Piotr Musialek

Almost one in five patient has reperfusion abnormalities despite the type of percutaneous interventional procedure after acute myocardial infarction. It has been shown with myocardial contrast echocardiographic and coronary angiographic studies that infarct related artery patency does not always correlate with the presence of adequate myocardial perfusion in the infarct related artery territory. Therefore, it is necessary to obtain further diagnostic and evaluation tools to assess coronary microcirculation and reperfusion failure. ST segment resolution time, TIMI flow grade, TIMI Frame Count and TIMI Myocardial Perfusion Grade (blush score) are helpful tools to assess myocardial perfusion and diagnosis of reperfusion abnormalities.

Purpose  Subclavian or innominate artery (SIA) stenosis affects up to 5% of patients referred to coronary bypass grafting; it is symptomatic in less than half of these. This study aimed to assess the Doppler ultrasonography (DU) findings in SIA obstruction and patients’ follow-up after percutaneous angioplasty (PTA). Methods  The study enrolled 118 patients (68 men, 50 women), aged 61.3 ± 8.7 years,

Successful delivery of progenitor cells to the injury zone is a prerequisite for any effect of myocardial regeneration therapy. This key issue, however, has received far less attention than, for instance, a potential need for cell type selection or ex-vivo expansion, the optimal timing of cell application or multimodal functional evaluation after cellular transplantation. By combining myocardial perfusion scintigraphy, magnetic resonance imaging and 99Tc-HMPAO-labelled autologous bone marrow-derived CD34+ cells visualisation, we show in a 63-year-old man with a large anterior myocardial infarction that transcoronary applied cells (via the central lumen of an inflated over-the-wire balloon positioned in the stent implanted in primary PCI) graft preferentially to the infarct border zone. This is consistent with the idea that the area of myocardial 'irreversible' injury (i.e. the no-perfusion zone on perfusion scintigraphy or late enhancement zone on magnetic resonance) remains...

To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.

To develop and prospectively evaluate the safety and efficacy of an algorithm for tailoring neuroprotection devices (NPD) and stent types to the patient/lesion in carotid artery stenting (CAS). From November 2002 to October 2007, 499 patients (360 men; mean age 65.2+/-8.4 years, range 36-88) were prospectively enrolled in a safety and efficacy study of tailored CAS using proximal (flow blockade or reversal) or distal (filters or occlusion) NPDs and closed- or open-cell self-expanding stents. Of the 535 lesions treated in the study, 175 (32.7%) were "high risk" by morphology. Half (50.1%) the patients were symptomatic. A quarter (137, 25.6%) of the procedures were performed under proximal protection and the remainder (398, 74.4%) with distal NPDs; the direct stenting rate was 66.9%. High-risk lesions were treated predominantly with a proximal NPD and closed-cell stent (77.1% and 82.9%, respectively) and less frequently by direct stenting (37.1%, p<0.0001 versus non-high-risk lesions). The in-hospital death/stroke rate was 2.0% (95% CI 0.85% to 3.23%), and the death/major stroke rate was 0.7% (95% CI 0.02% to 1.48%). There were no myocardial infarctions, but there was 1 (0.2%) further death within 30 days. With the tailored approach, symptom status and high-risk lesion morphology were not risk factors for an adverse outcome after CAS; only age >75 years (p<0.001) was a predictor of short-term death. Long-term survival (95.4% at 1 and 88.3% at 5 years) was similar for symptomatic versus asymptomatic patients, direct stenting versus predilation, and closed- vs. open-cell stent design; only coronary artery disease adversely impacted survival (p = 0.04). The rates of freedom from death/ipsilateral stroke were 94.9% at 1 year and 85.9% at 5 years. Tailored CAS is associated with a low complication rate and high long-term efficacy. CAS operators should have a practical knowledge of different NPDs, including at least one proximal type.

To report the use of the Parodi Anti-Emboli System (PAES) for cerebral protection during emergent vertebral artery recanalization. A 56-year-old chimney sweep was referred with recurrent episodes of vertigo and gait ataxia. Left vertebral artery (LVA) flow was barely detectable on duplex Doppler, and brain computed tomography revealed a small infarct in the posterior inferior cerebellar artery territory. Angiography showed subtotal ostial stenosis of the LVA with poor distal flow and possible thrombus. Due to a high risk of distal embolization with percutaneous treatment, anticoagulation was initiated, and the lesion was to be re-evaluated in 2 to 3 weeks. However, 2 days later, the patient developed severe, aggravating headache, gait and left-limb ataxia, horizontal nystagmus, and vomiting. Emergent angiography showed a total ostial LVA occlusion. The PAES was employed to elicit a temporary subclavian steal during percutaneous LVA recanalization, thus protecting the brain from embolization. The ostial LVA was successfully recanalized and stented, with immediate symptom cessation. The PAES can be successfully applied in the subclavian artery to prevent distal embolization during emergent vertebral artery recanalization. Since a significant proportion of vertebral strokes are embolic, PAES may play a novel role in the treatment of acute cerebellar stroke.

To report the utility of proximal brain protection by flow reversal in endovascular management of critical internal carotid artery (ICA) stenosis coexisting with ipsilateral external carotid artery (iECA) occlusion. Four patients with a symptomatic, critical ICA stenosis (in-stent restenosis in one) and iECA occlusion were admitted for carotid artery stenting (CAS). In all cases, the stenosis severity and high-risk lesion morphology precluded the use of filter protection. The "tailored" CAS algorithm indicated that a proximal anti-embolism system should be used to maximize the potential for effective neuroprotection. The flow reversal system, which consists of an independent guiding sheath balloon positioned in the common carotid artery (CCA) and an iECA balloon-wire, was employed, using the CCA balloon only. The system was well-tolerated, and the CAS procedures were uneventful. Due to a unique design with separate CCA and iECA balloons, the flow reversal system can be used for proximal neuroprotection during CAS in severe, symptomatic ICA lesions coexisting with iECA occlusion.

To evaluate the possible role of transcranial color-coded Doppler ultrasonography (TCD) in predicting cerebral reperfusion injury (CRI) in patients undergoing carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis. TCD was obtained in 210 patients (149 men; mean age 64.2+/-8.4 years, range 44-83) who underwent CAS for ICA stenosis averaging 86.7%+/-8.4%. Contralateral ICA occlusion or near occlusion (stenosis >90%) was present in 67 (31.9%) patients. TCD was performed before and 24 hours after CAS with assessment of peak systolic velocities (PSVs) in the ipsilateral middle cerebral artery (iMCA) and contralateral middle cerebral artery (cMCA). PSV ratios (PSVR) in the iMCA and cMCA were calculated from the PSVs before and after CAS. CRI syndrome occurred in 3 (1.4%) patients (2 intracranial bleedings, 1 subarachnoid hemorrhage). The mean iMCA and cMCA PSVRs were 2.66+/-0.19 and 4.16+/-2.77, respectively, in CRI patients, while the PSVRs in CAS patients without neurological sequelae were 1.56+/-0.46 and 1.21+/-0.39, respectively (both p<0.001). The combination of iPSVR>2.4 and cPSVR>2.4 occurred in 4 patients with bilateral ICA disease; 3 (75%) of them developed CRI (100% sensitivity and 99% specificity for CRI prediction). The following independent CRI predictors were identified: combined iPSVR>2.4 and cPSVR>2.4 (RR 2.06, CI 1.89 to 2.24;…

Effective progenitor cell recruitment to the ischemic injury zone is a prerequisite for any potential therapeutic effect. Cell uptake determinants in humans with recent myocardial infarction are not defined. We tested the hypothesis that myocardial uptake of autologous CD34(+) cells delivered via an intracoronary route after recent myocardial infarction is related to left ventricular (LV) ejection fraction (LVEF) and infarct size. Thirty-one subjects (age, 36-69 years; 28 men) with primary percutaneous coronary intervention-treated anterior ST-segment-elevation myocardial infarction and significant myocardial injury (median peak troponin I, 138 ng/dL [limits, 58-356 ng/dL]) and sustained LVEF depression at ≤45% were recruited. On day 10 (days 7-12), 4.3×10(6) (0.7-9.9×10(6)) (99m)Tc-extametazime-labeled autologous bone marrow CD34(+) cells (activity, 77 MBq [45.9-86.7 MBq]) were administered transcoronarily (left anterior descending coronary artery). (99m)Tc-methoxyisobutyl isonitrile (99(m)Tc-MIBI) single-photon emission computed tomography before cell delivery showed 7 (2-11) (of 17) segments with definitely abnormal/absent perfusion. Late gadolinium-enhanced infarct core mass was 21.7 g (4.4-45.9 g), and infarct border zone mass was 29.8 g (3.9-60.2 g) (full-width at half-maximum, signal intensity thresholding algorithm). One hour after administration, 5.2% (1.7%-9.9%) of labeled cell activity localized in the myocardium (whole-body planar γ scan). Image fusion of labeled cell single-photon emission computed tomography with LV perfusion single-photon emission computed tomography or with cardiac magnetic resonance infarct imaging indicated cell uptake in the peri-infarct zone. Myocardial uptake of labeled cells activity correlated in particular with late gadolinium-enhanced infarct border zone mass (r=0.84, P<0.0001) and with peak troponin I (r=0.76, P<0.001); it also correlated with severely abnormal/absent perfusion segment number (r=0.45, P=0.008) and late gadolinium-enhanced infarct core (r=0.58 and r=0.84, P<0.0001) but not with echocardiography LVEF (r=-0.07, P=0.68) or gated single-photon emission computed tomography LVEF (r=-0.28, P=0.16). The correlation with cardiac magnetic resonance imaging-LVEF was weak (r=-0.38; P=0.04). This largest human study with labeled bone marrow CD34(+) cell transcoronary transplantation after recent ST-segment-elevation myocardial infarction found that myocardial cell uptake is determined by infarct size rather than LVEF and occurs preferentially in the peri-infarct zone.

Percutaneous angioplasty (PTA) is widely used in the treatment of subclavian/innominate artery obstruction, but factors of long-term PTA outcome are poorly understood. Our aim was to evaluate the efficiency of PTA on symptom resolution and identify determinants of long-term outcome. Seventy-six lesions were treated in 75 patients (58.7% men) aged 60 +/- 8.5 years. PTA was successful in 70 (93.3%) patients, including 58/58 (100%) stenotic lesions and 13/18 (72.2%) occlusions. The mean stenosis grade (QCA) was reduced from 78.9% +/- 16.6% to 13.5% +/- 10.7% (P < 0.01). A great majority of lesions (87.1%) were stented. In 5 (7.1%) high-risk lesions a proximal or distal neuroprotection system was used. There were no strokes or embolic events. Minor complications occurred in 7 (9.3%) cases. Fifty-seven (89%) of 64 symptomatic patients had complete symptom resolution. The mean follow-up was 24.4 +/- 15.5 months (up to 66 months). Ten restenoses (15.6%), including 9 (13.8%) in-stent restenoses and 1 (16.7%) restenosis after balloon angioplasty, were diagnosed in 64 patients and followed up for at least 6 months. Nine symptomatic restenoses were successfully treated with repeated angioplasty. Cox multivariable analysis revealed the following independent predictors of restenosis: implantation of more than one stent (P = 0.005), low stent diameter (P = 0.088), and postprocedural systolic blood pressure difference between upper extremities (P = 0.044). PTA is a safe and effective method for the treatment of the subclavian/innominate artery obstruction and leads to symptom resolution in majority of patients. Restenosis is not frequent and it can be effectively treated with repeat angioplasty. Low stent diameter, implantation of two stents, and upper limb systolic blood pressure difference are independent predictors of restenosis.

Carotid intima-media thickness (CIMT) is an indicator of atherosclerosis, but its association with multi-level involvement is sparsely investigated. Study aimed to examine interrelation between CIMT and number of arterial territories with significant (>50%) stenoses, including coronary, supraaortic, renal and iliac/femoral arteries. Study formed 415 patients (294 men), aged 62.9+/-9.3 years referred to coronary angiography. CIMT assessment was performed in common, bulb and internal carotid segments, and expressed as the mean aggregate value. In all patients, both coronary, renal angiography and supraaortic, iliac/femoral arteries ultrasound was performed. Group I formed 102 patients without significant lesions in any of investigated territories; group II formed 131 patients with single territory; group III formed 102 patients with two territory and group IV formed 80 patients with three to four territory involvements. CIMT correlated with increasing number of involved territories (r=0.751, p<0.001). Aggregate CIMT, previous myocardial infarction, creatinine level, hypertension, hs-CRP, smoking were independent predictors of multi-level involvement (p<0.001, R=0.768). ROC curves showed that CIMT cut-off value of 1.308 mm could distinguish 0-1 from two to three level involvement with sensitivity of 81.6%, specificity 88.8%, PPV 85.1%, NPV 86.3% (odds ratio 35.9, range 20-65). CIMT increases with number of involved territories. CIMT is an independent predictor of significant multi-level atherosclerosis, showing high sensitivity and specificity for indicating more advanced territorial atherosclerotic involvement.

BACKGROUND: A 35-year-old man was referred to us in his third hour of severe retro-sternal pain, with ventricular fibrillation on paramedics' arrival. No contraindications to pPCl were revealed on telephone referral. Direct questioning on cathlab admission, however, ...