RESUMO
Background: Coronary access after transcatheter aortic valve implantation (TAVI) with supra-annular self-expandable valves may be challenging or un-feasible. There is little data concerning coronary access following transcatheter aortic valve-in-valve implantation (ViV-TAVI) for degenerated surgical bioprosthesis. Aims: To evaluate the feasibility and challenge of coronary access after ViV-TAVI with the supra-annular self-expandable ACURATE neo valve. Materials and methods: Sixteen patients underwent ViV-TAVI with the ACURATE neo valve. Post-procedural computed tomography (CT) was used to create 3D-printed life-sized patient-specific models for bench-testing of coronary cannulation. Primary endpoint was feasibility of diagnostic angiography and PCI. Secondary endpoints included incidence of challenging cannulation for both diagnostic catheters (DC) and guiding catheters (GC). The association between challenging cannulations with aortic and transcatheter/surgical valve geometry was evaluated using pre and post-procedural CT scans. Results: Diagnostic angiography and PCI were feasible for 97 and 95% of models respectively. All non-feasible procedures occurred in ostia that underwent prophylactic "chimney" stenting. DC cannulation was challenging in 17% of models and was associated with a narrower SoV width (30 vs. 35 mm, p < 0.01), STJ width (28 vs. 32 mm, p < 0.05) and shorter STJ height (15 vs. 17 mm, p < 0.05). GC cannulation was challenging in 23% of models and was associated with narrower STJ width (28 vs. 32 mm, p < 0.05), smaller transcatheter-to-coronary distance (5 vs. 9.2 mm, p < 0.05) and a worse coronary-commissural overlap angle (14.3° vs. 25.6 o , p < 0.01). Advanced techniques to achieve GC cannulation were required in 22/64 (34%) of cases. Conclusion: In this exploratory bench analysis, diagnostic angiography and PCI was feasible in almost all cases following ViV-TAVI with the ACURATE neo valve. Prophylactic coronary stenting, higher implantation, narrower aortic sinus dimensions and commissural misalignment were associated with an increased challenge of coronary cannulation.
Assuntos
Estenose da Valva Aórtica , Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/métodos , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Desenho de Prótese , Resultado do Tratamento , Implante de Prótese de Valva Cardíaca/efeitos adversosRESUMO
Refractory angina represents the final stage of chronic coronary artery disease, where anginal symptoms persist despite complete epicardial coronary artery revascularization and maximally tolerated pharmacological therapy. Percutaneous narrowing of the coronary sinus with the coronary sinus reducer (Reducer®, Neovasc, Inc., Richmond, Canada) device was first attempted in humans in 2005 and has been shown to improve angina symptoms and the quality of life of patients suffering chronic refractory angina. It was recently included in the European guidelines for the management of chronic coronary syndrome and is progressively gaining popularity. The authors hereby provide a review of current literature on the topic, intending to facilitate insights and to promote further research on this device and its clinical applications.
Coronary sinus reducer device implantation is a therapeutic option for patients suffering from chest tightness, discomfort and pain (collectively named angina when of clear cardiac origin), which persist for a long time despite optimal medical therapy and complete coronary revascularization. This is a novel device designed to be implanted, via a small puncture on the side of the neck, into the largest cardiac vein (i.e., the coronary sinus), to slow the outflow of blood from the cardiac venous system. Treatment is associated with significant improvement of symptoms in about 7085% of patients, while granting little or no benefit in the remaining 1530% for reasons that are yet to be determined. Importantly, the procedure has been shown to be safe and to have a very low rate of complications. Patients should keep this in mind when evaluating this therapeutic option.
Assuntos
Seio Coronário , Isquemia Miocárdica , Angina Pectoris/cirurgia , Seio Coronário/cirurgia , Humanos , Qualidade de Vida , Resultado do TratamentoAssuntos
Estenose da Valva Aórtica , Valva Aórtica , Bioprótese/efeitos adversos , Cateterismo , Vasos Coronários/diagnóstico por imagem , Próteses Valvulares Cardíacas/efeitos adversos , Imageamento Tridimensional/métodos , Reoperação , Substituição da Valva Aórtica Transcateter , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Cateterismo/instrumentação , Cateterismo/métodos , Humanos , Masculino , Planejamento de Assistência ao Paciente/tendências , Impressão Tridimensional , Falha de Prótese , Reoperação/instrumentação , Reoperação/métodos , Tomografia Computadorizada por Raios X/métodos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoAssuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Humanos , Imageamento Tridimensional , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Clinical efficacy of coronary sinus reducer (CSR) in refractory angina (RA) patients with ischemia due to the chronic total occlusion (CTO) of the right coronary artery (RCA) remains unknown. AIMS: To evaluate the efficacy of CSR implantation in RA patients with CTO RCA and compare them to CSR recipients with left coronary artery (LCA) ischemia. METHODS: Consecutive patients with CTO RCA from 2 centers were prospectively included and compared to patients with LCA ischemia. All patients underwent evaluation of angina severity and quality of life (QoL) at baseline and after 12 months. In a subgroup of CTO RCA patients, stress cardiac magnetic resonance (CMR) imaging was also performed. RESULTS: Twenty-two patients with CTO RCA and predominant inferior and/or inferoseptal wall ischemia (the CTO RCA group) were compared to 24 patients with predominant anterior, lateral, and/or anteroseptal wall ischemia (the LCA group). While the Canadian Cardiovascular Society (CCS) anginascore mean (SD) improved in the CTO RCA group from 2.73 (0.46) to 1.82 (0.73) (P <0.001) and in the LCA group from 2.67 (0.57) to 1.92 (0.72) (P <0.001), there was no intergroup difference (P = 0.350). Significant improvement in all domains of the Seattle Angina Questionnaire was observed. Stress CMR did not show a significant reduction of ischemic inferior and/or inferoseptal segments, however, improvements in the transmurality index (P = 0.03) and the myocardial perfusion reserve index in segments with inducible ischemia (P = 0.03) were observed in the CTO RCA group. CONCLUSIONS: In CTO RCA patients, CSR implantation alleviated angina symptoms and improved QoL. The extent of improvement was comparable to that observed in patients with LCA ischemia.
Assuntos
Oclusão Coronária , Seio Coronário , Intervenção Coronária Percutânea , Angina Pectoris/cirurgia , Canadá , Doença Crônica , Oclusão Coronária/cirurgia , Seio Coronário/cirurgia , Vasos Coronários/cirurgia , Humanos , Qualidade de Vida , Resultado do TratamentoRESUMO
BACKGROUND: Refractory angina affects an increasing proportion of the population with advanced coronary artery disease and microvascular dysfunction. Limited effective pharmacological and interventional therapies exist for this patient cohort. The coronary sinus (CS) reducer, recently recommended in the 2019 guidelines of the European Society of Cardiology for the management of chronic refractory angina, is a balloon-expandable, stainless-steel device designed for implantation in the CS. It acts by increasing CS pressure, thereby redistributing blood to ischemic myocardium, relieving symptoms, and improving quality of life. However, between 15%-30% of patients do not respond to this treatment. Six mechanisms appear to explain this poor response to CS reducer therapy: (1) inappropriate patient selection; (2) cardiac venous system heterogeneity; (3) CS size; (4) incomplete device endothelialization; (5) coronary artery disease phenotype and progression; and (6) limited myocardial ischemia at baseline. We hereby review these mechanisms in detail and highlight key areas that should be addressed in order to try and reduce the burden of non-responders following CS reducer implantation.
Assuntos
Doença da Artéria Coronariana , Seio Coronário , Angina Pectoris , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Seio Coronário/diagnóstico por imagem , Seio Coronário/cirurgia , Humanos , Qualidade de Vida , Resultado do TratamentoAssuntos
COVID-19/complicações , COVID-19/mortalidade , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Complicações do Diabetes/mortalidade , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Complicações do Diabetes/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Análise de Regressão , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/epidemiologiaRESUMO
INTRODUCTION: Refractory angina (RA) is considered the end-stage of coronary artery disease, and often has no interventional treatment options. Coronary sinus Reducer (CSR) is a recent addition to the therapeutic arsenal, but its efficacy has only been evaluated on small populations. The RESOURCE registry provides further insights into this therapy. METHODS: The RESOURCE is an observational, retrospective registry that includes 658 patients with RA from 20 centers in Europe, United Kingdom and Israel. Prespecified endpoints were the amelioration of anginal symptoms evaluated with the Canadian Cardiovascular Society (CCS) score, the rates of procedural success and complications, and MACEs as composite of all-cause mortality, acute coronary syndromes, and stroke. RESULTS: At a median follow-up of 502 days (IQR 225-1091) after CSR implantation, 39.7% of patients improved by ≥2 CCS classes (primary endpoint), and 76% by ≥1 class. Procedural success was achieved in 96.7% of attempts, with 3% of procedures aborted mostly for unsuitable coronary sinus anatomy. Any complication occurred in 5.7% of procedures, but never required bailout surgery nor resulted in intra- or periprocedural death or myocardial infarction. One patient developed periprocedural stroke after inadvertent carotid artery puncture. At the last available follow-up, overall mortality and MACE were 10.4% and 14.6% respectively. At one, three and five years, mortality rate at Kaplan-Meier analysis was 4%, 13.7%, and 23.4% respectively. CONCLUSIONS: CSR implantation is safe and reduces angina in patients with refractory angina.
Assuntos
Seio Coronário , Canadá , Seio Coronário/diagnóstico por imagem , Seio Coronário/cirurgia , Europa (Continente)/epidemiologia , Humanos , Israel , Estudos Retrospectivos , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
BACKGROUND AND AIMS: The potential impact of coronary atherosclerosis, as detected by coronary artery calcium, on clinical outcomes in COVID-19 patients remains unsettled. We aimed to evaluate the prognostic impact of clinical and subclinical coronary artery disease (CAD), as assessed by coronary artery calcium score (CAC), in a large, unselected population of hospitalized COVID-19 patients undergoing non-gated chest computed tomography (CT) for clinical practice. METHODS: SARS-CoV 2 positive patients from the multicenter (16 Italian hospitals), retrospective observational SCORE COVID-19 (calcium score for COVID-19 Risk Evaluation) registry were stratified in three groups: (a) "clinical CAD" (prior revascularization history), (b) "subclinical CAD" (CAC >0), (c) "No CAD" (CAC = 0). Primary endpoint was in-hospital mortality and the secondary endpoint was a composite of myocardial infarction and cerebrovascular accident (MI/CVA). RESULTS: Amongst 1625 patients (male 67.2%, median age 69 [interquartile range 58-77] years), 31%, 57.8% and 11.1% had no, subclinical and clinical CAD, respectively. Increasing rates of in-hospital mortality (11.3% vs. 27.3% vs. 39.8%, p < 0.001) and MI/CVA events (2.3% vs. 3.8% vs. 11.9%, p < 0.001) were observed for patients with no CAD vs. subclinical CAD vs clinical CAD, respectively. The association with in-hospital mortality was independent of in-study outcome predictors (age, peripheral artery disease, active cancer, hemoglobin, C-reactive protein, LDH, aerated lung volume): subclinical CAD vs. No CAD: adjusted hazard ratio (adj-HR) 2.86 (95% confidence interval [CI] 1.14-7.17, p=0.025); clinical CAD vs. No CAD: adj-HR 3.74 (95% CI 1.21-11.60, p=0.022). Among patients with subclinical CAD, increasing CAC burden was associated with higher rates of in-hospital mortality (20.5% vs. 27.9% vs. 38.7% for patients with CAC score thresholds≤100, 101-400 and > 400, respectively, p < 0.001). The adj-HR per 50 points increase in CAC score 1.007 (95%CI 1.001-1.013, p=0.016). Cardiovascular risk factors were not independent predictors of in-hospital mortality when CAD presence and extent were taken into account. CONCLUSIONS: The presence and extent of CAD are associated with in-hospital mortality and MI/CVA among hospitalized patients with COVID-19 disease and they appear to be a better prognostic gauge as compared to a clinical cardiovascular risk assessment.
Assuntos
COVID-19 , Doença da Artéria Coronariana , Idoso , Cálcio , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2RESUMO
AIM: Coronary sinus (CS) reducer implantation is associated with symptomatic relief of patients with refractory angina. However, 15% to 30% of the patients do not respond to this treatment. Aim if this study was to evaluate the effect of CS size in the effectiveness of the device. METHODS: Prior to device implantation and at 4-month resting ventricular function was assessed by stress cardiac magnetic resonance. Ischemia was assessed by the myocardial perfusion reserve index (MPRI). RESULTS: Fifteen patients (66 ± 10 years) underwent successful CS Reducer implantation, with improvements in angina class and exercise tolerance. Patients with a smaller CS size (<5.8 mm) presented a significantly higher percentage increase in MPRI (63 ± 51 vs 9 ± 30%, P = .03) and a higher reduction in left ventricle end-diastolic volumes. CONCLUSIONS: Greater benefits, in terms of ischemia improvement, after CS Reducer implantation were seen in patients with smaller CS sizes, suggesting a potential mechanism underlying the observed rates of reducer non-responsiveness.
Assuntos
Seio Coronário , Angina Pectoris , Seio Coronário/diagnóstico por imagem , Tolerância ao Exercício , Humanos , Isquemia , Resultado do TratamentoRESUMO
BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread worldwide determining dramatic impacts on healthcare systems. Early identification of high-risk parameters is required in order to provide the best therapeutic approach. Coronary, thoracic aorta and aortic valve calcium can be measured from a non-gated chest computer tomography (CT) and are validated predictors of cardiovascular events and all-cause mortality. However, their prognostic role in acute systemic inflammatory diseases, such as COVID-19, has not been investigated. OBJECTIVES: The aim was to evaluate the association of coronary artery calcium and total thoracic calcium on in-hospital mortality in COVID-19 patients. METHODS: 1093 consecutive patients from 16 Italian hospitals with a positive swab for COVID-19 and an admission chest CT for pneumonia severity assessment were included. At CT, coronary, aortic valve and thoracic aorta calcium were qualitatively and quantitatively evaluated separately and combined together (total thoracic calcium) by a central Core-lab blinded to patients' outcomes. RESULTS: Non-survivors compared to survivors had higher coronary artery [Agatston (467.76 â± â570.92 vs 206.80 â± â424.13 âmm2, p â< â0.001); Volume (487.79 â± â565.34 vs 207.77 â± â406.81, p â< â0.001)], aortic valve [Volume (322.45 â± â390.90 vs 98.27 â± â250.74 mm2, p â< â0.001; Agatston 337.38 â± â414.97 vs 111.70 â± â282.15, p â< â0.001)] and thoracic aorta [Volume (3786.71 â± â4225.57 vs 1487.63 â± â2973.19 mm2, p â< â0.001); Agatston (4688.82 â± â5363.72 vs 1834.90 â± â3761.25, p â< â0.001)] calcium values. Coronary artery calcium (HR 1.308; 95% CI, 1.046-1.637, p â= â0.019) and total thoracic calcium (HR 1.975; 95% CI, 1.200-3.251, p â= â0.007) resulted to be independent predictors of in-hospital mortality. CONCLUSION: Coronary, aortic valve and thoracic aortic calcium assessment on admission non-gated CT permits to stratify the COVID-19 patients in-hospital mortality risk.
Assuntos
COVID-19/mortalidade , COVID-19/fisiopatologia , Angiografia por Tomografia Computadorizada , Calcificação Vascular/mortalidade , Calcificação Vascular/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Doenças da Aorta/fisiopatologia , Valva Aórtica/diagnóstico por imagem , COVID-19/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/mortalidade , Pneumonia Viral/fisiopatologia , Pneumonia Viral/virologia , Valor Preditivo dos Testes , Estudos Retrospectivos , SARS-CoV-2 , Índice de Gravidade de Doença , Calcificação Vascular/diagnóstico por imagemRESUMO
BACKGROUND: Coronary sinus (CS) narrowing by reducer implantation has emerged as a safe and effective therapy for patients suffering from refractory angina. However, data regarding the clinical benefit of this treatment over time is lacking. METHODS: Patients undergoing successful reducer implantation were enrolled prospectively to clinical registries at three medical centers. Those with more than 2-years of follow-up were included in the present analysis. Peri-procedural data, data regarding adverse events, and current evaluation of angina severity (Canadian Cardiovascular Society [CCS] class) were collected. RESULTS: Overall, 99 consecutive patients (77% males, mean age 69.8 ± 9.4) with severe angina were enrolled between September 2010 and October 2017 and included in the present analysis. No procedure-related complications were recorded. During a median follow up time of 3.38 years (IQR 2.95-4.40), 15.1% of the patients died, 9% experienced myocardial infarction (MI) and 21% underwent percutaneous coronary intervention (PCI). Mean CCS class was 3.1 ± 0.5 at baseline, improved to 1.66 ± 0.8 at 1 year (p < .001), and remained low through 2-years and at last follow up (1.72 ± 0.8 and 1.71 ± 0.8, p > 0.5 for both, in comparison to 1 year). At baseline 91% of patients reported severe disabling angina (CCS class 3-4), at 1 year only 17.9% suffered from disabling angina, p < .001, and this portion remained low overtime (19% at last follow up). CONCLUSION: Long-term mortality of patients undergoing reducer implantation is similar to that reported for patients with stable coronary artery disease. The previously reported short-term efficacy of the reducer, reflected by significant improvement of angina symptoms, is maintained over time.
Assuntos
Seio Coronário , Intervenção Coronária Percutânea , Idoso , Angina Pectoris/diagnóstico , Angina Pectoris/terapia , Canadá , Seio Coronário/diagnóstico por imagem , Seio Coronário/cirurgia , Feminino , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an emerging alternative to re-do surgery. However, the challenge of coronary access (CA) following ViV-TAVR is a potential limitation as TAVR expands to younger lower-risk populations. OBJECTIVES: Using post-implantation computed tomography (CT) scans to evaluate the geometrical relationship between coronary ostia and valve frame in patients undergoing ViV-TAVR with the ACURATE neo valve. METHODS: Post-implant CT scans of 18 out of 20 consecutive patients treated with the ACURATE neo valve were analyzed. Coronary ostia location in relation to the highest plane (HP) (highest point of the ACURATE neo or surgical valve) was determined. Ostia located below the highest plan were further subclassified according to the gap available between the transcatheter heart valve frame and ostium (transcatheter-to-coronary [TTC] distance). The impact implantation depth has on these geometrical relationships was evaluated. RESULTS: A total of 21 out of 36 coronary ostia (58%) were located below the level of the HP with the left coronary artery (36%) more likely to be affected than the right (22%). Further sub-classification of these ostia revealed a large (>6 mm), moderate (4-6 mm), and small (<4 mm) TTC distance in 57% (12/21), 38% (8/21), and in 6% (1/18) of cases, respectively. At an implantation depth <4 mm compared to >4 mm, all ostia were located below the HP with no difference in post-procedural mean gradients (14.5 mmHg ± 4.7 vs. 12.6 mmHg ± 5.8; p = .5, 95%CI 3.8-7.5). CONCLUSIONS: CA following ACURATE neo implantation for ViV-TAVR could potentially be challenging in a significant proportion of patients and specific consideration should be given to the implantation depth.
Assuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Humanos , Desenho de Prótese , Tomografia , Tomografia Computadorizada por Raios X , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Previous randomized controlled trials demonstrated a higher rate of stent thrombosis with bioresorbable vascular scaffold (BVS) implantation as compared with second-generation drug-eluting stent in selected patients/lesions. However, long-term outcomes of BVS implantations that utilize an optimized technique (OIT) in unselected patients/lesions are lacking. The aim of this study was to assess the real-world, long-term clinical outcomes of BVS (Absorb; Abbott Vascular) with OIT. METHODS AND RESULTS: In a cohort of 156 patients, a total of 347 BVS devices (435 lesions) were implanted, with intravascular ultrasound (IVUS) guidance utilized in 303 (87.3%) of the scaffolds. The primary efficacy endpoint was target-lesion revascularization (TLR) and the primary safety endpoint was scaffold thrombosis. Despite performing routine high-pressure postdilation, postintervention IVUS detected BVS underexpansion/malapposition in 53 scaffolds (28.7%), requiring further postdilation. At a median follow-up of 60 months (interquartile range, 45-73 months), TLR and scaffold thrombosis occurred in 16 patients (10.3%) and 1 patient (0.6%), respectively. At univariable analysis, IVUS-guided scaffold implantation was associated with lower TLR (odds ratio, 0.24; 95% confidence interval, 0.09-0.62; P<.01). CONCLUSION: The use of first-generation BVS with OIT in real-world patients/lesions was associated with acceptable long-term outcomes.
Assuntos
Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Implantes Absorvíveis , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos/efeitos adversos , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Desenho de Prótese , Alicerces Teciduais , Resultado do TratamentoRESUMO
Contrast-induced acute kidney injury (CI-AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)-and in general of all those examinations requiring iodinated contrast injection-which affects not only renal function but also long-term prognosis. While several prophylactic approaches were designed in order to prevent CI-AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre-procedural bicarbonate or N-acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero- or ultra-low-contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.
Assuntos
Injúria Renal Aguda , Intervenção Coronária Percutânea , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/prevenção & controle , Meios de Contraste/efeitos adversos , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Fatores de Risco , Resultado do TratamentoRESUMO
Coronary sinus (CS) Reducer implantation improves myocardial perfusion and symptoms in patients with debilitating refractory angina. Its impact on myocardial remodeling remain uncertain. Aim of the present study was to assess possible impact of CS Reducer on myocardial systolic-diastolic deformation and microstructural remodeling, as assessed through cardiac magnetic resonance (CMR) feature tracking and mapping analysis. Twenty-eight consecutive patients with refractory angina underwent multiparametric stress CMR before and 4 months after CS Reducer implantation. Eight patients were excluded (6 for absence of inducible ischemia, 2 for artifacts). Modifications in 3D systo-diastolic myocardial deformation were evaluated using feature tracking analysis on rest cine images. Myocardial microstructural remodeling was assessed by native T1 mapping, cellular and matrix volume and extracellular volume fraction (ECV). Collaterally, the percentage of ischemic myocardium (ischemic burden %) and the myocardial perfusion reserve index (MPRI) were measured. After CS Reducer implantation, myocardial contractility improved (ejection fraction rose from 61 to 67%; p = 0.0079), along with longitudinal (from - 16 to - 19%; p = 0.0192) and circumferential strain (from - 18 to - 21%; p = 0.0017). Peak diastolic radial, circumferential and longitudinal strain rate did not change (p > 0.05), and no changes in native T1, ECV, cellular and matrix volume were observed. Myocardial perfusion improved, with a reduction of ischemic burden (13-11%; p = 0.0135), and recovery of intramural perfusion balance in segments with baseline ischemia (MPRi endocardial/epicardial ratio from 0.67 to 0.96; p = 0.0107). CS Reducer improves myocardial longitudinal and circumferential strain, without microstructural remodeling and no impact on diastolic proprieties.
Assuntos
Angina Pectoris/diagnóstico por imagem , Angina Pectoris/terapia , Cateterismo Cardíaco/instrumentação , Circulação Coronária , Seio Coronário/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética , Imagem de Perfusão do Miocárdio , Idoso , Angina Pectoris/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Seio Coronário/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda , Remodelação VentricularRESUMO
Aortitis is an uncommon systemic inflammatory disease affecting the aorta and its main branches. Severe aortic regurgitation (AR) represents a fearsome complication of aortitis and is associated with an increased mortality rate. Surgical aortic valve replacement represents the only treatment choice for these patients. However, it is associated with a higher risk of medium to long-term complications such as prosthetic valve detachment. This is the first reported case where severe AR secondary to aortitis was managed with transcatheter aortic valve implantation (TAVI). TAVI was safe and effective in this clinical setting and may be considered a viable alternative to high-risk surgery in these complex patients.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Aortite , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Aortite/diagnóstico por imagem , Aortite/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVES AND BACKGROUND: Iatrogenic aorto-coronary dissection (ICD) is one of the most feared complications of interventional cardiology. Although rare, it is characterized by anterograde coronary ischemia and a concomitant aortic dissection, with potentially fatal consequences. METHODS: We present an example case of IACD and an accurate case-series review of the literature including 125 published cases. RESULTS: There were no significant predisposing factors and the IACD occurred equally in elective and urgent procedures. A significant number of IACDs were associated with CTO procedures. The factors associated with a worse outcome were hemodynamic instability, the presence of anterograde ischemia, and the extent of dissection according to the Dunning classification. Bail-out stenting was the most used strategy and its failure was associated with mortality. CONCLUSION: The main features of IACD are anterograde ischemia, retrograde dissection, and hemodynamic instability, each of them should be addressed with no time delay, possibly with bailout stenting, the most employed exit-strategy. According to our proposed algorithm, a shock team approach is required to coordinate the interdisciplinary skills and enabled patients to receive the best treatment.