RESUMO
The growth of the available transcatheter treatment approaches for the mitral and tricuspid position was accompanied by important clinical trials and studies through the last years. The selection of appropriate candidates for transcatheter techniques requires significant insight into anatomical limitations of each patient undergoing clinical evaluation. Furthermore, technological characteristics of the available devices, and risks and benefits of each potential therapy, play the most important role in a physician's decision. This knowledge should be valuable to both interventional cardiologists and researchers. This paper aims to offer a concise overview of the technological advances in this field of Interventional Cardiology. Trials and studies announced at the major interventional cardiology congresses during 2018 and 2019 were systematically reviewed. Moreover, a literature search in PubMed for the same period identified an amount of publications eligible for inclusion, based on their relevance to the subject, and their potential impact on current guidelines of good clinical practice.
Assuntos
Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Valva Aórtica , Previsões , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Valva Mitral , Valva Tricúspide/cirurgiaAssuntos
Estenose da Valva Aórtica/cirurgia , Bioprótese/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Valva Aórtica/cirurgia , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Desenho de Prótese/tendências , Falha de Prótese , Procedimentos Cirúrgicos sem Sutura/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: Cardiac allograft vasculopathy (CAV) is a leading cause of mortality in heart transplantation patients. Despite optimal immunosuppression therapy, the rate of CAV post-transplantation remains high. In this review, we gathered all recent studies as well as experimental evidence focusing on the prevention and treatment strategies regarding CAV after heart transplantation. MATERIALS AND METHODS: A complete literature survey was performed using the PubMed database search to gather available information regarding prevention and treatment strategies of CAV after heart transplantation. RESULTS: Several non-immune and immune factors have been linked to CAV such as ischemic reperfusion injury, metabolic disorders, cytomegalovirus infection, coronary endothelial dysfunction, injury and inflammation respectively. Serial coronary angiography combined with intravascular ultrasound is currently the method of choice for detecting early disease. Biomarkers and noninvasive imaging can also assist in the early identification of CAV. Treatment strategies such as mammalian target of rapamycin inhibitors proceed to grow, but prevention remains the objective. CONCLUSIONS: Early detection is the key to therapy management. It enables early identification and diagnosis of patients with CAV, who would gain the most from prompt treatment. Further investigation is needed to elucidate the multifactorial pathophysiological process of CAV, develop detection methods and find treatments that prevent or slow disease progression.
Assuntos
Angiografia Coronária/métodos , Doença da Artéria Coronariana/prevenção & controle , Transplante de Coração/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Aloenxertos/irrigação sanguínea , Aloenxertos/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/etiologia , Vasos Coronários/diagnóstico por imagem , Coração/diagnóstico por imagem , Humanos , Revascularização Miocárdica/métodos , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , ReoperaçãoAssuntos
Bioprótese/efeitos adversos , Implante de Prótese de Valva Cardíaca/tendências , Estenose da Valva Tricúspide/diagnóstico por imagem , Estenose da Valva Tricúspide/cirurgia , Idoso , Cateterismo Cardíaco/métodos , Ecocardiografia Transesofagiana/métodos , Feminino , Veia Femoral/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Desenho de Prótese/tendências , Falha de Prótese/etiologia , Resultado do Tratamento , Valva Tricúspide/fisiopatologiaRESUMO
Left main coronary artery aneurysms (LMCA) are usually asymptomatic and are rarely encountered during coronary angiography. The most serious complications include coronary thrombosis, acute myocardial infarction and sudden death. Atherosclerosis is the most common cause, although several autoimmune diseases and congenital abnormalities have been associated with the presence of coronary aneurysms. The case of a symptom-free 63-year-old man with a giant LMCA and severely ectatic coronary arteries is presented.
Assuntos
Aneurisma Coronário/diagnóstico , Aneurisma Coronário/tratamento farmacológico , Diagnóstico por Imagem/métodos , Inibidores da Agregação Plaquetária/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
The purpose of the paper is to define predictors of the kerma-area product (KAP) in percutaneous coronary intervention (PCI). Two new digital X-ray interventional cardiology systems recently installed were included. A total of 398 PCI procedures were carried out by 6 board-certified senior interventional cardiologists with more than 15 years' experience and good knowledge of radiation protection measures. Clinical, radiation and procedural data were collected based on a detailed protocol developed by the SENTINEL cardiology subgroup. Correlation with clinical and procedure factors was then investigated. A significant correlation was found between fluoroscopy time and (i) lesion classification, (ii) the level of tortuosity and (iii) the number of vessels treated. No statistically significant differences were observed in the complexity of the case between operators. However, large differences were found in the KAP among operators, which were mostly attributed to the different number of frames taken by each operator. There was no statistically significant correlation between complexity and the total number of frames. The study showed that, in certain circumstances, the clinical need to successfully perform PCI takes precedence over radiation safety concerns.
Assuntos
Angioplastia Coronária com Balão/métodos , Doença das Coronárias/terapia , Radiografia Intervencionista/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/patologia , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Doses de Radiação , Monitoramento de Radiação/métodos , Radiografia Intervencionista/instrumentaçãoRESUMO
The objective of this study was to investigate the patient and staff doses in the most frequent interventional cardiology (IC) procedures performed in Onassio, the largest Cardiac Centre in Greece. Data were collected from three digital X-ray systems for 212 coronary angiographies, 203 percutaneous transluminal coronary angioplasties (PTCA) and 134 various electrophysiological studies. Patient skin dose was measured using suitably calibrated slow radiotherapy films and cardiologist dose using suitably calibrated thermoluminescent dosemeters placed on left arm, hand and foot. Patient median dose area product (DAP) (all examinations) ranged between 6.7 and 83.5 Gy cm2. Patient median skin dose in PTCA was 799 mGy (320-1660 mGy) and in RF ablation 160 mGy (35-1920 mGy). Median arm, hand and foot dose to the cardiologist were 12.6, 27 and 13 microSv, respectively, per procedure. The great range of radiation doses received by both patients and operators confirms the need for continuous monitoring of all IC techniques.
Assuntos
Angioplastia Coronária com Balão/métodos , Cardiologia/normas , Angiografia Coronária/métodos , Doses de Radiação , Monitoramento de Radiação , Radiografia Intervencionista/métodos , Pele/efeitos da radiação , Angioplastia Coronária com Balão/estatística & dados numéricos , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Fluoroscopia/métodos , Fluoroscopia/normas , Grécia , Humanos , Controle de Qualidade , Dosimetria TermoluminescenteRESUMO
OBJECTIVE: The prevention of contrast-mediated nephropathy (CMN), which accounts for considerable morbidity and mortality, remains a vexing problem. Contrast induced renal vasoconstriction is believed to play a pivotal role in the CMN mechanism. The aim of this pilot study was to examine the safety and efficacy of two doses of the prostacyclin analogue iloprost in preventing CMN in high-risk patients undergoing a coronary procedure. METHODS: Forty-five patients undergoing coronary angiography and/or intervention who had a serum creatinine concentration >or=1.4 mg/dL were randomized to receive iloprost at 1 or 2 ng/kg/min or placebo, beginning 30-90 minutes before and terminating 4 hours after the procedure. CMN was defined by an absolute increase of serum creatinine >or=0.5 mg/dL or a relative increase of >or=25% measured 2 to 5 days after the procedure. Study drug infusion was discontinued in 2 patients in the low-dose iloprost group due to flush/nausea and in 5 patients in the high-dose group due to severe hypotension. RESULTS: The mean creatinine concentration change in the placebo group (0.02 mg/dL) was unfavorable compared to that in the low-dose iloprost group (-0.11 mg/dL; p=0.08) and high-dose iloprost group (-0.23 mg/dL; p=0.048). The difference between the absolute changes in creatinine clearance was favorable compared to placebo for both the low (mean difference 6.1 mL/min, 95%CI -0.5 to 12.8 mL/min, p=0.07) and the high-dose iloprost group (11.8 mL/min, 95%CI 4.7 to 18.8 mL/min, p=0.002). Three cases of CMN were recorded; all in the placebo group (p=0.032). CONCLUSIONS: The results of this pilot study suggest that prophylactic administration of iloprost may effectively prevent CMN, but higher dosages are connected with substantial tolerability issues.
Assuntos
Meios de Contraste/efeitos adversos , Angiografia Coronária , Iloprosta/uso terapêutico , Nefropatias/prevenção & controle , Vasodilatadores/uso terapêutico , Idoso , Creatinina/sangue , Feminino , Humanos , Nefropatias/etiologia , Masculino , Projetos Piloto , Fatores de RiscoRESUMO
The aim of this study was to investigate the use of an electronic personal dosemeter (EPD) worn by a senior cardiologist in an Interventional Cardiology (IC) Laboratory of a busy cardiac centre and how the results could help in the evaluation of radiation protection equipment used. Patient samples consist of 28 patients (10 coronary angiographies (CAs) and 18 percutaneous transluminal coronary angioplasties (PTCAs)). Patient dose was measured with a dose-area product (DAP) meter. Cardiologist radiation dose value written on the EPD as well as the protective equipment used was collected. Between patient and cardiologist dose, a significant correlation was found in CA and a moderate correlation in PTCA. Mean cardiologist effective dose E per procedure was found to be 0.2 microSv in CA and 0.3 microSv in PTCA. EPD proved to be an easy, direct and straightforward way to measure the radiation dose that the cardiologist receives in an IC laboratory.
Assuntos
Cardiologia , Análise de Falha de Equipamento/métodos , Exposição Ocupacional/análise , Radiologia Intervencionista , Radiometria/instrumentação , Medição de Risco/métodos , Angioplastia Coronária com Balão , Angiografia Coronária , Eletrônica Médica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medicina Nuclear , Saúde Ocupacional , Radiometria/métodos , Fatores de RiscoRESUMO
BACKGROUND: Tangier disease (TD) is the phenotypic expression of rare familial syndromes with mutations in the ABCA1 transporter. TD results in extremely low high density lipoprotein (HDL) cholesterol and reduced low density lipoprotein cholesterol, with normal or mildly increased fasting triglyceride (TG) concentrations. Although there is a close relation between HDL cholesterol values and atherogenesis, the risk of coronary artery disease is variable in TD. Raised fasting or postprandial TG values frequently accompany low HDL cholesterol and can add to the risk of a vascular event. AIMS: To investigate the postprandial TG response in TD. PATIENTS AND METHODS: Five patients (three homozygotes (HTD) and two heterozygotes (hTD)) from one family were studied. One was defined by DNA analysis as homozygous for a new mutation (C2033A) resulting in truncation of the ABCA1 protein. Their TG concentrations were measured before and four, six, and eight hours after a standardised fat load and compared with a control group. RESULTS: Two patients with HTD had high fasting TG concentrations. The third patient with HTD, the two with hTD, and the control group had TG concentrations within the reference range. The patients with HTD had increased postprandial peak TG values when compared with those with hTD and controls. CONCLUSION: Patients with HTD, with or without fasting hypertriglyceridaemia, may have an increased TG response to a fatty meal. The small number of patients does not allow definitive conclusions to be made. However, postprandial hypertriglyceridaemia could be a reason why some patients with TD develop premature atherosclerosis.
Assuntos
Hipertrigliceridemia/etiologia , Doença de Tangier/sangue , Adulto , Feminino , Homozigoto , Humanos , Masculino , Mutação/genética , Linhagem , Período Pós-Prandial , Doença de Tangier/genéticaRESUMO
In the measurement of coronary blood flow to determine the success of percutaneous coronary intervention, invasive techniques, coupled with plaque characterisation and other intracoronary imaging modalities, may prove invaluable.
Assuntos
Circulação Coronária/fisiologia , Velocidade do Fluxo Sanguíneo , Volume Sanguíneo , Angiografia Coronária/métodos , Reestenose Coronária/fisiopatologia , Previsões , Hemorreologia/métodos , Humanos , Reperfusão Miocárdica/métodos , Valor Preditivo dos Testes , Tomografia Computadorizada de Emissão/métodosRESUMO
BACKGROUND: Observational studies in selected patients have shown remarkably low restenosis rates after ultrasound-guided stent implantation. However, it is unknown whether this implantation strategy improves long-term angiographic and clinical outcome in routine clinical practice. Methods and Results-- A total of 550 patients with a symptomatic coronary lesion or silent ischemia were randomly assigned to either ultrasound-guided or angiography-guided implantation of =2 tubular stents. The primary end points were angiographic dichotomous restenosis rate, minimal lumen diameter, and percent diameter stenosis after 6 months as determined by quantitative coronary angiography. Secondary end points were the occurrence rates of major adverse cardiac events (death, myocardial infarction, coronary bypass surgery, and repeat percutaneous intervention) after 6 and 12 months of follow-up. At 6 months, repeat angiography revealed no significant differences between the groups with ultrasound- or angiography-guided stent implantation with respect to dichotomous restenosis rate (24.5% versus 22.8%, P=0.68), minimal lumen diameter (1.95+/-0.72 mm versus 1.91+/-0.68 mm, P=0.52), and percent diameter stenosis (34.8+/-20.6% versus 36.8+/-19.6%, P=0.29), respectively. At 12 months, neither major adverse cardiac events (relative risk, 1.07; 95% CI 0.75 to 1.52; P=0.71) nor repeat percutaneous interventions (relative risk 1.04; 95% CI 0.64 to 1.67; P=0.87) were reduced in the ultrasound-guided group. CONCLUSIONS: This study does not support the routine use of ultrasound guidance for coronary stenting. Angiography-guided optimization of tubular stents can be performed with comparable angiographic and clinical long-term results.
Assuntos
Implante de Prótese Vascular/métodos , Angiografia Coronária , Doença das Coronárias/cirurgia , Oclusão de Enxerto Vascular/prevenção & controle , Ultrassonografia , Implante de Prótese Vascular/instrumentação , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Risco , Stents , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: There are limited data regarding the immediate and long-term effect of balloon angioplasty on the coronary flow reserve evaluated in a multicentre setting. METHODS AND RESULTS: A total of 86 patients with one-vessel disease and normal left ventricular function were analysed before and after optimal balloon angioplasty (diameter stenosis <35%) and at 6-month follow-up. Coronary flow reserve was assessed with a Doppler guide wire. A low coronary flow reserve (
Assuntos
Angioplastia Coronária com Balão , Velocidade do Fluxo Sanguíneo/fisiologia , Vasos Coronários/fisiologia , Adulto , Fatores Etários , Idoso , Dor no Peito/diagnóstico por imagem , Dor no Peito/fisiopatologia , Dor no Peito/terapia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/fisiopatologia , Isquemia Miocárdica/terapia , Valor Preditivo dos Testes , Tempo , Resultado do Tratamento , Ultrassonografia DopplerRESUMO
Intracoronary irradiation emerges as a promising method in a variety of restenosis prone coronary lesions. We report the acute and long-term clinical, angiographic, and ICUS follow-up of a patient who underwent a successful angioplasty with stent placement in a chronic coronary occlusion with adjuvant gamma-intracoronary radiation.
Assuntos
Angioplastia Coronária com Balão , Braquiterapia/métodos , Doença das Coronárias/terapia , Stents , Ultrassonografia de Intervenção , Doença Crônica , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/radioterapia , Raios gama , Humanos , Masculino , Pessoa de Meia-Idade , Prevenção SecundáriaRESUMO
Stent prosthesis is a high efficacious method with low complication rates. However, the ideal adjunctive therapy following stent implantation remains controversial. The authors compared the effectiveness and complication rates of aspirin-ticlopidine antiplatelet therapy vs. anticoagulant therapy with acenocoumarol within 30 days following stent prosthesis. They prospectively studied 404 patients following stent prosthesis while randomly receiving anticoagulant (Group A: 201 patients) vs. antiplatelet treatment (Group B: 203 patients). Groups A and B were similar in demographic data (age, gender), stent location, clinical presentation, indication of stenting, and type of implanted stent. Chi-square test, t test, and Wilcoxon test for two samples were used for statistical analysis of the results. Stent implantation was attempted in 434 cases. This was successful in 70/85 (82%) of the bailout, 122/135 (90%) of the suboptimal, and 212/214 (99%) of the elective cases. In 201 patients anticoagulant treatment with acenocoumarol was administered for 4 weeks (group A), while 203 received antiplatelet treatment with ticlopidine (group B). The need for reintervention was less and total cardiac events were fewer in group B than in group A: three (1.5%) and nine (4.4%) vs 18 (9%) and 29 (14.4%), p<0.0008 and p<0.006 respectively. Hemorrhagic complications and total noncardiac events were fewer in group B than in group A: six (3%) and six (3%) vs. 18 (9%) and 19 (9.5%), p<0.01 and p<0.007 respectively. The length of hospital stay was shorter in group B than in A, p<0.0001. In conclusion, in this study of intracoronary stenting the authors had a high success rate in 434 attempted cases. Antiplatelet therapy was accompanied by fewer cardiac and noncardiac 1 month events when compared with anticoagulant therapy, supporting its role as the adjunctive treatment of choice post-stenting for the time being.
Assuntos
Acenocumarol/uso terapêutico , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Doença das Coronárias/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Stents , Ticlopidina/uso terapêutico , Idoso , Angina Pectoris/terapia , Angioplastia Coronária com Balão , Doença das Coronárias/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Estudos ProspectivosRESUMO
BACKGROUND: It has been shown recently that postangioplasty coronary flow reserve and the degree of residual stenosis have a modest predictive value for short- and long-term clinical outcomes after coronary angioplasty. Corrected TIMI frame count (CTFC) is a simple quantitative index of coronary blood flow. Its relationship with Doppler coronary flow velocity and clinical outcome after coronary angioplasty has not been fully clarified. The aim of this study was to identify clinical, angiographic, and functional predictors of clinical and angiographic restenosis after conventional coronary angioplasty. METHODS AND RESULTS: We studied 70 consecutive patients in whom intracoronary Doppler flow-velocity measurements were performed before and after angioplasty. Patients were evaluated for restenosis by clinical follow-up, exercise stress test/(201)Tl scintigraphy, and follow-up angiography, which was performed at 10. 5+/-10.3 months in 63 patients. According to the results of univariate analysis, a new index, postangioplasty CTFC/minimal luminal diameter (MLD) ratio, was created. Multivariate analysis revealed that CTFC/MLD ratio was the only independent predictor of angiographic (OR 2.02; 95% CI 1.37 to 2.97; P<0.0004) and clinical (OR 1.60; 95% CI 1.15 to 2.21; P<0.005) restenosis. The receiver operating characteristic curve area of this index was 79% for angiographic and 73% for clinical restenosis. The optimal CTFC/MLD ratio cutoff values were 7.88 for angiographic and 7.94 for clinical restenosis, respectively. CONCLUSIONS: Our data indicate that postangioplasty CTFC/MLD ratio, which incorporates both the angiographic and functional features of coronary lesions, is a reliable, objective, and inexpensive index for prediction of angiographic and clinical restenosis after conventional coronary angioplasty.