Background: Acute ST-elevation myocardial infarction (STEMI) is a life-threatening emergency cardiovascular condition. Mortality is still high in rural region. Objective: to identify mortality rate and evaluate the clinical outcomes of acute STEMI patients using the fast tract management system at Naresuan University Hospital (NUH) Material and Method: Descriptive review of clinical parameters from STEMI patients who participated in the fast tract management system Results: Between Jan 2010 to Sep 2013 , 191 STEMI patients were enrolled. The 147 patients (77%) were referrals and 44 patients (23%) were non-referrals. They were predominantly male patients with an average age of 65 years. The risk factors of coronary artery disease (CAD) were dyslipidemia (86.9%), hypertension (61.3%), smoking (51.3%) and diabetes mellitus (18.3%). Cardiac arrest was found in 16.2% and 14.1% presented with cardiogenic shock. 86.4% received reperfusion therapy with 37.2% got primary percutaneous coronary intervention (PCI). The median door to balloon time and door to needle time for non-referral patients were 89 and 58 minutes, respectively. The median time to treatment was 226 min in the thrombolytic group and 234 min in the primary PCI group. The overall mortality rate was 11.5% which was much lower than the previous data of NUH (33.3%). For the referred patients, the median first medical contact (FMC) to device time was 344 min. Mortality rate of primary PCI in referral group (17.9%) was higher than in non-referral group (6.3%). Conclusion: The mortality rate at NUH is lower than before having established fast tract management system but still high as compare to standard of care. Fibrinolytic therapy is preferred for the treatment of choice at non-PCI capable hospital and PCI will be considered for failed fibrinolysis or presence of contraindication to fibrinolysis. Shortening of pain to treatment time by fast tract management system is the mainstay to improve survival in the patients who suffer from STEMI. Keywords: ST elevation myocardial infarction, fast tract
Atrial septal defect (ASD) is a common congenital heart disease in adults. Amplatzer septal occluder is one of the most common devices used for transcatheter closure due to its high success rate and ease to implant. Cocoon atrial septal occluder is a new nitinol-based device, its shape resembles Amplatzer septal occluder but coated with platinum to prevent nickel release. Little is known about clinical outcomes of large ASD closure using Cocoon atrial septal occluderTo review our experience in closure of secundum ASD in adults by Cocoon septal occluder and to compare the clinical outcomes and results of the patients who had ASD closure with a device greater than or equal to 30 mm and less than 30 mm.Between November 2005 and October 2008, 63 consecutive patients underwent transesophageal echocardiography (TEE)--guided transcatheter closure of secundum ASD. The patients were divided into two groups (Groups' 1 and 2) according to device diameter that is greater than or equal to 30 mm (n = 31) and less than 30 mm (n = 32), respectively. Clinical outcomes, complications, and transthoracic echocardiography (TTE) before hospital discharge, one to three months, and one-year were analyzed.Device implantations were successful in 27 patients (87.1%) in group 1 and 31 patients (96.9%) in group 2 (p = 0.196). The maximum size of secundum ASD in group 1 determined by TTE, TEE, and balloon sizing diameter (BSD) were 22.6 +/- 5.0 mm (range 15-32), 28.1 +/- 4.8 mm (range 19-39), and 31 +/- 3.5 mm (range 23-38) respectively. The maximum size of secundum ASD in group 2 determined by TTE, TEE, and BSD were 19.7 +/- 4.4 mm (range 12-31), 20.4 +/- 3.4 mm (range 13-26), and 23.1 +/- 2.9 mm (range 15-30) respectively. The mean device size in groups 1 and 2 were 33.5 +/- 3.1 mm and 24.6 +/- 3.3 mm, respectively. Four patients (12.9%) in group 1 had unsuccessful implantations. All of them were in the first 15 cases of using large device and two of them had device embolization requiring surgical removal. One patient (3.1%) in group 2 had an unsuccessful implantation and had device embolization requiring surgical removal. The patients in both groups gradually improved in clinical symptoms with decreased RVsystolic pressure and decreased RV size with complete ASD closure at one yearTranscatheter closure of large secundum ASD by Cocoon septal occluder is feasible with hemodynamic benefit. However complication rates are higher with large ASD closure with device size greater than or equal to 30 mm especially during the early "learning curve" period. With experience, the complication rate declines and the success rate is no different from the group with smaller device size.
