RESUMO
Therapeutic advances have resulted in increased life expectancy in patients with hemophilia. Consequently, the prevalence of coronary artery disease in this population is increasing. Little is known about the optimal management of acute coronary syndrome in these patients. Current guidelines for the management of this condition are based mainly on expert opinion and generally recommend administration of the clotting factor prior to the anticoagulant, antiplatelet, and interventional therapies. We report a case that illustrates the potential harm that may come from this approach: evolution of non-ST-segment elevation acute coronary syndrome into ST-elevation acute coronary syndrome during the administration of recombinant clotting factor. We review available literature and describe the refined informatics-based guidelines for managing acute coronary syndrome in patients with hemophilia we developed in response to the presented clinical case. We propose adopting this novel informatics-based approach, which aids in the identification and early treatment of these patients, operationalizes timely involvement of hematology experts, and gathers data for further study.
Assuntos
Síndrome Coronariana Aguda , Doença da Artéria Coronariana , Hemofilia A , Síndrome Coronariana Aguda/tratamento farmacológico , Anticoagulantes/uso terapêutico , Hemofilia A/complicações , Hemofilia A/tratamento farmacológico , HumanosAssuntos
Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/métodos , Síndrome do Carcinoide Maligno/complicações , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Idoso , Valvuloplastia com Balão , Bioprótese , Cateterismo Cardíaco/instrumentação , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Síndrome do Carcinoide Maligno/diagnóstico , Desenho de Prótese , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Índice de Gravidade de Doença , Resultado do Tratamento , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/fisiopatologiaRESUMO
Cardiac catheterization has been increasingly utilized to evaluate coronary artery disease in patients with end stage liver disease (ESLD). It is known in other populations that radial access reduces access site complications;however, there is a paucity of data in ESLD patients. We investigated vascular and bleeding complications rates between trans-femoral and trans-radial cardiac catheterizations in this high risk population. In this retrospective cohort study, three hundred and thirty four ESLD patients were identified between August 2004 and December 2012 who had undergone trans-femoral (femoral group) or trans-radial (radial group) cardiac catheterizations at our institution. The radial group was not significantly different from the femoral group in age (p = 0.056), proportions of genders (p = 0.85), and weight (p = 0.19); however, compared to the femoral group, the radial group had significantly lower blood pressure (p < 0.0001), hemoglobin (10.4 ± 1.9 vs 11.1 ± 2.02 g/dL, p = 0.001), and hematocrit (30.3 ± 5.7% vs 32.6 ± 6.0%, p < 0.0006), and had a significantly higher INR (1.94 ± 1.16 vs 1.59 ± 0.62, p = 0.0001). In terms of vascular complications, the radial group had a significantly lower rate of pseudoaneurysms (0% vs 3.7%, p = 0.019) than the femoral group. While there were no bleeding complications in either group or differences in transfusion requirements, there was a significantly lower percentage drop in hematocrit in the radial group compared to the femoral group (5.4% vs 7.8%, p = 0.039). In conclusion, trans-radial catheterization is associated with lower rates of vascular access site complications compared to trans-femoral catheterization.
RESUMO
Recent advances in technology have led to an increase in the use of bilateral femoral artery access and the requirement for large-bore access. Optimal access is in the common femoral artery (CFA), rather than higher (in the external iliac artery) or lower (in one of the branches of the CFA). However, there is a paucity of data in the literature about the relationship between bifurcation level of one CFA and the contralateral CFA. To define the prevalence of high bifurcation of the CFA and the relationship between bifurcation level on both sides, we performed a retrospective analysis of all patients with bilateral femoral angiography. From 4880 femoral angiograms performed at UCSF cardiac catheterization laboratory between 2005-2013, a total of 273 patients had bilateral femoral angiograms. The prevalence of low/normal, high, and very-high femoral bifurcations was 70%, 26%, and 4%, respectively, with no difference between sides. A high or very-high bifurcation significantly increased the likelihood of a high bifurcation on the contralateral side (odds ratio >3.0). Multivariable logistic regression analysis revealed age, gender, self-reported race, height, weight, and body mass index were not predictive of high or very-high bifurcations on either side. In conclusion, high femoral artery bifurcations are common and increase the likelihood of a high bifurcation of the contralateral femoral artery.
Assuntos
Cateterismo Cardíaco/métodos , Artéria Femoral/anatomia & histologia , Artéria Femoral/diagnóstico por imagem , Idoso , Angiografia , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Transradial access (TRA) offers advantages including decreased vascular complications, reduced length of hospital stay, and reduced cost. The size of the radial artery (RA) limits the equipment that can be used via TRA. Intra-arterial (IA) vasodilators prevent and treat RA spasm, yet are not uniformly used in TRA and their effect on the absolute size of the RA remains unknown. METHODS AND MATERIALS: 121 patients undergoing TRA for cardiac catheterization were included. 78 patients underwent RA angiography prior to administration of IA vasodilators ('no vasodilator' group), 43 patients underwent radial angiography after administration of an IA verapamil and nitroglycerin cocktail ('vasodilator' group). Quantitative angiography was used to compare the RA diameters. RESULTS: Clinical characteristics were similar between the groups, except that patients in the 'no vasodilator' cohort were taller (1.67 ± 0.1 m vs. 1.73 ± 0.1 m, p=0.002), and heavier (84.9 ± 18.2 kg vs. 75 ± 17.1 kg, p=0.003). In the 'vasodilator' group the proximal RA diameter was larger (2.29 ± 0.47 mm vs. 2.09 ± 0.41 mm, p=0.02) as was the narrowest segment (1.83 ± 0.56 mm vs 1.39 ± 0.43, p<0.0001) compared to the 'no vasodilator' group. At the RA origin, 79.4% of those in the 'vasodilator' group were larger than a 6 Fr guide catheter, compared to 51.4% in the 'no vasodilator' group (p=0.004). At the narrowest segment a higher percentage of RAs in the 'vasodilator' group were larger than a 5 Fr guide catheter (65.1% vs 26.9%, p<0.001) and a 6 Fr catheter (34.9% vs 10.3%, p=0.001). CONCLUSION: IA vasodilators increase pre-procedural RA diameter in patients undergoing cardiac catheterization via TRA. This increase in diameter has important implications for procedural planning. SUMMARY FOR TABLE OF CONTENTS: Boyer et al. performed a blinded controlled clinical trial investigating the effects of intra-arterial vasodilators on radial artery size and spasm during cardiac catheterization. The study demonstrates that intra-arterial vasodilators significantly increased the radial artery size throughout the entire course of the vessel and significantly decreased the amount of radial artery spasm. The authors conclude that these findings support the use of intra-arterial vasodilators during cardiac catheterization and have important implications for emerging technologies such as larger bore sheathless radial procedures.
Assuntos
Intervenção Coronária Percutânea , Artéria Radial/efeitos dos fármacos , Espasmo/prevenção & controle , Vasodilatadores/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/métodos , Artéria Radial/patologia , Resultado do TratamentoRESUMO
BACKGROUND/OBJECTIVES: Transradial access (TRA) is being increasingly used for both diagnostic and interventional cardiac procedures. Use of TRA offers many advantages: decreased bleeding, vascular complications, reduced length of hospital stay, and reduced cost. However, the small size of the radial artery limits the size of the equipment that can be used via this approach. We sought to determine whether pre-procedural administration of topical nitroglycerin and lidocaine increases the size of the radial artery. METHODS: Patients undergoing transradial cardiac catheterization were randomized in a double-blind fashion to a topical combination of nitroglycerin+lidocaine or placebo ointment. The primary endpoint was change in radial artery size. Secondary endpoints included radial artery spasm and radial artery patency. RESULTS: 86 patients were enrolled (43 allocated to treatment group and 43 to placebo group). Patients underwent ultrasound of the radial artery at baseline and before the catheterization. Complications were rare: one hematoma (placebo group) and one radial artery occlusion (placebo group). Baseline demographic and clinical characteristics were similar. The baseline radial artery cross-sectional area (CSA) was similar in both groups (4.95 ± 0.24 mm(2) in placebo group and 5.14 ± 0.34 mm(2) in the treatment group). However, the final CSA decreased to 4.66 ± 0.25 mm(2) in the placebo group and increased to 5.78 ± 0.38 mm(2) in the treatment group (p=0.02), which corresponded to a decrease in CSA by -5.6 ± 2.1% and an increase in CSA by 16.5 ± 4.2% (p<0.0001), respectively. CONCLUSIONS: Pre-procedural administration of topical mixture of nitroglycerin+lidocaine increases the size of the radial artery in patients undergoing transradial cardiac catheterization. CLINICALTRIALSGOV IDENTIFIER: NCT01155167.
Assuntos
Cateterismo Cardíaco/métodos , Lidocaína/administração & dosagem , Nitroglicerina/administração & dosagem , Artéria Radial/efeitos dos fármacos , Vasodilatação/efeitos dos fármacos , Vasodilatadores/administração & dosagem , Administração Tópica , Método Duplo-Cego , Feminino , Humanos , Lidocaína/farmacologia , Masculino , Pessoa de Meia-Idade , Nitroglicerina/farmacologia , Vasodilatadores/farmacologiaRESUMO
Transradial cardiac catheterization has lower rates of arterial access site complications than transfemoral procedures. However, there are complications that are unique to the transradial route. We present the case of a sterile granuloma occurring at the site of radial arterial access as a reaction to the hydrophilic coating on the sheath. The clinical presentation was suggestive of an infected pseudoaneurysm. Awareness of this entity may help clinicians avoid unnecessary surgical procedures, as these granulomata are transient self-limiting reactions.
Assuntos
Cateterismo Cardíaco/efeitos adversos , Catéteres/efeitos adversos , Materiais Revestidos Biocompatíveis/efeitos adversos , Granuloma de Corpo Estranho/etiologia , Artéria Radial , Falso Aneurisma/diagnóstico , Aneurisma Infectado/etiologia , Cateterismo Cardíaco/instrumentação , Erros de Diagnóstico , Feminino , Granuloma de Corpo Estranho/diagnóstico por imagem , Granuloma de Corpo Estranho/patologia , Humanos , Pessoa de Meia-Idade , Artéria Radial/diagnóstico por imagem , Artéria Radial/patologia , Ultrassonografia Doppler em CoresRESUMO
The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P = 0.046), increased length of stay (22 versus 15 days, P = 0.050), and postoperative pressor requirements (27% versus 4%, P = 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup.
Assuntos
Doença da Artéria Coronariana , Vasos Coronários/patologia , Falência Hepática/cirurgia , Transplante de Fígado , Fatores Etários , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/patologia , Doença da Artéria Coronariana/fisiopatologia , Creatinina/sangue , Progressão da Doença , Feminino , Humanos , Tempo de Internação , Falência Hepática/sangue , Falência Hepática/complicações , Falência Hepática/mortalidade , Falência Hepática/fisiopatologia , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Resultado do TratamentoRESUMO
Trans-radial cardiac catheterization has lower rates of arterial access site complications. Hydrophilic-coated sheaths designed specifically for trans-radial procedures have resulted in numerous reports of a foreign body reaction to retained material. Although this is a self-limited condition that should be managed expectantly, it is often confused with an infected pseudoaneurysm, resulting in unnecessary surgery. We searched the FDA MAUDE (Manufacturer and User Facility Device Experience) database to determine which brands of sheath have been associated with this complication. In addition, we performed a literature search for all reported cases of this complication. Only one brand of sheath has been associated with this condition. As trans-radial procedures become more common in the US, knowledge of such complications, which appear to be specific to the Cook radial hydrophilic-coated sheaths, is imperative for all radial interventionalists to prevent unnecessary surgical procedures. © 2010 Wiley-Liss, Inc.
Assuntos
Cateterismo Cardíaco/efeitos adversos , Granuloma de Corpo Estranho/etiologia , Artéria Radial , Cateterismo Cardíaco/instrumentação , Erros de Diagnóstico/prevenção & controle , Desenho de Equipamento , Granuloma de Corpo Estranho/diagnóstico , Granuloma de Corpo Estranho/prevenção & controle , Humanos , Medição de Risco , Fatores de RiscoRESUMO
Patients with end-stage liver disease (ESLD) are predisposed to bleeding complications due to thrombocytopenia, reduced synthesis of coagulation factors, and increased fibrinolytic activity. The exact incidence of vascular access site and bleeding complications related to cardiac catheterization in this group remains unknown. Eighty-eight consecutive patients with ESLD who underwent left-sided cardiac catheterization from August 2004 to February 2007 were identified. Eighty-one patients without known liver disease matched for age, gender, and body mass index who underwent left-sided cardiac catheterization during the same period were chosen as the control group. Vascular complications were defined as hematoma >5 cm, pseudoaneurysm, arteriovenous fistula, or retroperitoneal bleeding. Patients with ESLD had lower baseline mean hematocrit (32.3 +/- 6.0% vs 39.2 +/- 6.2%, p <0.001) and mean platelet count (90.1 +/- 66.3 vs 236.1 +/- 77.1 x 10(9)/L, p <0.001) compared with controls. They also had higher mean serum creatinine (1.9 +/- 1.7 vs 1.2 +/- 0.8 mg/dl, p = 0.002) and mean international normalized ratio (1.6 +/- 0.7 vs 1.1 +/- 0.2, p <0.001). There were more complicated pseudoaneurysms in the patients with liver failure (5.7% [5 of 88]), compared with 0% in controls (p = 0.029). Patients with ESLD had lower starting hemoglobin levels and greater reductions in hemoglobin after cardiac catheterization, resulting in greater need for packed red blood cell transfusion (16% vs 4%, p = 0.008), fresh frozen plasma (51.7% vs 1.2%, p <0.001), and platelet transfusions (48.3% vs 1.2%, p <0.001). Major bleeding was higher in the ESLD group (14.8% vs 3.7%, p = 0.014), driven mainly by the need for blood transfusion. In conclusion, despite severe coagulopathy, left-sided cardiac catheterization may be performed safely in this patient population, with correction of coagulopathy and meticulous attention to procedural technique.
Assuntos
Cateterismo Cardíaco/efeitos adversos , Falência Hepática , Transplante de Fígado , Falso Aneurisma/etiologia , Fístula Arteriovenosa/etiologia , Transtornos da Coagulação Sanguínea/complicações , Transfusão de Sangue , Feminino , Hematoma/etiologia , Hemoglobinas/análise , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Falência Hepática/sangue , Falência Hepática/complicações , Falência Hepática/cirurgia , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: We tested the hypothesis that the use of motion-corrected fluoroscopic images results in enhanced coronary stent visualization and improved detection of inadequate stent expansion. BACKGROUND: Intravascular ultrasound (IVUS) more accurately detects inadequate stent expansion when compared with coronary angiography. Stent under-expansion is associated with stent restenosis and thrombosis. Developing a technique to improve fluoroscopic-based assessment of stent expansion is desirable. METHODS: We analyzed measurements of 48 coronary stents implanted in 30 patients using quantitative coronary angiography (QCA), IVUS, and StentBoost (SB), a novel fluoroscopic image processing technique. Correlations of stent diameter between the modalities were determined. Using established IVUS criteria for adequate stent deployment, we assessed the diagnostic test characteristics of SB to detect inadequate stent expansion. RESULTS: Correlations of minimum stent diameter were highest between IVUS and SB (r=0.75; P<0.0001) when compared with QCA and IVUS (r=0.65; P<0.0001), and QCA and SB (r=0.49; P=0.0004). IVUS and SB demonstrated a small difference in minimum stent diameter, 0.043 mm (95% CI: 0.146-0.061 mm). The correlation between IVUS and SB was lower for vessels with intimal calcification (r=0.57; P=0.002) when compared with vessels with deeper calcification (r=0.84; P<0.0001). A SB minimum diameter of <2.5 mm predicted inadequate stent expansion by IVUS with 88% sensitivity, 70% specificity, and a positive likelihood ratio of 2.9. CONCLUSIONS: SB had superior correlations for stent expansion measured by IVUS when compared with QCA. A minimum stent diameter by SB measurement<2.5 mm is associated with inadequate stent expansion using IVUS criteria.
Assuntos
Estenose Coronária/diagnóstico por imagem , Estenose Coronária/terapia , Fluoroscopia/métodos , Interpretação de Imagem Radiográfica Assistida por Computador , Radiografia Intervencionista , Stents , Idoso , Angiografia Coronária , Feminino , Humanos , Masculino , Estudos Prospectivos , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
We sought to assess survival, predictors of adverse outcomes, and complication rates in a more recent series of adults undergoing percutaneous aortic balloon valvuloplasty (PABV) for symptomatic calcific aortic stenosis. While aortic valve replacement is the treatment of choice for adults with symptomatic calcific aortic stenosis, PABV has been used in selected patients who are not good surgical candidates. Registries of patients who underwent PABV over 15 years ago have shown poor long-term survival and high procedural complication rates. This single-center cohort study enrolled consecutive adults undergoing PABV between 1989 and 2005 for calcific aortic stenosis. Demographic, hemodynamic, and procedural data, as well as vital status, were collected by chart review and query of the National Death Index. The study included 78 patients: mean age 78 +/- 11 years, 51% female, 90% heart failure, 61% coronary disease, and 8% end-stage renal disease. While 22% had a major procedural complication, this rate tended to decrease over time (P=0.068). In the cohort, 87% died with a median survival of 6.6 months. According to NDI records, the primary cause of death was cardiac in 54% of deaths. Survival was significantly higher in patients Assuntos
Estenose da Valva Aórtica/terapia
, Valva Aórtica/patologia
, Calcinose/terapia
, Cateterismo/métodos
, Causas de Morte
, Adulto
, Idoso
, Idoso de 80 Anos ou mais
, Estenose da Valva Aórtica/mortalidade
, Calcinose/mortalidade
, Cateterismo/efeitos adversos
, Cateterismo/mortalidade
, Constrição Patológica
, Feminino
, Humanos
, Masculino
, Pessoa de Meia-Idade
, Estudos Retrospectivos
, Análise de Sobrevida
, Fatores de Tempo
RESUMO
The purpose of this study was to test the hypothesis that rotational angiography improves patient safety while maintaining diagnostic accuracy for patients undergoing coronary angiography. Despite advances in angiographic technique, patients remain at risk for complications of coronary angiography, including contrast-induced nephropathy and radiation exposure. Technology has been developed to perform coronary angiography with active rotation of the imaging system that may reduce the quantity of contrast and radiation to which the patient is exposed. Fifty patients undergoing diagnostic cardiac catheterization were randomized to either standard vs. rotational angiography of the coronary arteries using a prespecified protocol with a flat-panel single-plane imaging system. We measured the quantity of radiographic contrast utilized and radiation exposure. Using an intention-to-treat analysis, there was a 40% reduction (24 +/- 5 vs. 40 +/- 10 ml; P < 0.0001) in contrast utilization in the rotational group compared to the standard group. Neither radiation exposure (35 +/- 14 vs. 30 +/- 20 Gycm(2); P = 0.35), fluoroscopic time (44 +/- 33 vs. 44 +/- 40 sec; P = 0.99), nor procedure time (249 +/- 137 vs. 214 +/- 79 sec; P = 0.26) differed, although significant intraoperator variability was noted for both standard and rotational angiography. The radiation exposure using this flat-panel system is significantly lower than prior reports that used an image intensifier system. Rotational coronary angiography has the potential to improve patient safety by markedly reducing radiographic contrast exposure while maintaining comparable diagnostic accuracy, radiation exposure, and procedure time compared to standard coronary angiography.
Assuntos
Angiografia Coronária/instrumentação , Doença da Artéria Coronariana/diagnóstico por imagem , Adolescente , Adulto , Idoso , Inteligência Artificial , Angiografia Coronária/métodos , Segurança de Equipamentos , Feminino , Fluoroscopia , Humanos , Processamento de Imagem Assistida por Computador/classificação , Processamento de Imagem Assistida por Computador/instrumentação , Masculino , Pessoa de Meia-Idade , Variações Dependentes do ObservadorRESUMO
Elderly patients with severe symptomatic calcific aortic stenosis do poorly with medical management. The optimal treatment for this group of patients is surgical valve replacement. Balloon valvuloplasty may be useful as a bridge to aortic valve replacement in hemodynamically unstable patients, in patients undergoing emergent noncardiac surgery, and in patients with severe comorbidities who are too ill to undergo cardiac surgery. Balloon valvuloplasty often results in symptomatic improvement; however, the postvalvuloplasty valve area is usually <1.0 cm2, the major periprocedural complication rate is roughly 5%, and the 6-month restenosis rate is quite high. There is no evidence that balloon valvuloplasty alters the natural history of aortic stenosis, although no randomized study has been performed.
Assuntos
Estenose da Valva Aórtica/terapia , Calcinose/terapia , Cateterismo , Idoso , Estenose da Valva Aórtica/cirurgia , Calcinose/cirurgia , Cateterismo/estatística & dados numéricos , Humanos , Sistema de Registros/estatística & dados numéricosRESUMO
BACKGROUND: Enhanced external counterpulsation (EECP) is a noninvasive, pneumatic technique that provides beneficial effects for patients with chronic, symptomatic angina pectoris. However, the physiological effects of EECP have not been studied directly. We examined intracoronary and left ventricular hemodynamics in the cardiac catheterization laboratory during EECP. METHODS AND RESULTS: Ten patients referred for diagnostic evaluation underwent left heart catheterization and coronary angiography from the radial artery. At baseline and then during EECP, central aortic pressure, intracoronary pressure, and intracoronary Doppler flow velocity were measured using a coronary catheter, a sensor-tipped high-fidelity pressure guidewire, and a Doppler flow guidewire, respectively. Similar to changes in aortic pressure, EECP resulted in a dramatic increase in diastolic (71+/-10 mm Hg at baseline to 137+/-21 mm Hg during EECP; +93%; P<0.0001) and mean intracoronary pressures (88+/-9 to 102+/-16 mm Hg; +16%; P=0.006) with a decrease in systolic pressure (116+/-20 to 99+/-26 mm Hg; -15%; P=0.002). The intracoronary Doppler measure of average peak velocity increased from 11+/-5 cm/s at baseline to 23+/-5 cm/s during EECP (+109%; P=0.001). The TIMI frame count, a quantitative angiographic measure of coronary flow, showed a 28% increase in coronary flow during EECP compared with baseline (P=0.001). CONCLUSIONS: EECP unequivocally and significantly increases diastolic and mean pressures and reduces systolic pressure in the central aorta and the coronary artery. Coronary artery flow, determined by both Doppler and angiographic techniques, is increased during EECP. The combined effects of systolic unloading and increased coronary perfusion pressure provide evidence that EECP may serve as a potential mechanical assist device.
Assuntos
Pressão Sanguínea , Circulação Coronária , Vasos Coronários/fisiopatologia , Contrapulsação/métodos , Função Ventricular Esquerda , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Cateterismo Cardíaco , Angiografia Coronária , Ecocardiografia Doppler , Feminino , Coração/fisiopatologia , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Intragraft verapamil is effective in treating no-reflow during saphenous vein graft (SVG) percutaneous coronary intervention (PCI). In this study, we assessed the use of intragraft verapamil given pre-PCI to prevent no-reflow. METHODS: Patients undergoing SVG PCI were randomized to receive intragraft 200 g verapamil or no verapamil immediately prior to PCI. Pre- and post-PCI, vessel flow was assessed using TIMI flow grade and TIMI frame count by blinded angiographic readers. Tissue level perfusion in the graft territory was assessed using the TIMI myocardial perfusion grade (TMPG). CK-MB or troponin I levels were measured 6 12 hours post-PCI. RESULTS: Ten patients were randomized to the verapamil group and 12 were assigned to the placebo group. No-reflow occurred in 33.3% of the placebo group, compared to none of the verapamil patients (p = 0.10). The use of intragraft verapamil prior to SVG PCI increased flow rate in the vessel as assessed by TIMI frame count (53.3 22.4% faster in the verapamil group versus 11.5 38.9% in the placebo group; p = 0.016). There was a trend toward improved myocardial perfusion as assessed by TMPG. There was no difference in the incidence of cardiac biomarker release following PCI. CONCLUSIONS: Intragraft administration of verapamil prior to saphenous vein graft PCI reduces no-reflow and is associated with a trend toward improved myocardial perfusion.