RESUMO
Immune-mediated acute coronary syndrome, also known as Kounis syndrome (KS), is an underrecognized and challenging diagnosis. In this case report, we present a case of cardiac arrest secondary to iodinated contrast allergy requiring emergent cardiac catheterization and hemodynamic support secondary to type 2 KS. KS necessitates a high index of clinical suspicion by the treating physician in order to address both the hypersensitivity reaction and its cardiac implications. Learning objectives: Kounis syndrome (KS) is a clinically distinct entity from anaphylaxis; managing KS in the same way as anaphylaxis can worsen cardiac demand and ischemia. In addition, KS may present as coronary vasospasm or plaque rupture; regardless, percutaneous coronary intervention (PCI) should be performed as worse outcomes have been described in cases where PCI is not performed or delayed.
RESUMO
Approximately 300,000 people in the United States are estimated to have Chagas' disease, with cardiac manifestations including arrhythmias occurring in 20%-30% of patients. We report a patient diagnosed with Chagas' cardiomyopathy after presenting in ventricular tachycardia. This patient was asymptomatic before her presentation with recurrent episodes of ventricular tachycardia, which motivated us to screen her since she was an immigrant from an endemic Chagas region. This manuscript highlights some of the characteristic cardiac magnetic resonance imaging (MRI) and electrophysiology findings present in patients with Chagas' cardiomyopathy. We also detail the management of patients with Chagas' cardiomyopathy who have suffered from ventricular tachycardia.
Assuntos
Doenças Cardiovasculares , Diabetes Mellitus , Doença Arterial Periférica , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Diabetes Mellitus/epidemiologia , Fatores de Risco de Doenças Cardíacas , Humanos , Doença Arterial Periférica/complicações , Doença Arterial Periférica/epidemiologia , Fatores de RiscoRESUMO
BACKGROUND: Femoropopliteal (FP) artery is one of the most anatomically challenging areas for sustained stent patency. The incidence of FP in-stent restenosis (ISR) is estimated at 50% at 24 months. Prior studies have shown that lesion debulking with laser atherectomy (LA) combined with drug coated balloon (DCB) have superior outcomes compared to LA + balloon angioplasty (BA) ISR, but there have not been studies evaluating 2-year outcomes. METHODS: This was a dual-center retrospective cohort study that compared patients with FP-ISR treated with LA + DCB versus LA + BA. Cox regression analysis was used to examine 2-year outcomes of target lesion revascularization (TLR) and the composite outcome of TLR or restenosis. Multivariable analysis was performed for clinical and statistically significant (in the univariate analysis) variables. RESULTS: One hundred and seventeen consecutive patients with Tosaka II (n = 32) and III (n = 85) ISR were analyzed. Sixty-six patients were treated with LA + DCB and 51 with LA + BA. The LA + DCB group had more lesions with moderate to severe calcification (58% vs. 13%; p < .0001). The LA + DCB group was more likely to be treated with the use of embolic protection devices (64% vs. 23%, p < .001) and cutting balloons (61% vs. 6%, p < .001). Bail-out stenting rates were lower in the LA + DCB group (32% vs. 57%, p = .008). LA + DCB was superior (HR: 0.57; 95% CI: 0.34-0.9, p = .027) for the composite outcome of 2-year TLR or restenosis. The 12-month KM estimates for freedom from TLR or restenosis were 66% in the LA + DCB group versus 46% in the LA + BA group. The 24-month KM estimates were 45% in the LA + DCB group versus 24% in the LA + BA group. CONCLUSIONS: The combination of DCB + LA was associated with decreased rates of bail-out stenting and improved 2-year TLR or restenosis rates. Randomized clinical trials examining the DCB + LA combination for FP-ISR are needed.
Assuntos
Angioplastia com Balão/instrumentação , Aterectomia , Materiais Revestidos Biocompatíveis , Procedimentos Endovasculares/instrumentação , Artéria Femoral/cirurgia , Terapia a Laser , Doença Arterial Periférica/terapia , Artéria Poplítea/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Aterectomia/efeitos adversos , Constrição Patológica , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Terapia a Laser/efeitos adversos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Grau de Desobstrução VascularRESUMO
BACKGROUND: Femoropopliteal (FP) artery in-stent restenosis (ISR) is associated with high rates of re-intervention and occlusion. The combined use of laser atherectomy (LA) with balloon angioplasty (BA) is superior to conventional balloon angioplasty (BA). Drug-coated balloons (DCBs) when combined with LA have provided additional efficacy for the treatment of FP-ISR. The aim of this study was to investigate the combination of DCBâ¯+â¯LA with the recently approved Turbo-Power™ (Spectranetics Inc., Colorado Springs, CO, USA) LA device. METHODS: This was a dual-center retrospective study enrolling 78 consecutive patients with Tosaka type II (nâ¯=â¯18) or III (nâ¯=â¯60) FP-ISR. The lesions were treated with either Turbo-Power™ LA followed by DCB (nâ¯=â¯27) or with other LA devices followed by plain BA (LAâ¯+â¯BA; nâ¯=â¯51) from 2015 to 2017. A Cox regression analysis was performed to examine the association between the two groups in terms of target lesion revascularization (TLR) and occlusion rates over a follow up period of 12â¯months. Kaplan-Meier survival curves were estimated and compared with the log-rank test. RESULTS: The overall procedural success was 90%. Eight periprocedural complications occurred without any difference between the two groups (Turbo-Power™â¯+â¯DCB: 7.4% vs LAâ¯+â¯BA: 11.8%, pâ¯=â¯.7). The 12-month KM estimates for freedom from TLR were 90.9% in the Turbo-Power™â¯+â¯DCB group vs 55.7% in the LAâ¯+â¯BA group (pâ¯=â¯.005). Among Toasaka III lesions, the 12â¯m-KM survival estimates for freedom from TLR were 88.9% in the Turbo-Power™â¯+â¯DCB group vs 54.2% in the LAâ¯+â¯BA group (pâ¯=â¯.009). The 12â¯m-KM estimates for freedom from re-occlusion were 89.0% in the Turbo-Power™â¯+â¯DCB group vs 58.9% in the LAâ¯+â¯BA group (pâ¯=â¯.070). CONCLUSIONS: Turbo-Power™ laser atherectomy combined with DCB exerted synergistic mechanism of actions and improved 12-month TLR rates for the treatment of complex FP-ISR lesions.