RESUMO
INTRODUCTION: Fusion of left ventricular pacing with intrinsic conduction provides superior resynchronization compared to biventricular pacing. His bundle pacing (HBP) preserves intrinsic conduction and allows for constant fusion with left ventricular pacing. This study evaluated sequential His bundle and left ventricular pacing for cardiac resynchronization therapy (CRT). METHODS: In patients referred for CRT, sequential His bundle and left ventricular pacing was performed when HBP did not correct the QRS. At implant, QRS duration and area were compared between biventricular pacing and His bundle and left ventricular pacing. Devices were programmed for His and left ventricular pacing. Functional status and echocardiography were evaluated in follow up. RESULTS: Twenty-one patients, seven female, 70.7 ± 9.9 years, 57% with nonischemic cardiomyopathy were included. Baseline QRS duration was 170 ± 21 ms and was 157 ± 16 ms with HBP. Biventricular pacing resulted in a QRS duration of 141 ± 15 ms and decreased to 110 ± 14 ms with His bundle and left ventricular pacing (p < .0005). His bundle and left ventricular pacing resulted in a smaller paced QRS area (38.5 ± 22.6 µVs) compared to biventricular pacing (67.5 ± 24.0 µVs) and baseline (78.1 ± 28.1 µVs; p < .0005). Left ventricular ejection fraction increased from 27.6 ± 6.4% to 41.1 ± 12.5 (at 25 mean months, p = .001) and functional class improved from 3.1 ± 0.5 to 2.1 ± 0.8 (at mean 32 months, p < .001). CONCLUSIONS: Sequential His bundle and left ventricular pacing results in superior electrical synchrony in patients with indication for CRT when HBP does not correct the QRS and resulted in promising clinical and echocardiographic response rates.
Assuntos
Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca , Idoso , Idoso de 80 Anos ou mais , Fascículo Atrioventricular , Estimulação Cardíaca Artificial , Eletrocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Humanos , Masculino , Volume Sistólico , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
The appropriateness use criteria (AUC) for coronary revascularization have been formulated through the joint efforts of several professional societies. The goals of AUC were to aid in physician decision making and to objectively define the need and context for revascularization. These criteria, developed using a standardized approach, were widely promoted and adopted in many practices. Rigorous use in daily practice and public reporting of adherence to these criteria has exposed some of their deficiencies. Revisions to the original version were made to accommodate public and physician sentiments. Not surprisingly, the recent percutaneous coronary intervention performance measures developed by the same professional societies that have proposed AUC, have suggested that AUC should be used for internal quality improvement only at this time. Therefore, the present role and future application of AUC to cardiology practice is uncertain. The goals of this review are to describe methodology and development of the coronary revascularization AUC, to focus on the strengths and limitations of AUC, and to identify challenges related to application of these criteria in daily practice.
RESUMO
Background Sodium-glucose cotransporter-2 (SGLT2) inhibitors reduce atherosclerotic cardiovascular disease (ASCVD) events in patients with prior ASCVD and type 2 diabetes; however, this benefit is uncertain in patients without established ASCVD. Methods and Results Large-scale cardiovascular outcome randomized controlled trials or their prespecified subgroup analyses were selected, evaluating SGLT2 inhibitors versus placebo for primary prevention of ASCVD (inception, March 2023). The primary outcome was atherosclerotic major adverse cardiovascular events (MACEs), which was a composite of cardiovascular mortality, myocardial infarction, and stroke. The secondary outcomes were individual components of MACEs and all-cause mortality. The outcomes were reported as random-effect relative risk (RR) with a 95% CI. This analysis, comprising 23 987 patients enrolled in 5 randomized controlled trials with a mean follow-up duration of ≈135 weeks, found no significant reduction in atherosclerotic MACEs with SGLT2 inhibitors in comparison to placebo (RR, 0.85 [95% CI, 0.71-1.01]; P=0.07; I2=44). There were no significant differences in cardiovascular mortality (RR, 0.93 [95% CI, 0.77-1.14]; P=0.50; I2=0), myocardial infarction (RR, 0.88 [95% CI, 0.69-1.11]; P=0.28; I2=23), and stroke (RR, 0.84 [95% CI, 0.62-1.16]; P=0.29; I2=46). SGLT2 inhibitors significantly improved all-cause mortality (RR, 0.85 [95% CI, 0.72-1.0]; P=0.04; I2=23). On subgroup analyses, the use of SGLT2 inhibitors led to significant reductions in MACEs (RR, 0.74 [95% CI, 0.61-0.89]; P=0.001), myocardial infarction (RR, 0.67 [95% CI, 0.47-0.97]; P=0.03), and stroke (RR, 0.61 [95% CI, 0.41-0.91]; P=0.01) primarily in patients with chronic kidney disease along with type 2 diabetes, whereas these benefits were not observed in patients with type 2 diabetes without chronic kidney disease. Conclusions SGLT2 inhibitors significantly reduced atherosclerotic MACEs in subjects having both chronic kidney disease and type 2 diabetes without established ASCVD.
Assuntos
Aterosclerose , Doenças Cardiovasculares , Diabetes Mellitus Tipo 2 , Infarto do Miocárdio , Insuficiência Renal Crônica , Inibidores do Transportador 2 de Sódio-Glicose , Acidente Vascular Cerebral , Humanos , Aterosclerose/tratamento farmacológico , Aterosclerose/prevenção & controle , Aterosclerose/induzido quimicamente , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Infarto do Miocárdio/induzido quimicamente , Prevenção Primária , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal Crônica/complicações , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/induzido quimicamenteRESUMO
BACKGROUND: The long-term safety and effectiveness of drug-eluting stents (DES) versus bare metal stents (BMS) in non-ST-segment elevation myocardial infarction (NSTEMI) beyond 2 years after percutaneous coronary intervention (PCI) is unknown. METHODS: We studied 674 NSTEMI patients who underwent successful PCI with DES (n = 323) or BMS (n = 351). The primary study end-points were time to occurrence of death or nonfatal recurrent myocardial infarction (MI), and stent thrombosis (ST). Secondary end-points included time to occurrence of target vessel revascularization (TVR) and any major adverse cardiovascular event (MACE, defined as the composite of death, MI, ST, TVR). RESULTS: The DES and BMS groups were well matched except that DES patients received dual antiplatelet therapy for a longer duration and had smaller final vessel diameter. In survival analysis, at a mean follow-up of 1333 ± 659 days after PCI, the DES group had similar incidence of death/myocardial infarction (24% vs. 27%, log rank p = 0.23) and ST (4.0% vs. 2.6%, p = 0.18) as the BMS group. The DES patients had lower incidence of TVR (8.1% vs. 17%, p = 0.0018) but similar MACE (26% vs. 37%, p = 0.31). In multivariable analysis, DES vs. BMS implantation showed no significant impact on death/myocardial infarction [adjusted hazards ratio (HR) 1.0, 95% confidence intervals (CI) 0.7-1.4], ST (HR 1.7; CI 0.7 - 4.0), or MACE (HR 0.8; CI 0.6 - 1.1). However, TVR was lower in the DES group (HR 0.4; CI 0.3 - 0.7). CONCLUSION: In patients presenting with NSTEMI, DES implantation appears to be as safe as BMS implantation at long-term follow-up. In addition, DES are effective in reducing TVR compared to BMS.
Assuntos
Cateterismo Cardíaco/métodos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Stents/normas , Idoso , Idoso de 80 Anos ou mais , Stents Farmacológicos , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Prospectivos , Recidiva , Sistema de Registros , Análise de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Multiple randomized trials and observational studies have shown drug-eluting stents (DES) to be safe and effective at 3-year follow-up in stent thrombosis (ST)-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). However, outcomes data beyond 3-4 years after DES implantation are sparse. METHODS: We studied 554 STEMI patients who underwent successful PCI with either DES or bare metal stent (BMS). Primary study end-points were time to occurrence of ST and the composite of death or myocardial infarction (MI). Secondary end-points were time to occurrence of major adverse cardiac events (MACEs) and discrete events that comprise MACE (death, MI, and target vessel revascularization [TVR]). Outcomes of the DES and BMS groups were assessed by survival analysis and multivariable Cox regression. RESULTS: There were 205 (37%) patients who received DES and 349 (63%) patients who received BMS. At a median follow-up of 41.4 months after PCI, there were no differences in the unadjusted incidence of ST (ST, 3.4 vs. 4.3%, log-rank P = 0.61) and MI (6.8% vs. 8%, P = 0.61) between DES versus BMS groups, respectively. However, DES implantation was associated with lower unadjusted incidence of death or MI (11% vs. 23.5%, P = 0.0002), MACE (16% vs. 34%, P < 0.0001), death (6.3% vs. 17%, P = 0.0004), and TVR (9.8% vs. 18%, P = 0.008) than BMS implantation. In multivariable analyses, DES implantation was associated with significantly lower incidence of MACE (adjusted HR = 0.47 [95% CI: 0.31-0.76], P = 0.0007) than BMS implantation. CONCLUSION: In our study of STEMI patients, DES implantation was safer than BMS implantation and was associated with lower MACE at long-term follow-up.
Assuntos
Stents Farmacológicos , Infarto do Miocárdio/terapia , Stents , Idoso , Angiografia Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/diagnóstico por imagem , Sistema de Registros , Resultado do TratamentoRESUMO
BACKGROUND: Obesity is a risk factor for hypertension (HTN) and left ventricular hypertrophy (LVH). However, the association between obesity, HTN or LVH in adolescents has not been studied in a large population. METHOD: Utilizing a database of screening echocardiograms, we assessed for the presence of LVH and HTN (defined as systolic blood pressure (SBP) > 140 mmHg or diastolic blood pressure (DBP) > 90 mmHg) in obese adolescents (BMI > 30) using univariate and multivariate analysis. RESULTS: A total of 2072 subjects were identified between the ages of 13-19 years. LVH was significantly more prevalent in obese subjects (47/166 [28.3%] vs. nonobese subjects (99/1612 [6.1%]) with a P-value of <0.001. Using multivariate analysis adjusting for age, gender and blood pressure, obesity remained strongly associated with the presence of LVH (OR 4.51, CI: 2.83-7.19, P < 0.001). Elevated SBP and DBP were also strongly associated with obesity. SBP > 140 was present in 38% of obese subjects (54/142) versus 12.7% of nonobese subjects (172/1, 353). DBP > 90 was present in 10.6% of obese subjects (15/141) of versus 3.1% of nonobese subjects (42/1352). After adjustment for age, gender and LVH, obesity remained independently associated with HTN (for SBP > 140, OR 2.24, CI: 1.46-3.45, P < 0.001, and for DBP > 90, OR 2.10, CI: 1.063-4.17, P = 0.03). CONCLUSION: Obese adolescents have a significantly higher prevalence of HTN and LVH. Our analysis suggests a direct negative effect of obesity on cardiovascular function starting early in teenage years. (Echocardiography 2011;28:150-153).
Assuntos
Hipertensão/diagnóstico por imagem , Hipertensão/epidemiologia , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/epidemiologia , Obesidade/diagnóstico por imagem , Obesidade/epidemiologia , Ultrassonografia/estatística & dados numéricos , Adolescente , Arizona/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Prevalência , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND: Syncope has many aetiologies but from a cardiac standpoint, if arrhythmogenic and ischaemic causes are not present, obstructive lesions should be considered. Cardiac spindle cell sarcomas are incredibly rare and difficult to cure. CASE SUMMARY: A 62-year-old man presented for exercise stress test and had a syncopal episode on the treadmill. He was found to have a massive mass obstructing the transmitral flow. Patient was taken to the operating room and the mass was resected successfully. Histopathological confirmation revealed the mass to be a cardiac intimal sarcoma. Patient was initiated on a trial regimen of doxorubin, ifosfamide, and mesna. DISCUSSION: Cardiac intimal sarcomas are aggressive cancers and are difficult to treat; there are no established treatment guidelines. They can lead to obstruction of blood flow through the cardiac chambers. From a cardiac perspective, without arrhythmogenic and ischaemic causes of syncope, obstructive lesions should be considered.
RESUMO
Infective endocarditis (IE) is an infection of the endothelium of the heart, that typically affects heart valves. While echocardiography remains crucial in the diagnosis and management of IE, multimodality cardiac imaging helps obtain additional information for the management of complex cases. Alternative imaging modalities such as computed tomography (CT), computed tomography angiography (CTA), and magnetic resonance imaging (MRI) are playing an increasing role in the diagnosis and management of IE, especially for patients with prosthetic valve endocarditis (PVE). Here we present a case of a 60-year-old Caucasian male who was diagnosed with IE, complicated by aortic root abscess, and multiorgan failure. In this challenging case, multimodality cardiac imaging helped in the precise understanding of the extent of endocarditis, cannulation strategy, and direct the course of the surgical procedure that resulted in successful patient management.
RESUMO
BACKGROUND: The goal of this study was to evaluate the prevalence of suspected hypertrophic cardiomyopathy (HCM) in a population of teenagers undergoing screening echocardiography for the detection of HCM. METHOD: The Anthony Bates Foundation performs screening echocardiography for the prevention of sudden death. A total of 2,066 students were studied between the ages of 13 to 19 years. Suspected HCM was defined as any wall thickness ≥ 15 mm. LVH was defined as wall thickness ≥ 13 mm RESULTS: Prevalence of suspected HCM was 0.7% (14/2066). After adjusting for hypertension (HTN), the total prevalence was 0.5% (8/1457). In a subgroup analysis, 551 teenagers with documented race and LV wall thickness were identified between the ages of 13-19 years. African American teenagers [6% (3/50)] had higher prevalence of suspected HCM [0.8% (4/501), OR 7.93, CI 1.72-36.49, p = 0.002]. After multivariate adjustment for age, gender, BMI and HTN (systolic BP >140 and diastolic BP of > 90), African American race remained independently associated with suspected HCM (OR 4.89, CI 1.24-39.62, p = 0.02). CONCLUSION: The prevalence of suspected HCM in young teenagers is approximately 0.2%. This prevalence appears to be higher in African Americans. However, due to small number of African Americans in our population, our result needs to be confirmed in larger trials.
Assuntos
Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/epidemiologia , Ecocardiografia/estatística & dados numéricos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/epidemiologia , Grupos Raciais/estatística & dados numéricos , Adolescente , Arizona/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Programas de Rastreamento , Prevalência , Medição de Risco , Fatores de Risco , Distribuição por Sexo , Adulto JovemRESUMO
Diabetes mellitus (DM) and hypertension (HTN) are common risk factors for heart disease in the population. The goal of this study was to evaluate independent association between type 2 DM and HTN using a very large database. We used ICD-9 codes for type 2 DM (250.00, 250.02) and HTN (401.0, 401.1, 401.9) from the Nationwide Inpatient Sample (NIS) database. We randomly selected the years in the database between 1992 and 2002. We used uni- and multi-variate analysis to evaluate any association between type 2 DM and HTN adjusting for co-morbid conditions. The 1992 database contained a total of 6,195,744 patients. Type 2 DM was associated with 37.5% of patients with HTN vs. 11.4% of the control group (odds ratio (OR): 4.63, Confidence interval (CI) 4.61-4.693, p < 0.001). The 2002 database contained a total of 7,853,982 patients. Type 2 DM was associated with 57.2% of patients with HTN vs. 22.9% of the control group (OR: 4.49, CI 4.47-4.52, p < 0.001). Using multivariate analysis adjusting for age, gender, hyperlipidemia, obesity, smoking, and chronic renal failure, type 2 DM remained independently associated with HTN in both years (for the year 1992: OR: 2.49, CI: 2.47-2.51, p < 0.001 and for the year 2002 OR: 2.19, CI: 2.18-2.20, p < 0.001). The same association was persistently found using samples for each year between 1992 and 2002. The presence of type 2 DM is strongly associated with HTN. This association is independent of co-morbid conditions and was persistent with similar odds ratio over a period of 10 years.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Hipertensão/complicações , Estudos de Casos e Controles , Intervalos de Confiança , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Pacientes Internados/estatística & dados numéricos , Classificação Internacional de Doenças , Masculino , Razão de Chances , Prevalência , Sistema de Registros , Análise de Regressão , Fatores de RiscoRESUMO
BACKGROUND: Aortic stenosis (AS) is one of the most common valvular disorders worldwide. An increasing number of transcatheter aortic valve implantation (TAVI) procedures are being performed yearly for managing AS. This, along with the occurrence of common complications, makes timely diagnosis essential to manage rare complications and improve patient outcomes. CASE SUMMARY: We present a case of a 77-year-old Caucasian male with severe AS with a dysfunctional bioprosthetic valve following previous surgical valve replacement. During valve-in-valve TAVI, we noted bioprosthetic valve leaflet avulsion and embolization causing a major vascular occlusion that resulted in vascular insufficiency of the left lower extremity. This condition was managed successfully via immediate diagnosis using transoesophageal echocardiogram, angiogram, and vascular surgical intervention for retrieving the embolized valve to re-establish circulation. DISCUSSION: To our knowledge, this is the first case of aortic valve leaflet embolization during TAVI resulting in significant vascular insufficiency. Vascular complications are common during TAVI. However, not all vascular complications are the same. Our case highlights an embolic vascular complication from an avulsed prosthetic material during a challenging valve-in-valve TAVI procedure.
RESUMO
BACKGROUND: High calcium score is independently associated with a greater cardiac event rate. Using a large database of patients who underwent coronary angiography for clinical reasons, we evaluated the association between reported degree of coronary calcification with mortality and baseline risk factors. METHODS: Using angiographic data of 1917 patients from 1993 to 1997, we studied any association between the locations of coronary calcium that were seen during coronary angiography with coronary artery risk factors. Furthermore, we correlated the locations of calcium with all cause mortality. RESULTS: A total of 1917 patients who underwent cardiac catheterization from 1993 to 1997 were studied. Total mortality was 22.9%. There was no association between the classic coronary risk factors (history of hypertension, hyperlipidemia, smoking, diabetes mellitus and family history) or race (White, Black, Hispanic, and Asian) with the occurrence of angiographic visible calcium in any location. Furthermore, we did not find any association between the locations of coronary calcium with all cause mortality. (All cause mortality occurred in 21.8% of patients with left main calcification vs. 23.3%, P = 0.63, in 24.6% of patients with left anterior descending artery calcification vs. 22.7%, P = 0.48, in 25.6% of patients with circumflex calcification vs. 23.1%, P = 0.52, in 25.7% of right coronary calcification vs. 22.7%, P = 0.47, in 24.6 of any coronary calcification vs. 22.5%, P = 0.4). CONCLUSIONS: Race, coronary risk factors, and all cause mortality are not associated with angiographic documented coronary calcification in any location in patients undergoing diagnostic coronary angiography.
Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Mortalidade , Calcificação Vascular/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Causas de Morte , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Calcificação Vascular/epidemiologia , Calcificação Vascular/patologia , Adulto JovemRESUMO
Described is a complication of rescue left main coronary stenting due to threatened left main closure following a "valve in valve" TAVR procedure. Left main stent post dilatation with a NC Trek balloon was complicated by a failure to deflate the balloon. The patient spiraled into cardiogenic shock and was stabilized by an intra-aortic balloon pump. Attempts to withdraw the balloon resulted in shearing of the balloon off the shaft. Parallel wiring and sequential balloon dilatations allowed left main bifurcation stenting while crushing the inflated balloon underneath the stent's struts. Follow up of 13â¯months was uneventful. The management of entrapped inflated coronary balloon is reviewed.
Assuntos
Angioplastia Coronária com Balão , Angioplastia com Balão , Angiografia Coronária , Vasos Coronários , Humanos , Choque Cardiogênico , Stents , Resultado do TratamentoRESUMO
BACKGROUND: African American (AA) has higher prevalence of abnormal electrocardigrams (ECG) in general population. However, the degree of these abnormalities in a healthy population undergoing screening echocardiography is not known. The goal of this study was to evaluate the prevalence of ECG abnormalities reported during screening echocardiography based on race. METHOD: The Anthony Bates Foundation has been performing screening across the United States for the prevention of sudden death since 2001. We evaluated a total of 633 participants with documented race and ECG for the presence of any abnormalities. RESULTS: The age of the study population ranged between 6 and 75 years old. The prevalence of abnormal ECG in AA participant was 20.7% (12/58) versus 6.6% (38/578) in other races [odds ratio (OR), 3.70; confidence interval (CI), 1.8-7.58; P < 0.001]. Using multivariate analysis adjusting for age, sex, body mass index, left ventricular hypertrophy, and hypertension (systolic blood pressure >140 and diastolic blood pressure of >90), AA race remained independently associated with abnormal ECG (OR, 2.58; CI, 1.12-5.97; P = 0.02). Limiting our study only to teenagers (age, 13-19 years), AA race remained significantly associated with higher prevalence of ECG abnormalities [23.1% (12/58) of teenage AA had abnormal ECG vs. 7.5% (24/321) of other teenage races; OR, 3.71; CI, 1.36-10.11; P = 0.006]. After excluding benign ECG abnormalities such as sinus bradycardia and early repolarization, AA race remained significantly associated with higher prevalence of abnormal ECG (16.7% vs. 7.3%; OR, 2.52; CI, 0.998-6.39; P = 0.054). CONCLUSIONS: The prevalence of abnormal ECG is higher in AA race independent of echocardiographic abnormalities or demographics. However, some of these abnormalities appear to be related to sinus bradycardia and early repolarization.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Bradicardia , Ecocardiografia , Eletrocardiografia , Programas de Rastreamento , Adulto , Idoso , Índice de Massa Corporal , Bradicardia/diagnóstico , Bradicardia/etnologia , Criança , Morte Súbita Cardíaca/prevenção & controle , Ecocardiografia/métodos , Ecocardiografia/estatística & dados numéricos , Eletrocardiografia/métodos , Eletrocardiografia/estatística & dados numéricos , Feminino , Coração/diagnóstico por imagem , Coração/fisiopatologia , Humanos , Hipertensão/epidemiologia , Masculino , Programas de Rastreamento/métodos , Programas de Rastreamento/estatística & dados numéricos , Vigilância da População , Prevalência , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
The Impella CP (ICP) catheter (Abiomed) offers hemodynamic superiority over the intra-aortic balloon pump. However, device-specific issues are occasionally encountered, especially when long-term mechanical circulatory support (MCS) is required. These include ICP dislodgment, ICP mechanical failure, and the need to remove the ICP while maintaining arterial access to either insert a new MCS device or to perform suture-based arteriotomy site closure. We offer a case in which ICP-based MCS involved ICP distal dislodgment, kinking of the ICP catheter, and removal of the device in a coagulopathic and thrombocytopenic patient. The literature regarding potential solutions to these problems is reviewed. Future ICP design is likely to reduce the frequency and complexity of such events and facilitate the management of these scenarios. This is the first report of a novel method to address ICP kinking dislodgment that did not respond to conventional repositioning maneuvers.
Assuntos
Angioplastia Coronária com Balão/métodos , Reanimação Cardiopulmonar/métodos , Estenose Coronária/terapia , Hemodinâmica/fisiologia , Balão Intra-Aórtico/métodos , Choque Cardiogênico/terapia , Cateterismo Cardíaco/métodos , Terapia Combinada , Estenose Coronária/diagnóstico por imagem , Remoção de Dispositivo/métodos , Ecocardiografia Doppler , Fluoroscopia/métodos , Seguimentos , Humanos , Balão Intra-Aórtico/efeitos adversos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Choque Cardiogênico/diagnóstico por imagem , Resultado do TratamentoRESUMO
Aorto-right ventricular fistula is a potentially fatal complication following transcatheter aortic valve implantation (TAVI). This paper presents a case of successful percutaneous repair of aorto-right ventricular fistula and paravalvular leak after TAVI by using 3D-printed models for pre-procedural planning, and a review of published aorto-right ventricular fistula cases to date. (Level of Difficulty: Advanced.).
RESUMO
Temporal and surgical risk dependent associations with clinical outcomes in patients receiving transcatheter versus surgical aortic valve implantation (TAVI vs SAVI) are uncertain. In this meta-analysis, 7 randomized controlled trials (7,771 patients) were included to investigate trends in outcomes in TAVI versus SAVI up to 5 years, and variation in outcomes with respect to low-, intermediate-, and high-surgical risk of the patients up to 1 year. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI). All-cause mortality was similar in TAVI and SAVI at 30 days (HR 0.81, 95% CI 0.55 to 1.21, pâ¯=â¯0.31), 1 year (HR 0.97, 95% CI 0.89 to 1.06, pâ¯=â¯0.49), 2 years (HR 0.96, 95 CI 0.85 to 1.09, pâ¯=â¯0.54), and 5 years (HR 1.04, 95% CI 0.89 to 1.21, pâ¯=â¯0.62). Cardiac mortality, myocardial infarction and stroke were similar in both interventions up to 5 years. TAVI was associated with lower risk of atrial fibrillation, but higher risk of vascular complications, pacemaker implantation, and paravalvular leak up to 5 years. The lower risks of major bleeding and acute kidney injury with TAVI versus SAVI were limited to 1 and 2 years, respectively. Compared with SAVI, TAVI was superior in reducing all-cause mortality in low surgical risk patients at 30 days only, whereas TAVI was noninferior to SAVI in intermediate- and high-risk patients at 30 days and across all risks at 1 year. In conclusion, TAVI was noninferior to SAVI in terms of mortality, myocardial infarction, and stroke up to 5 years. TAVI improved survival versus SAVI in low-risk patients at 30 days.
Assuntos
Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Valva Aórtica/cirurgia , Saúde Global , Humanos , Incidência , Fatores de Risco , Taxa de Sobrevida/tendências , Substituição da Valva Aórtica Transcateter/efeitos adversosRESUMO
Background The relationship between lowering LDL (low-density lipoprotein) cholesterol with contemporary lipid-lowering therapies and incident diabetes mellitus ( DM ) remains uncertain. Methods and Results Thirty-three randomized controlled trials (21 of statins, 12 of PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors, and 0 of ezetimibe) were selected using Medline , Embase, and the Cochrane Central Register of Controlled Trials (inception through November 15, 2018). A total of 163 688 nondiabetic patients were randomly assigned to more intensive (83 123 patients) or less intensive (80 565 patients) lipid-lowering therapy. More intensive lipid-lowering therapy was defined as the more potent pharmacological strategy ( PCSK 9 inhibitors, higher intensity statins, or statins), whereas less intensive therapy corresponded to active control group or placebo/usual care of the trial. Metaregression and meta-analyses were conducted using a random-effects model. No significant association was noted between 1-mmol/L reduction in LDL cholesterol and incident DM for more intensive lipid-lowering therapy (risk ratio: 0.95; 95% CI , 0.87-1.04; P=0.30; R2=14%) or for statins or PCSK 9 inhibitors. More intensive lipid-lowering therapy was associated with a higher risk of incident DM compared with less intensive therapy (risk ratio: 1.07; 95% CI , 1.03-1.11; P<0.001; I2=0%). These results were driven by higher risk of incident DM with statins (risk ratio: 1.10; 95% CI , 1.05-1.15; P<0.001; I2=0%), whereas PCSK 9 inhibitors were not associated with incident DM (risk ratio: 1.00; 95% CI , 0.93-1.07; P=0.96; I2=0%; P=0.02 for interaction). Conclusions Among intensive lipid-lowering therapies, there was no independent association between reduction in LDL cholesterol and incident DM . The risk of incident DM was higher with statins, whereas PCSK 9 inhibitors had no association with risk of incident DM .
Assuntos
Anticolesterolemiantes/efeitos adversos , LDL-Colesterol/efeitos dos fármacos , Diabetes Mellitus/induzido quimicamente , Inibidores de PCSK9 , Anticorpos Monoclonais Humanizados/efeitos adversos , Ezetimiba/efeitos adversos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de RiscoRESUMO
BACKGROUND: There is inconsistency in the literature regarding the clinical effects of proton pump inhibitors (PPI) when added to dual antiplatelet therapy (DAPT) in subjects with coronary artery disease (CAD). We performed meta-analysis stratified by study design to explore these differences. METHODS AND RESULTS: 39 studies [4 randomized controlled trials (RCTs) and 35 observational studies) were selected using MEDLINE, EMBASE and CENTRAL (Inception-January 2018). In 221,204 patients (PPIâ¯=â¯77,731 patients, no PPI =143,473 patients), RCTs restricted analysis showed that PPI did not increase the risk of all-cause mortality (Risk Ratio (RR): 1.35, 95% Confidence Interval (CI), 0.56-3.23, Pâ¯=â¯0.50, I2â¯=â¯0), cardiovascular mortality (RR: 0.94, 95% CI, 0.25-3.54, Pâ¯=â¯0.92, I2â¯=â¯56), myocardial infarction (MI) (RR: 0.97, 95% CI, 0.62-1.51, Pâ¯=â¯0.88, I2â¯=â¯0) or stroke (RR: 1.11, 95% CI, 0.25-5.04, Pâ¯=â¯0.89, I2â¯=â¯26). However, PPI significantly reduced the risk of gastrointestinal (GI) bleeding (RR: 0.32, 95% CI, 0.20-0.52, Pâ¯<â¯0.001, I2â¯=â¯0). Conversely, analysis of observational studies showed that PPI significantly increased the risk of all-cause mortality (RR: 1.25, 95% CI, 1.11-1.41, Pâ¯<â¯0.001, I2â¯=â¯82), cardiovascular mortality (RR: 1.25, 95% CI, 1.03-1.52, Pâ¯=â¯0.02, I2â¯=â¯71), MI (RR: 1.30, 95% CI, 1.16-1.47, Pâ¯<â¯0.001, I2â¯=â¯82) and stroke (RR: 1.60, 95% CI, 1.43-1.78, Pâ¯<â¯0.001, I2â¯=â¯0), without reducing GI bleeding (RR: 0.74, 95% CI, 0.45-1.22, Pâ¯=â¯0.24, I2â¯=â¯79). CONCLUSION: Meta-analysis of RCTs endorsed the use of PPI with DAPT for reducing GI bleeding without worsening cardiovascular outcomes. These findings oppose the negative observational data regarding effects of PPI with DAPT.
Assuntos
Doença da Artéria Coronariana/tratamento farmacológico , Hemorragia Gastrointestinal/prevenção & controle , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Bomba de Prótons/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/mortalidade , Quimioterapia Combinada , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Bomba de Prótons/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) has multiple definitions. We attempted to identify the optimal definition of CIN. In 985 patients undergoing PCI (derivation group), we assessed the prognostic significance of 4 commonly used contemporary definitions of CIN (increases in serum creatinine after PCI [deltaCr] >1.0 mg/dl, >0.5 mg/dl, and >25% after PCI; and the American College of Cardiology National Cardiovascular Data Registry definition) with respect to 6-month major adverse cardiovascular events (MACEs) and all-cause mortality (at 863 +/- 324 days). Incidence of CIN ranged widely (2.0% to 15%) depending on the definition used. Only 2 definitions (deltaCr >0.5 mg/dl, >25%) consistently correlated with study outcomes. Using these 2 definitions, we devised a new grading system (grade 0 deltaCr