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386Flow Impairment During Saphenous Vein Graft Inter-vention is Associated With Greater Plaque EmbolizationDespite Use of Distal Protection Device

Gary Liew 1,∗, Michael Leung 1, Christopher Hammett 1,Matthew Worthley 1, Azfar Zaman 2, Stephen Worthley 1

1 Royal Adelaide Hospital, Adelaide, SA, Australia; 2 The Free-man Hospital, Newcastle-Upon-Tyne, United Kingdom

Background and aims: Saphenous vein graft percutaneouscoronary intervention (SVG-PCI) has a 10–30% risk ofmyocardial infarction (AMI) by the ‘slow or no-reflow’phenomenon. This is partly mediated by the embolizationof atheromatous material. We sought to identify factorsassociated with reduced flow as assessed by TIMI framecount (TFC) post SVG-PCI.Methods: Consecutive patients (n = 24, age 68 ± 9) under-going SVG-PCI utilizing the distal protection device,FilterWire EZ (Boston Scientific, Natick, MA) wereenrolled. Quantitative coronary analysis (QCA) and TFCwere performed on all angiograms by two cardiologists.We evaluated patients in two groups defined as improvedor impaired TFC post-procedure.Results: The mean age of SVG was 14.4 (±4.4) years. A totalof 26 lesions were analysed with a mean lesion length of23.3 (±17.9) mm. The inter-observer variability in TFC was2.3%. Increased TFC post-PCI, a marker of reduced flow,waprstFlgCuiflsb

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chance of restenosis compared to if all BMS usage andreduce chance of late stent thrombosis compared to if allDES usage.Objectives: We retrospectively analysed procedural, inhospital and follow up results in patients treated with bothBMS and DES based upon lesion morphology.Methods: 78 patients comprised the study group each hav-ing received at least one BMS and DES. Lesions requiringstents more than 3 mm or more in diameter and stentlengths 18 mm or less received BMS, others received DES.This cohort was followed for Procedural, in-Hospital andfollow-up MACE.Results: There were 58 males and 20 females in this study.There were no major procedural or in hospital compli-cations. On a mean follow up of 8 ± 4 months, no MACEwas reported. Nineteen patients underwent clinically indi-cated angiograms. Six patients had BMS instent restenosis(ISR) including. One patient had ISR in both the BMS andthe DES. One patient had ISR in the DES alone. Over-all only 8 patients (10.4%) had restenosis requiring TargetVessel Revascularisation.Conclusions: In this retrospective analysis the TVR of10.4% are comparable to reported 6–10.5% TVR in DEStrials. Large trials are needed to test this hypothesis that ahybrid strategy can reduce costs and the risk of late stentthrombosis.In this retrospective analysis the TVR of 10.4% are com-ptst

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as associated with new thrombus formation (p = 0.006)nd greater embolic material weight (6.0 mg vs. 15.1 mg;= 0.009). Embolic material weight correlated with QCA

eference diameter (rs = 0.483; p = 0.012) and number oftents used (rs = 0.463; p = 0.017), but not with lesion ulcera-ion, eccentricity, calcification or SVG degeneration score.ormation of new thrombus during PCI was influenced byonger lesion length (29.2 mm vs. 17.3 mm; p = 0.035) andreater number of stents used (p = 0.017).onclusions: Our study has demonstrated that despitese of distal protection device, greater embolic material

s associated with a greater likelihood of post-proceduralow impairment. QCA reference diameter and number oftents used, were contributors to the amount of atheroem-oli during SVG-PCI.

oi:10.1016/j.hlc.2008.05.387

87esults in Complex Multivessel and Multilesion PCI inatients Treated with a Combination of Drug Elutingtents and Bare Metal Stents in Real World Practice

avinder Batra 2,∗, Akshay Mishra 1, Rohan Jayasinghe 2,harmalar Rajendran 2, Naylin Bissessor 2, Johnedgwick 1

The Prince Charles Hospital, Brisbane, QLD, Australia; 2 Theold Coast Hospital, Gold Coast, QLD, Australia

ackground: The debate on usage of Drug Eluting StentsDES) is ongoing. There is no data on the Major Adverseardiovascular Events (MACE) in patients treated with a

ombination of DES and BMS. This strategy could reduce

arable to reported 6–10.5% TVR in DES trials. Largerials are needed to test this hypothesis that a hybridtrategy can reduce costs and the risk of late stenthrombosis.

oi:10.1016/j.hlc.2008.05.388

88nprotected Left Main Intervention: Procedural, in Hos-ital and Follow up Results in an Emergency Situationithout on Site Surgery

kshay Mishra 1,∗, Ravinder Batra 2, Rohan Jayasinghe 2,harmalar Rajendran 2, Naylin Bissesor 2, John Sedgwick 1

The Prince Charles Hospital, Brisbane, QLD, Australia; 2 Theold Coast Hospital, Gold Coast, QLD, Australia

ackground: Left Main stentings are deemed to be high-isk interventions. There is not much literature availablen performing such procedures without surgical backupnsite.ethods: We retrospectively reviewed our data on unpro-

ected Left Main interventions over the last two years androcedural, in hospital, follow-up results and the stentsage pattern.esults: Of 1200 PCIs carried out 10 were unprotected Leftain stentings, 6 M and 4 F. The mean age was 73. Two pro-

edures were following dissection of the Left Main whilearrying out PCI in the LAD. Four patients were done fol-owing multiple ventricular fibrillations during admissionnd were considered too unstable for transfer for surgery.wo patients were considered too high risk by the surgeonsnd were offered and underwent Left Main stenting. One

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S164 Abstracts Heart, Lung and Circulation2008;17S:S1–S209

patient underwent Left Main bifurcation stenting as a semielective procedure. One unstable patient died during theemergency procedure.Five of these patients had multiple vessel stenting in thesame procedure. Nine patients survived the procedureand were discharged after stabilizing. There was no MACEin 30-day follow-up. Five of these patients have had pro-tocol follow-up angiograms. One showed restenosis andrequired repeat PCI. All patients were doing well at a meanfollow-up of 10 ± 4 months.Conclusions: Unprotected Left Main stenting in anemergent situation can be life saving. It can also beuseful when surgeons refuse the case for co-existingmorbidities.Reduce costs and the risk of late stent thrombosis.

doi:10.1016/j.hlc.2008.05.389

389Primary Percutaneous Coronary Interventions WithoutOn-site Cardiac Surgery: Two Years’ Observational Expe-rience and Follow-up

Akshay Mishra 1,∗, Ravinder Batra 2, Rohan Jayasinghe 2,Sharmalar Rajendran 2, Naylin Bissesor 2, John Sedgwick 1

1 The Prince Charles Hospital, Brisbane, QLD, Australia; 2 TheGold Coast Hospital, Gold Coast, QLD, Australia

390Outcomes with Targeted Use of Drug Eluting Stents inPatients with Acute ST Elevation Myocardial Infarction(STEMI)

Calvin Hsieh ∗, Harshini Sivaramakrishnan, ArunNarayan, Norman Sadick, Andrew Ong, Pramesh Kovoor

Westmead Hospital, NSW, Australia

Introduction: Given the cost differential of drug elut-ing stents (DES) compared to bare metal stents (BMS),we assessed the outcomes of selective use of DES inSTEMI patients with high risk of in-stent restenosis(ISR).Methods and results: 787 consecutive patients with acuteSTEMI over a 41-month period were recruited andprospectively followed up for a mean of 12 ± 9 months.All had a stent implanted, BMS = 433 (55%) and DES = 354(55%). Criteria for DES selection were target vessel≤2.5 mm diameter in non-diabetics, target vessel ≤3.0 mmin diabetics, target vessel lesion length >18 mm, ISR,saphenous vein graft lesions, ostial lesions, bifurcationlesion, left main coronary artery lesions, and multi-vesseldisease. The Kaplan Meier survival estimates at 24 monthswere 91% and 93% for the BMS and DES groups respec-tively (p = 0.637). Using ARC classification there were 4/433(0.9%) and 12/354 (3.4%) definite, 3/433 (0.7%) and 1/354probable, 5/433 (1.2%) and 0/354 possible, episodes of

Background: The drive to achieve rapid revascularizationin STEMI patients has led to many centres using PrimaryPCI without having the option of backup surgery. Our cen-tre is located 75 km from the nearest hospital with on-sitecardiac surgery.Objectives: We studied the safety and efficacy of perform-ing round the clock acute infarct percutaneous coronaryinterventions at a hospital without cardiac surgical facility.Methods: A total of 115 patients presented with acuteinfarct in our hospital in the period between October2005 till November 2007. Periodically newer and morerigorous protocols were implemented to reduce our door-to-balloon times.Results: The procedure was successful in 112 patientsachieving TIMI III flow in the culprit vessel. We achieveda mean Door to Balloon time of 89.6 min. The culprit ves-sel was the RCA/PDA in 50 patients, LAD/Diagonal in 54,LCX/OM/Intermediate in 11, Diagonal in 3.These patients were followed up for procedural in hospital,30 days and follow-up MACE. One patient died on thetable (he was 92 years). Two more died within 30 days oneof whom had a VSD. One patient died at 9 months froma reinfarction at home. There was reinfarction in anotherpatient due to instent restenosis. Eight patients were lost tofollow-up. The others were doing well at a mean follow-upof 6 ± 4 months.Conclusions: Acute infarct percutaneous coronary inter-ventions can be performed with safety and efficacy at ahospital without cardiac surgical capability with similarresults as a centre with surgical facilities.

doi:10.1016/j.hlc.2008.05.390

stent thrombosis in the BMS and DES groups respec-tively (p = 0.014). Of these 0/433 and 1/354 were acute, 7/433(1.6%) and 3/354 (0.8%) were subacute, 2/433 (0.5%) and8/254 (3.1%) were late, and 3/433 and 1/354 were very late(p = 0.101). The rate of clinically driven TLR for ISR was17/433 (3.0%) and 2/354 (0.6%) during the follow-up period(p = 0.002).Conclusions: Selective use of DES significantly decreasesthe rate of clinically driven TVR for ISR in STEMI patients.There was a slightly higher rate of stent thrombosis withDES compared to BMS using this protocol.

doi:10.1016/j.hlc.2008.05.391

391ST-Elevation Myocardial Infarction: Strategies to Ensurethat all Patients Receive Prompt Percutaneous CoronaryIntervention

Wai Ping Alicia Chan 1,∗, Aaron Sverdlov 1, BernadetteHoffman 2, Kathryn Hines 2, Christopher Zeitz 1

1 The Queen Elizabeth Hospital, Adelaide, SA, Australia; 2 LyellMcEwin Health Service, Adelaide, SA, Australia

Percutaneous coronary intervention (PCI) is the preferredstrategy for acute management of ST elevation myocar-dial infarction (STEMI), provided it can be delivered ina timely fashion by experienced operators. The targetdoor to balloon interval of 90 min is seldom achieved inpractice. Reported times focus on median values with asubstantial cohort of patients having delays >2 h. We re-designed our PCI management of STEMI to aim for atarget of 90% of balloon inflations within 90 min. Phase 1