RESUMEN
Recent efforts directed at potential litigation in Hawai'i have resulted in a renewed interest for genetic screening for cytochrome P450 2C19 (CYP2C19) polymorphisms in patients treated with clopidogrel. Clopidogrel is an antiplatelet agent, frequently used in combination with aspirin, for the prevention of thrombotic complications with acute coronary syndrome and in patients undergoing percutaneous coronary interventions. Cytochrome P-450 (CYP) 2C19 is an enzyme involved in the bioactivation of clopidogrel from a pro-drug to an active inhibitor of platelet action. Patients of Asian and Pacific Island background have been reported to have an increase in CYP2C19 polymorphisms associated with loss-of-function of this enzyme when compared to other ethnicities. This has created an interest in genetic testing for CYP2C19 polymorphisms in Hawai'i. Based upon our review of the current literature, we do not feel that there is support for the routine screening for CYP2C19 polymorphisms in patients being treated with clopidogrel; furthermore, the results of genetic testing may not be helpful in guiding therapeutic decisions. We recommend that decisions on the type of antiplatelet treatment be made based upon clinical evidence of potential differential outcomes associated with the use of these agents rather than on the basis of genetic testing.
Asunto(s)
Citocromo P-450 CYP2C19/genética , Pruebas Genéticas/métodos , Ticlopidina/análogos & derivados , Clopidogrel , Hawaii , Humanos , Tamizaje Masivo , Polimorfismo Genético , Ticlopidina/efectos adversos , Ticlopidina/uso terapéuticoRESUMEN
Percutaneous left ventricular assist device (pLVAD) utilization is increasing as the potential applications expand. We report a case of high-risk balloon aortic valvuloplasty and percutaneous coronary intervention using the Impella 2.5 pLVAD in a patient with severely depressed left ventricular function as a bridge to heart transplantation.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Estenosis de la Válvula Aórtica/terapia , Insuficiencia Cardíaca/terapia , Trasplante de Corazón , Corazón Auxiliar , Angioplastia Coronaria con Balón/métodos , Estenosis Coronaria/terapia , Insuficiencia Cardíaca/cirugía , Humanos , Masculino , Persona de Mediana Edad , Stents , Disfunción Ventricular Izquierda/terapiaRESUMEN
Access closure is a key element to successful retrograde percutaneous transfemoral transcatheter aortic valve implantation. It requires large-bore femoral arterial access (18Fr-28Fr) which most operators manage with surgical access and closure under general anesthesia. We report a case example of how, using our center's peripheral interventional experience, we have developed a simple five step technique to achieve hemostasis percutaneously.
Asunto(s)
Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco/efectos adversos , Arteria Femoral , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hemorragia/prevención & control , Técnicas Hemostáticas , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico , Arteria Femoral/diagnóstico por imagen , Implantación de Prótesis de Válvulas Cardíacas/métodos , Hemorragia/etiología , Humanos , Masculino , Punciones , Radiografía Intervencional , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: Current "best" medical therapy with anti-platelet and/or anti-thrombotic agents for symptomatic atherosclerotic intracranial (IC) disease is associated with high recurrence. IC catheter-based therapy (CBT) using balloon angioplasty with or without stent placement is an option for patients who have failed medical therapy. We sought to examine the outcomes of CBT for patients with symptomatic IC arterial disease managed by experienced interventional cardiologists. METHODS: We retrospectively studied 89 consecutive symptomatic patients with 99 significant (≥70% diameter) IC arterial stenoses who underwent CBT. CBT was performed by experienced interventional cardiologists with the consultative support of a neurovascular team. The primary endpoint was stroke and vascular death. RESULTS: Procedure success was achieved in 96/99 (97%) lesions and percent diameter stenosis was reduced from 91% ± 7.5% preprocedure to 19% ± 15% postprocedure (P < 0.001). The rate of in-hospital periprocedural stroke and all death was 3%. The primary endpoint of stroke and vascular death rate at 1 year was 5.7% (5/88) and at 2 years was 13.5% (11/81). The 2-year all-cause mortality was 11.3% (10/88). CONCLUSIONS: For patients with symptomatic IC arterial stenosis who have failed medical therapy or are considered very high risk for stroke, CBT performed by experienced interventional cardiologists is safe and offers both high procedural success rates and excellent clinical outcomes at 1 year. CBT is an attractive option for this high-risk patient population considering the expected 12-15% rate of recurrent stroke at 1 year.
Asunto(s)
Angioplastia de Balón , Infarto de la Arteria Cerebral Media/terapia , Arteriosclerosis Intracraneal/terapia , Anciano , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Angiografía Cerebral , Supervivencia sin Enfermedad , Femenino , Mortalidad Hospitalaria , Humanos , Infarto de la Arteria Cerebral Media/complicaciones , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/mortalidad , Arteriosclerosis Intracraneal/complicaciones , Arteriosclerosis Intracraneal/diagnóstico por imagen , Arteriosclerosis Intracraneal/mortalidad , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/mortalidad , Ataque Isquémico Transitorio/prevención & control , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Nueva Orleans , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Factores de Tiempo , Resultado del TratamientoRESUMEN
Spontaneous coronary artery dissection is a rare condition, usually presenting as an acute coronary syndrome, and is often seen in states associated with high systemic estrogen levels such as pregnancy or oral contraceptive use. While topical hormonal replacement therapy may result in increased estrogen levels similar to those documented with oral contraceptive use, there are no reported cases of spontaneous coronary dissection with topical hormonal replacement therapy. We describe a 53-year-old female who developed two spontaneous coronary dissections while on topical hormonal replacement therapy. The patient had no other risk factors for coronary dissection. After withdrawal from topical hormonal therapy, our patient has done well and has not had recurrent coronary artery dissections over a one-year follow-up period. The potential contributory role of topical hormonal therapy as a cause of spontaneous coronary dissection should be recognized.
RESUMEN
A comprehensive endovascular skill set is desirable and key to successful intervention in the patient with complex cardiovascular disease. Acute stroke intervention is the next frontier for the endovascular specialist. We report a case of acute stroke intervention in a patient with severe peripheral vascular disease performed by interventional cardiologists with peripheral endovascular skills that clearly demonstrates the new paradigm of global revascularization.
Asunto(s)
Estenosis Carotídea/terapia , Procedimientos Endovasculares/instrumentación , Enfermedades Vasculares Periféricas/terapia , Stents , Accidente Cerebrovascular/terapia , Terapia Trombolítica , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/fisiopatología , Angiografía Cerebral , Circulación Cerebrovascular , Competencia Clínica , Circulación Colateral , Evaluación de la Discapacidad , Procedimientos Endovasculares/educación , Hemodinámica , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Examen Neurológico , Enfermedades Vasculares Periféricas/complicaciones , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/fisiopatología , Recuperación de la Función , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVES: To report the technical success and clinical outcomes of catheter-based therapy (CBT) for acute ischemic stroke in patients ineligible for intravenous thrombolysis. BACKGROUND: Acute ischemic stroke is common but undertreated. CBT for acute ischemic stroke is a therapeutic option in selected patients who are not candidates for intravenous thrombolysis. METHODS: Consecutive stroke patients who were ineligible for intravenous thrombolysis and underwent CBT were identified by retrospective chart review. Demographic information, National Institutes of Health Stroke Scale (NIHSS), procedural characteristics, and clinical outcomes during hospitalization and at 90 days follow up were collected. Experienced interventional cardiologists with the consultative support of stroke neurologists were on call for acute strokes. RESULTS: A total of 33 acute ischemic stroke patients underwent emergency cerebral angiography, with 26 patients undergoing CBT. Successful "culprit" artery recanalization was achieved in 23 (88%) of the 26 patients. In-hospital adverse events occurred in 4 (15%) patients, with intracerebral hemorrhage (ICH) (12%) representing the most common adverse event. The baseline NIHSS for patients who underwent intervention was 16.5 +/- 9.9 (median 16) and improved significantly to 9.9 +/- 8.7 (median 9) (P < 0.001) at hospital discharge. A modified Rankin score of two or less (indicating mild disability) was achieved in half (n = 13) of the CBT treated patients. All cause mortality at 90 days was 8% (2/26). CONCLUSIONS: In selected patients, CBT provided by qualified interventional cardiologists supported by stroke neurologists, offers a safe and effective option for patients with acute stroke who are not eligible for intravenous thrombolysis.
Asunto(s)
Angioplastia de Balón , Isquemia Encefálica/complicaciones , Cardiología/métodos , Angiografía Cerebral , Radiografía Intervencional , Radiología Intervencionista/métodos , Accidente Cerebrovascular/terapia , Anciano , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/mortalidad , Isquemia Encefálica/terapia , Conducta Cooperativa , Evaluación de la Discapacidad , Embolectomía , Femenino , Humanos , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/mortalidad , Masculino , Persona de Mediana Edad , Neurología , Grupo de Atención al Paciente , Admisión y Programación de Personal , Derivación y Consulta , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Stents , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: We investigated whether repeat renal artery stent placement compared with treatment with balloon angioplasty alone results in better patency in patients presenting with renal artery in-stent restenosis (ISR). BACKGROUND: Although stent placement for renal artery stenosis has been demonstrated to be superior to balloon angioplasty for "de novo" renal artery lesions, the optimal therapy for ISR remains unclear. METHODS: Between January 1997 and August 2006, 34 consecutive patients (41 renal arteries) with ISR were treated at the discretion of the operator with balloon angioplasty or repeat stent placement. Quantitative angiography was performed before and immediately after intervention and at follow-up. Angiographic follow-up was obtained for clinical indications in 75% of lesions and routine noninvasive follow-up imaging was obtained in 95% of lesions. RESULTS: Repeat renal artery stent placement demonstrated improved patency compared with balloon angioplasty alone with a 58% reduction in recurrent ISR (29.4% vs. 71.4%, P = 0.02) and a 30% reduction in follow-up diameter stenosis (41% vs. 58.2%, P = 0.03). The repeat stent group also had better secondary patency (P = 0.05) and a greater freedom from repeat ISR (P = 0.01) when compared with balloon angioplasty alone. There was a trend favoring repeat stent placement for cumulative freedom from target vessel revascularization (TVR) (P = 0.08). CONCLUSIONS: Repeat stent placement appears to result in superior patency compared with balloon angioplasty alone for the treatment of renal ISR.
Asunto(s)
Angioplastia de Balón/efectos adversos , Obstrucción de la Arteria Renal/terapia , Stents , Grado de Desobstrucción Vascular , Anciano , Angioplastia de Balón/instrumentación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Metales , Persona de Mediana Edad , Diseño de Prótesis , Radiografía , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/fisiopatología , Proyectos de Investigación , Estudios Retrospectivos , Medición de Riesgo , Prevención Secundaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the preferred method of treatment of the complex floppy mitral valve. Immediate repair failure, due to systolic anterior motion (SAM), is related to excessive anterior mitral valve leaflet (AMVL) tissue and/or anterior displacement of the leaflet coaptation point by the posterior mitral valve leaflet (PMVL) with resultant left ventricular outflow tract (LVOT) obstruction. Herein are reported the authors' experience of the AMVL valvuloplasty, a simple alternative to the sliding technique, to prevent post-MVR SAM. METHODS: Between January 1996 and June 2003, elliptical excisions of the base of the AMVL and annuloplasty rings (nine Physio, 38 Seguin) were performed in 47 patients (mean age 66 years; range: 29-86 years). The surgical procedure included posterior mitral valve leaflet (PMVL) resection in 37 patients (80%), AMVL resection in 28 (61%), and transposition flaps in nine (19%). Four patients (8%) had a tricuspid valve repair, six (13%) had an aortic valve replacement, and nine (19%) had coronary bypass grafting. Intraoperative transesophageal echocardiography before and after MVR was performed to assess mitral valve anatomy, the presence and severity of mitral regurgitation (MR), and SAM. RESULTS: There was no postoperative SAM. The severity of MR was reduced to trace or mild in all 47 patients. The mean AMVL length was 3.0 cm before and 2.2 cm after MVR, a tissue reduction of 27%. In those patients with a PMVL resection, the mean length was decreased from 1.95 cm to 1.5 cm, a tissue reduction of 23%. The mean annulus diameter decreased from 3.9 cm to 3.0 cm. The mean AMVL:PMVL ratio decreased from 1.6 to 1.4. The proportional size reduction of the AMVL compared to the PMVL was 17%. The mean coaptation point to annulus distance (CPAD) decreased from 1.1 cm to 0.9 cm. There was no 30-day in-hospital mortality. CONCLUSION: The AMVL valvuloplasty eliminated postoperative SAM. There was both reduction of the AMVL surface area, limiting the excursion of the AMVL into the LVOT, and reduction of CPAD. This technique does not compromise the geometry of the mitral valve apparatus.