronary wire perforations (WPs) in the era of heparin use compared to the era of bivalirudin use.. Percutaneous coronary intervention (PCI) advances have led to progressive decrease in complications. Therefore, complex coronary lesions such as chronic total occlusions and calcified lesions are being attempted with stiff/hydrophilic wires with resultant higher incidence of coronary WP.. A single-center retrospective data analysis of coronary perforation (CP) for the last 4 years with review of coronary angiograms was done and WPs were identified. A simple classification scheme based on angiographic appearance of CP was made: Type I ("myocardial stain," with no frank dye extravasation) and type II ("myocardial fan," with dye extravasation to pericardial cavity or cardiac chambers).. Overall incidence of CP was 0.49% (82/16,859). Of these 50 (61%) were caused by WP; 30 occurred with heparin use (Group A) and 20 with bivalirudin use (Group B). WPs always occurred in type B2/C lesions (100%) and commonly with use of hydrophilic guidewires (70%). Major adverse cardiac events and cardiac tamponade were frequent in group A (50%) and none in group B (0%); P < 0.01. All WP in group B responded to stopping anticoagulation and prolonged balloon inflation, while group A type II perforations frequently required additional interventions (pericardiocentesis, coil embolization).. Cardiac tamponade and major adverse cardiac events from WPs were less frequent with bivalirudin use compared to heparin use. This beneficial effect of bivalirudin may be explained on the basis of its short half-life and reversible thrombin inhibition property. Therefore, bivalirudin may offer a safer alternative for anticoagulation in complex PCI.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Balloon Occlusion; Cardiac Tamponade; Cineangiography; Coronary Angiography; Coronary Artery Disease; Coronary Vessels; Female; Heparin; Heparin Antagonists; Hirudins; Hospital Mortality; Humans; Male; Middle Aged; Myocardial Infarction; Peptide Fragments; Pericardiocentesis; Recombinant Proteins; Registries; Retrospective Studies; Treatment Outcome; Wounds, Penetrating

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Balloon Occlusion; Blood Coagulation; Cardiac Tamponade; Coronary Vessels; Heparin; Heparin Antagonists; Hirudins; Humans; Myocardial Infarction; Peptide Fragments; Pericardiocentesis; Recombinant Proteins; Treatment Outcome; Wounds, Penetrating