RESUMO
BACKGROUND: Short-term outcome after percutaneous coronary intervention (PCI) has improved dramatically, but the association between clinical or angiographic characteristics and long-term outcome remains less well described. The SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) II score has been designed to overcome the limitations of the purely angiographic SYNTAX I score by including clinical parameters and comorbidities. It has not been tested extensively in "real-world" PCI patients, outside of randomized clinical studies. METHODS AND RESULTS: We identified unique patients undergoing PCI between January 1, 2011 and January 24, 2013 and followed for at least 60 days. We calculated the SYNTAX I and II scores for each patient and collected data at longest follow-up available for vital status, recurrent PCI, systolic heart failure, stroke, or Q-wave myocardial infarction. Cox proportional hazards regression was used to assess independent predictors of mortality. There were 831 patients followed for a mean of 4 years. The average age was 66 ± 10 years. Nearly 40% were women and 50% had diabetes mellitus. The mean follow-up interval was 4 years, during which 42 patients died (Kaplan-Meier rate, 4.3% [IQR, 3.0-6.2%]). The PCI-SYNTAX II score was significantly higher in patients who died than in survivors (43 ± 12 vs 32 ± 12, respectively; P<.001). The SYNTAX II score was the only variable associated with death at a mean follow-up of 4 years (hazard ratio per 1 point, 1.05 [95% confidence interval, 1.03-1.08]; P<.001). CONCLUSION: The SYNTAX II score, incorporating angiographic and clinical parameters, is a useful tool for risk stratification and prediction of 4-year mortality in "real-world" patients.
Assuntos
Stents Farmacológicos , Intervenção Coronária Percutânea , Sistema de Registros , Medição de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Idoso , Angiografia Coronária , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Injury to the coronary circulation during percutaneous interventions is an existent risk. One of these is coronary artery perforation that can have grave consequences. Fortunately, this is rare and overall there is a declining incidence of complications due to technological advances and extensive experience over time. Predictors of coronary artery perforation include the administration of glycoprotein IIb/IIIa inhibitors, the use of hydrophilic guide wires, and the use of noncompliant high-pressure intracoronary balloons. Complex coronary lesions and the presence of total chronic occlusion are additional risk factors. In this paper, we present a rare class III coronary artery perforation with spilling into the right ventricle. Our case exemplifies all the aforementioned risk factors for perforation. The perforation was successfully sealed with a polytetrafluoroethylene covered stent and the patient remained hemodynamically stable.
Assuntos
Vasos Coronários/lesões , Ventrículos do Coração/lesões , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/etiologia , Humanos , Politetrafluoretileno , Complicações Pós-Operatórias/terapia , Stents , Resultado do TratamentoRESUMO
This is a case of a 54-year-old female with a history of mechanical aortic valve replacement who presented in cardiogenic shock. Her primary care provider started her on rivaroxaban for anticoagulation therapy. An urgent transesophageal echocardiogram revealed a significant gradient and thrombosis on one leaflet of the valve that was immobile. Given that she was not a surgical candidate, she underwent thrombolysis. However, she later died due to complications from the thrombotic valve. The utility of target-specific oral anticoagulants has yet to be established in clinical practice.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Inibidores do Fator Xa/uso terapêutico , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Rivaroxabana/uso terapêutico , Trombose/etiologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Evolução Fatal , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Pessoa de Meia-Idade , Uso Off-Label , Terapia Trombolítica , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Resultado do TratamentoRESUMO
BACKGROUND: Cryoballoon ablation of atrial fibrillation (AF) involves successful electrical pulmonary vein isolation (PVI). Pulmonary vein (PV) ostial occlusion with cryoballoon is classically assessed using PV angiography. A pressure-guided technique to assess ostial occlusion has been evaluated in small cohorts with mixed results. We evaluated the efficacy of this pressure-guided PVI technique and its impact on reducing contrast and fluoroscopy time as compared to the traditional approach. METHODS: We evaluated patients with paroxysmal AF, who underwent cryoballoon PVI. Patients prior to January 20th, 2013 underwent confirmation of PV occlusion by angiography only. Patients ablated after this time had PV occlusion initially determined by pressure monitoring and further confirmed by contrast injection into the PV in most cases (Pressure-guided PVI). Differences in the volume of contrast used and fluoroscopy time were evaluated. RESULTS: 46 patients had pressure-guided PVI and29 patients had occlusion of PV confirmed by angiography alone. Pressure-guided PVI was 99.5% successful in ablating AF, which was non-inferior to traditional method of PV isolation. This technique used an average of 8cc of contrast and 21.5min of fluoroscopy time, which was significantly less than the contrast amount used, and fluoroscopy time with angiographic isolation of PV. CONCLUSION: Pressure-guided PVI is an effective method for cryoablation of AF. This method not only significantly reduces the volume of contrast used but also decreases the fluoroscopy without compromising the success of PVI.
Assuntos
Fibrilação Atrial/cirurgia , Criocirurgia/normas , Sistema de Condução Cardíaco/cirurgia , Guias de Prática Clínica como Assunto , Veias Pulmonares/cirurgia , Fibrilação Atrial/fisiopatologia , Criocirurgia/métodos , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pressão , Estudos Retrospectivos , Fatores de TempoRESUMO
Papillary muscle rupture is a rare, life-threatening post myocardial infarction mechanical complication. Without surgical intervention, prognosis is very poor. Clinicians need to recognize this complication early, as prompt therapy is crucial. We present a case of inferior ST elevation myocardial infarction complicated by posteromedial papillary muscle rupture resulting in severe acute mitral regurgitation (flail anterior mitral leaflet), acute pulmonary edema and cardiogenic shock. In our patient, a new mitral regurgitation murmur suggested this mechanical complication. Complete disruption of papillary muscle was visualized by transesophageal echocardiography. This case illustrates the importance of good physical examination for early diagnosis of papillary muscle rupture, so that life-saving treatment can be administered without delay.
Assuntos
Bioprótese , Ponte de Artéria Coronária/métodos , Ruptura Cardíaca Pós-Infarto , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Infarto Miocárdico de Parede Inferior , Insuficiência da Valva Mitral , Músculos Papilares , Idoso , Angiografia Coronária/métodos , Diagnóstico Precoce , Ecocardiografia Transesofagiana/métodos , Ruptura Cardíaca Pós-Infarto/complicações , Ruptura Cardíaca Pós-Infarto/diagnóstico , Ruptura Cardíaca Pós-Infarto/fisiopatologia , Humanos , Infarto Miocárdico de Parede Inferior/complicações , Infarto Miocárdico de Parede Inferior/diagnóstico , Infarto Miocárdico de Parede Inferior/fisiopatologia , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/fisiopatologia , Músculos Papilares/diagnóstico por imagem , Músculos Papilares/lesões , Exame Físico/métodos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Coronary artery stent fracture is a well described complication during percutaneous intervention, with rates ranging from 0.84 to 8.4 percent in first generation drug eluting stents. Complications of stent fractures usually present with symptoms of acute coronary syndrome or progressive angina days, months to years after initial implantation. We present a case of an acute stent fracture during post balloon dilation of an everolimus eluting stent at a critical stenosis junction of a saphenous vein graft to the first diagonal of the left anterior descending artery. A shorter oversized drug eluting stent was placed to cover the stent fracture with good angiographic results. To our knowledge, this is the first incidence in literature of an acute stent fracture in a saphenous vein graft.
Assuntos
Angina Instável , Angioplastia Coronária com Balão , Infarto Miocárdico de Parede Anterior/cirurgia , Ponte de Artéria Coronária , Stents Farmacológicos/efeitos adversos , Complicações Pós-Operatórias , Falha de Prótese , Reoperação/métodos , Idoso , Angina Instável/diagnóstico , Angina Instável/etiologia , Angina Instável/fisiopatologia , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/métodos , Angiografia Coronária/métodos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/instrumentação , Ponte de Artéria Coronária/métodos , Everolimo/uso terapêutico , Feminino , Humanos , Imunossupressores/uso terapêutico , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Falha de Prótese/efeitos adversos , Falha de Prótese/etiologia , Veia Safena/transplante , Resultado do TratamentoRESUMO
Takotsubo cardiomyopathy, also called "broken heart" syndrome or apical ballooning syndrome, is a reversible cardiomyopathy characterized by left ventricular dysfunction and ballooning of the left ventricular apex on imaging during systole. It predominantly occurs in post-menopausal women and is commonly associated with emotional or physical stress. Patients commonly present with chest pain and electrocardiographic evidence of ST segment elevation or T-wave-mimicking acute coronary syndrome, but with an absence of angiographic evidence of obstructive coronary disease. The exact cause is unknown, but potential contributors include catecholamine excess and sympathetic nervous system hyperactivity. There is no consensus on pharmacological treatment of takotsubo cardiomyopathy. Based on the suspected pathophysiology of the disease, adrenergic blockade using beta-blocker therapy is employed. Near complete resolution of left ventricular wall motion dyskinesis occurs in the majority of takotsubo cardiomyopathy patients within a month. Although the prognosis is generally favorable, there are reports of complications during the acute phase, including cardiogenic shock, pulmonary edema, ventricular tachycardia, apical thrombus formation, and death. This review article will briefly discuss the epidemiology, etiology, clinical features, diagnostic evaluation, and treatment of this condition.
Assuntos
Cardiomiopatia de Takotsubo , Humanos , Prognóstico , Fatores de Risco , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/epidemiologia , Cardiomiopatia de Takotsubo/etiologia , Cardiomiopatia de Takotsubo/terapiaRESUMO
Q fever is a zoonotic disease with a reservoir in mammals, birds, and ticks. Acute cases in human beings can be asymptomatic, or they can present with a flu-like illness, pneumonia, or hepatitis. Approximately 5% of cases progress to chronic Q fever. Endocarditis, the most typical manifestation of chronic Q fever, is usually associated with small vegetations that occur in patients who have had prior valvular damage or who are immunocompromised. We present what we think is the first reported case of superior mesenteric artery embolism from Q fever endocarditis of the aortic valve, in a 39-year-old woman who needed surgical embolectomy and subsequent aortic valve replacement.
Assuntos
Embolia/complicações , Endocardite Bacteriana/complicações , Infarto/etiologia , Rim/irrigação sanguínea , Artéria Mesentérica Superior , Febre Q/complicações , Adulto , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Embolia/diagnóstico , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/microbiologia , Feminino , Humanos , Infarto/diagnóstico , Febre Q/diagnóstico , Febre Q/microbiologia , Tomografia Computadorizada por Raios XRESUMO
Trans-catheter aortic valve replacement (TAVR) was approved by the U.S. Food and Drug Administration in 2012 for treatment of severe symptomatic aortic stenosis in non-surgical and high risk patients. Implementation of this complex procedure requires a comprehensive heart team approach. Rural demographics in the Midwest pose many challenges related to low volumes of operations both at institutional and individual levels, leading to serious concerns about the quality of care delivered in such a setting. We compared the TAVR data at the University of South Dakota Sanford Medical Center to the national registry with the aim of looking at differences in outcomes of this procedure in a rural setting.
Assuntos
Estenose da Valva Aórtica/cirurgia , População Rural , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Equipe de Assistência ao Paciente , Avaliação de Programas e Projetos de Saúde , South Dakota , Resultado do TratamentoAssuntos
Anticoagulantes/administração & dosagem , Varfarina/administração & dosagem , Administração Oral , Anticoagulantes/efeitos adversos , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Dieta , Humanos , Pirazóis/administração & dosagem , Pirazóis/efeitos adversos , Piridinas/administração & dosagem , Piridinas/efeitos adversos , Piridonas/administração & dosagem , Piridonas/efeitos adversos , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Tiazóis/administração & dosagem , Tiazóis/efeitos adversos , Varfarina/efeitos adversosRESUMO
Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure that affects women during the last month of pregnancy to the first five months after delivery. The disease occurs in about one in 1,000 births in the U.S. Risk factors include advanced age, multiparity, twin pregnancy, African origin, preeclampsia or preexisting hypertension, and severe anemia. Heart failure in PPCM is treated similarly to heart failure from other causes, bearing in mind the pregnancy and lactation status. In this review article, we discuss the background, etiology, clinical evaluation, treatment, and natural history of peripartum cardiomyopathy, with a major emphasis on treatment.
Assuntos
Cardiomiopatia Dilatada , Complicações Cardiovasculares na Gravidez , Transtornos Puerperais , Antagonistas Adrenérgicos beta/uso terapêutico , Anticoagulantes/uso terapêutico , Bromocriptina/uso terapêutico , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/diagnóstico , Cardiomiopatia Dilatada/etiologia , Cardiomiopatia Dilatada/terapia , Parto Obstétrico , Diuréticos/uso terapêutico , Agonistas de Dopamina/uso terapêutico , Cardioversão Elétrica , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Período Periparto , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico , Complicações Cardiovasculares na Gravidez/etiologia , Complicações Cardiovasculares na Gravidez/terapia , Transtornos Puerperais/diagnóstico , Transtornos Puerperais/etiologia , Transtornos Puerperais/terapia , Fatores de RiscoRESUMO
Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome (ACS) that tends to affect young females. Diagnosis is confirmed by a dissection flap that is seen on coronary angiogram in the absence of underlying coronary atherosclerosis. New techniques in intra-coronary imaging such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are useful in diagnosing SCAD. These techniques are helpful because SCAD is often associated with intra-mural hematoma within the vessel wall that would not be visualized on coronary angiography. Given the lack of randomized trials, most data on treatment of this relatively uncommon condition is controversial and based on expert opinion. Postpartum SCAD comprises a small subgroup of all patients presenting with SCAD.
Assuntos
Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/etiologia , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/diagnóstico por imagem , Período Pós-Parto , Doenças Vasculares/congênito , Síndrome Coronariana Aguda/cirurgia , Adulto , Angiografia Coronária , Anomalias dos Vasos Coronários/cirurgia , Diagnóstico Diferencial , Feminino , Humanos , Stents , Doenças Vasculares/complicações , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/cirurgiaAssuntos
Estenose da Valva Aórtica/terapia , Valva Aórtica , Cateterismo Cardíaco/efeitos adversos , Procedimentos Endovasculares , Implante de Prótese de Valva Cardíaca/efeitos adversos , Infarto da Artéria Cerebral Média/terapia , Embolia Intracraniana/terapia , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Biópsia , Cateterismo Cardíaco/métodos , Angiografia Cerebral , Ecocardiografia Transesofagiana , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/etiologia , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Angiografia por Ressonância Magnética , Masculino , Resultado do TratamentoRESUMO
Coronary artery disease (CAD) involving the left main (LM) artery has traditionally been considered an indication for coronary artery bypass surgery (CABG). With recent advances in the field of percutaneous coronary interventions (PCI), angioplasty and stenting of the unprotected' LM has been performed in patients at high surgical risk. This is a challenging intervention as a large area of myocardium is at risk during the procedure. Features that make it especially high risk are distal stenosis of this vessel and presence of coronary disease in other territories. Left ventricular assist devices need to be considered in these situations so as to minimize the risk involved. We present a case of a 90-year-old female with myocardial infarction who underwent complex angioplasty involving the distal LM and proximal left anterior descending (LAD) coronary artery, without left ventricular assist device or balloon pump support.
Assuntos
Vasos Coronários/cirurgia , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/métodos , Idoso de 80 Anos ou mais , Feminino , Humanos , Infarto do Miocárdio/fisiopatologiaRESUMO
Patients with permanent pacemaker or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of tricuspid regurgitation. However, the roles of cardiac rhythm and lead-placement duration in the development of severe tricuspid regurgitation are unclear. We reviewed echocardiographic data on 26 consecutive patients who had severe tricuspid regurgitation after permanent pacemaker or AICD placement; before treatment, they had no organic tricuspid valve disease, pulmonary hypertension, left ventricular dysfunction, or severe tricuspid regurgitation. We compared the results to those of 26 control subjects who had these same devices but no more than mild tricuspid regurgitation. The patients and control subjects were similar in age (mean, 81 ±6 vs 81 ±8 yr; P = 0.83), sex (male, 42% vs 46%; P = 0.78), and left ventricular ejection fraction (0.60 ±0.06 vs 0.58 ± 0.05; P = 0.4). The patients had a higher prevalence of atrial fibrillation (92% vs 65%; P=0.01) and longer median duration of pacemaker or AICD lead placement (49.5 vs 5 mo; P < 0.001). After adjusting for age, sex, and right ventricular systolic pressure by multivariate logistic regression analysis, we found that atrial fibrillation (odds ratio=6.4; P = 0.03) and duration of lead placement (odds ratio=1.5/yr; P = 0.001) were independently associated with severe tricuspid regurgitation. Out study shows that atrial fibrillation and longer durations of lead placement might increase the risk of severe tricuspid regurgitation in patients with permanent pacemakers or AICDs.
Assuntos
Fibrilação Atrial/terapia , Desfibriladores Implantáveis , Ecocardiografia Doppler em Cores/métodos , Marca-Passo Artificial , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Velocidade do Fluxo Sanguíneo , Feminino , Seguimentos , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/fisiopatologia , Humanos , Masculino , Valor Preditivo dos Testes , Prevalência , Prognóstico , Estudos Retrospectivos , Volume Sistólico , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/epidemiologia , Insuficiência da Valva Tricúspide/etiologia , Estados Unidos/epidemiologiaAssuntos
Implante de Prótese de Valva Cardíaca/efeitos adversos , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Complicações Pós-Operatórias/cirurgia , Falha de Prótese , Ecocardiografia , Ecocardiografia Doppler em Cores , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Reoperação , Técnicas de SuturaRESUMO
Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient regional wall motion abnormalities of the left ventricular apex or midventricle. Patients often present with chest pain or dyspnoea, ST-segment elevation, and minor elevations of cardiac enzyme levels. Takotsubo cardiomyopathy has been associated with severe emotional or physical stress such as severe burns, spinal cord injury, subarachnoid haemorrhage, and multiple traumas. We report a case of takotsubo cardiomyopathy in a 79-year-old woman with pulmonary embolism. Although pulmonary embolism has been listed as a potential cause of takotsubo cardiomyopathy, this is the first case reported with this association.
Assuntos
Embolia Pulmonar/complicações , Cardiomiopatia de Takotsubo/etiologia , Idoso , Feminino , Humanos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Cardiomiopatia de Takotsubo/diagnóstico , UltrassonografiaRESUMO
Pericardial cysts are most commonly located at the cardiophrenic angle or, rarely, in the posterior or anterior superior mediastinum. The majority of pericardial cysts are asymptomatic and are found incidentally. Symptomatic pericardial cysts present with dyspnoea, chest pain, or persistent cough. We describe four patients with symptomatic pericardial cysts who were treated with either echocardiographically guided percutaneous aspiration or video-assisted thoracoscopic surgery, or both; thoracotomy; or conservative therapy.