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BACKGROUND AND AIMS: Coronary flow capacity (CFC) is associated with an observed 10-year survival probability for individual patients before and after actual revascularization for comparison to virtual hypothetical ideal complete revascularization. METHODS: Stress myocardial perfusion (mL/min/g) and coronary flow reserve (CFR) per pixel were quantified in 6979 coronary artery disease (CAD) subjects using Rb-82 positron emission tomography (PET) for CFC maps of artery-specific size-severity abnormalities expressed as percent left ventricle with prospective follow-up to define survival probability per-decade as fraction of 1.0. RESULTS: Severely reduced CFC in 6979 subjects predicted low survival probability that improved by 42% after revascularization compared with no revascularization for comparable severity (P = .0015). For 283 pre-and-post-procedure PET pairs, severely reduced regional CFC-associated survival probability improved heterogeneously after revascularization (P < .001), more so after bypass surgery than percutaneous coronary interventions (P < .001) but normalized in only 5.7%; non-severe baseline CFC or survival probability did not improve compared with severe CFC (P = .00001). Observed CFC-associated survival probability after actual revascularization was lower than virtual ideal hypothetical complete post-revascularization survival probability due to residual CAD or failed revascularization (P < .001) unrelated to gender or microvascular dysfunction. Severely reduced CFC in 2552 post-revascularization subjects associated with low survival probability also improved after repeat revascularization compared with no repeat procedures (P = .025). CONCLUSIONS: Severely reduced CFC and associated observed survival probability improved after first and repeat revascularization compared with no revascularization for comparable CFC severity. Non-severe CFC showed no benefit. Discordance between observed actual and virtual hypothetical post-revascularization survival probability revealed residual CAD or failed revascularization.
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Doença da Artéria Coronariana , Humanos , Radioisótopos de Rubídio , Estudos Prospectivos , Tomografia por Emissão de Pósitrons/métodos , Angiografia Coronária/métodosRESUMO
OBJECTIVES: We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST-PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST-elevation myocardial infarction (STEMI). BACKGROUND: Current standard therapy for STEMI is PPCI. However, FAST-PCI may shorten ischemic time (IT) and improve outcomes. METHODS: Eligible STEMI patients received prehospital, reduced dose fibrinolysis along with standard therapy, and were transported for urgent percutaneous coronary intervention, or else they received usual treatment without prehospital fibrinolysis. Patients were divided retrospectively into four groups based on IT (<120, 120-179, 180-239 min, ≥240) for a mortality analysis cohort, and into three groups (<120, 120-179, ≥180 min) for a CMR analysis cohort. Within each IT group, patients were compared by FAST-PCI vs. PPCI strategy. RESULTS: Between 1/2007 and 2/2014, 1,112 STEMI patients were treated. FAST-PCI was employed in 551 and PPCI in 561. Of these, 357 (32.1%) underwent CMR. The treatment groups were well matched. In STEMI patients with short IT (<120 and 120-179 min groups), those treated by FAST-PCI had lower 30-day mortality and myocardial scar sizes compared with PPCI treatment. For IT ≥180 min, the mortalities and myocardial scar sizes were equivalent for both groups. CONCLUSIONS: In STEMI patients with IT <180 min, FAST-PCI may reduce 30-day mortality and myocardial scar size compared with PPCI. This suggests that infarct interventions must be instituted within 3 hr of symptom onset in order to detect an optimal beneficial effect both clinically and by CMR measurement. © 2016 Wiley Periodicals, Inc.
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Fibrinolíticos/administração & dosagem , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica/métodos , Relação Dose-Resposta a Droga , Eletrocardiografia , Feminino , Seguimentos , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Taxa de Sobrevida/tendências , Texas/epidemiologia , Fatores de TempoRESUMO
BACKGROUND: Current guidelines for ST-elevation myocardial infarction (STEMI) recommend early revascularization with optimal ischemic time (IT) < 120 min and door-to-balloon (D2B) time < 90 min. The focus of most studies has been D2B time, while IT is not frequently reported. We tested the hypothesis that total IT is a better predictor than D2B time for mortality and infarct size. METHODS AND RESULTS: Between December 2008 and April 2013, 786 patients with STEMI were treated in our STEMI center, and 262 of these had cardiac magnetic resonance imaging 3-5 days after the index event. Total IT was defined as time from symptom onset to device activation, while D2B time was defined as hospital arrival to device activation. Patients were divided into three groups according to IT (<120, 120-239, ≥240 min) and into four groups according to D2B time (<30, 30-59, 60-89, ≥90 min). Baseline demographics including age, cardiac risk factors, and LAD infarct location were similar between groups. The 30-day mortality rate significantly increased across IT groups but did not correlate with D2B time groups. Similarly, infarct size significantly increased across IT groups but did not correlate with D2B time groups. CONCLUSIONS: In STEMI patients, IT was a better predictor than D2B time for 30-day mortality and infarct size. Our findings suggest that the focus of STEMI care should be directed at early initiation of therapy and minimizing IT rather than on D2B time alone. The potential impact of IT reporting in current STEMI registries merits further consideration. © 2015 Wiley Periodicals, Inc.
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Angioplastia Coronária com Balão/mortalidade , Miocárdio/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tempo para o Tratamento , Adulto , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Bases de Dados Factuais , Feminino , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Texas , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this study was to evaluate safety, efficacy, and durability of coil embolization of the major septal perforator of the left anterior descending coronary artery in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: The long-term effect of coil embolization therapy in HOCM patients is not well defined. METHODS: We evaluated 24 symptomatic HOCM patients in a single center who underwent coil embolization of the septal perforator artery(ies). RESULTS: Twenty-four patients on optimal medical therapy presented with NYHA functional class III (75%) or IV (25%) underwent the procedure. The procedure was successful in 22 patients, with significant reduction in left ventricular outflow tract (LVOT) gradient. The functional class significantly improved to class I (54.2%) or II (41.7%) (P < = 0.01). The LVOT gradient was significantly lower during follow up echocardiography (21.3 ± 19 vs. 81.3 ± 41 mm Hg; P < = 0.01). Interventricular septal thickness decreased over time (16.3 ± 3 vs. 18.5 ± 2 mm, P< = 0.01). The procedure was aborted in one of the patients after the third coil prolapsed from the septal perforator in to the left anterior descending artery. The coil was effectively snared out. Three patients required additional coil placement in the second major septal perforator. New permanent pacemaker placement was required in one patient. However, three patients underwent ICD implantation at follow up due to ventricular arrhythmias. CONCLUSIONS: The results of this study suggest that the use of coil embolization for septal ablation is safe, effective, and durable in patients with symptomatic HOCM. © 2016 Wiley Periodicals, Inc.
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Cardiomiopatia Hipertrófica/cirurgia , Ablação por Cateter/métodos , Vasos Coronários/cirurgia , Embolização Terapêutica/instrumentação , Septos Cardíacos/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cardiomiopatia Hipertrófica/diagnóstico , Vasos Coronários/diagnóstico por imagem , Ecocardiografia , Desenho de Equipamento , Feminino , Septos Cardíacos/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do TratamentoRESUMO
Optical coherence tomography (OCT) is a novel intracoronary imaging modality that utilizes near-infrared light to provide information regarding lesion length and severity, vessel lumen diameter, plaque morphology, as well as the opportunity for stent procedure guidance and follow-up. While analogous to intravascular ultrasound (IVUS), the specific imaging properties, including significantly higher resolution, and technical specifications of OCT offer the ability for intracoronary diagnostic and interventional procedure guidance roles that require a thorough understanding of the technology. We provide coronary interventionalist's a user's guide to OCT, focusing on techniques and approaches to optimize imaging, with a focus on efficiency, safety and strategies for effective imaging.
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Estenose Coronária/diagnóstico , Radiografia Intervencionista/métodos , Stents , Tomografia de Coerência Óptica/métodos , Angioplastia Coronária com Balão/métodos , Cardiologia/normas , Estenose Coronária/terapia , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Radiografia Intervencionista/normas , Sensibilidade e Especificidade , Tomografia de Coerência Óptica/normasRESUMO
Objective: The objective of this study is to explore the role of adjunctive percutaneous revascularization of the hand in the management of patients with systemic sclerosis-associated refractory digital ischemia. Methods: We present our initial experience of using percutaneous upper extremity interventions to treat patients with systemic sclerosis and symptomatic Raynaud's phenomenon who presented with either refractory digital ischemia or non-healing ulcers. We discuss patient characteristics, procedural findings, and short-term clinical outcomes of these interventions. Results: We performed 14 interventions in 6 patients with non-healing digital ulcers or refractory ischemia secondary to systemic sclerosis. Angioplasty was performed at or below the wrist in conjunction with intravenous prostaglandin therapy, started prior to or immediately after the revascularization procedure. All patients experienced symptomatic relief and demonstrated accelerated wound healing. Two patients required an additional procedure to treat recurrent ischemia (without new ulceration) in the treated digit. Three of the patients underwent multiple procedures during the study period to treat new ischemic lesions or Raynaud's phenomenon symptoms, highlighting the progressive nature of the vascular occlusions in systemic sclerosis. There were no adverse events related to the interventions. Conclusions: Our retrospective analysis suggests that percutaneous revascularization in combination with vasodilator therapy in systemic sclerosis-associated digital ischemia is safe and can facilitate the healing of long-standing ulcers. Its role in the management of refractory digital ischemia in patients with systemic sclerosis should be explored further.
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The use of the Impella 2.5 liter (L) device for hemodynamic support has been well described. The typical access site for the Impella 2.5 L device is the femoral artery. The use of the axillary and subclavian artery has been described via surgical cut down for the Impella 5 L device when femoral artery access is not possible. In patients with severe aortoiliac disease and difficult anatomy the femoral artery access for the Impella 2.5 L device is not feasible. We describe the successful percutaneous use of the Impella 2.5 L device for hemodynamic support via the left axillary artery in 2 patients undergoing high-risk PCI with concomitant severe aortoiliac disease.
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Arteriopatias Oclusivas/epidemiologia , Arteriopatias Oclusivas/terapia , Artéria Axilar , Cateterismo/métodos , Coração Auxiliar , Implantação de Prótese , Idoso , Angioplastia Coronária com Balão , Aorta/patologia , Artéria Axilar/anatomia & histologia , Humanos , Artéria Ilíaca/patologia , Masculino , Pessoa de Meia-IdadeRESUMO
We present the case of a young woman with systemic sclerosis (SSc) and refractory digital ulceration who was successfully treated with percutaneous revascularization of chronically occluded ulnar and radial arteries. To our knowledge, this is the first detailed report of limb salvage in SSc-induced hand ischemia in which contemporary endovascular techniques were used. (Level of Difficulty: Advanced.).
RESUMO
Acute kidney injury (AKI) is a common complication of percutaneous coronary interventions (PCI), and it is associated with increased morbidity, mortality, and healthcare costs. Post-PCI AKI is a major quality outcome measured by the National Cardiovascular Data Registry for hospitals that perform PCI. We report the experience of a large, tertiary center with high standardized, post-PCI AKI rates in which we implemented multilevel interventions that included: (1) a multidisciplinary education module for all personnel involved in care of patients undergoing cardiac angiography, (2) a standardized electronic medical record based preprocedure hydration protocol order set for patients undergoing cardiac angiography, and (3) a hydration task list to be completed by the care team the evening before the procedure or prior to admission. All this resulted in a constant decrease of the post-PCI AKI rates in remarkable magnitude, significantly stronger than the national tendency, demonstrating a center-specific behavior.
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Injúria Renal Aguda , Intervenção Coronária Percutânea , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/prevenção & controle , Angiografia Coronária , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Fatores de RiscoRESUMO
It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.
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Procedimentos Endovasculares/tendências , Mortalidade Hospitalar , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Injúria Renal Aguda/epidemiologia , Idoso de 80 Anos ou mais , Amputação Cirúrgica/estatística & dados numéricos , Angioplastia/tendências , Aterectomia/tendências , Endarterectomia/tendências , Feminino , Humanos , Masculino , Infarto do Miocárdio/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Risco , Stents , Acidente Vascular Cerebral/epidemiologia , Enxerto Vascular/tendências , Procedimentos Cirúrgicos Vasculares/tendênciasRESUMO
The impact of atrial fibrillation (AF) on clinical outcomes among patients with peripheral artery disease (PAD) who undergo limb revascularization procedures is not well understood. We aim to compare in-hospital outcomes for patients with and without AF who underwent limb revascularization. We identified patients with PAD aged ≥18 years that underwent limb revascularization using endovascular or surgical approaches in the National Inpatient Sample between 2002 and 2014. Multivariate logistic regression analysis was performed to examine in-hospital outcomes. A total of 2,283,568 patients underwent limb revascularization during the study duration and 294,469 (12.9%) had AF. Patients with AF were older (mean age 76.1 ± 10.0 years), more likely to be women and white, compared with non-AF group. Among patients who had surgical revascularization, AF was associated with a higher rates of in-hospital mortality (6.4% vs 2.5%, adjusted odds ratio [aOR]: 1.09 [95% confidence interval {CI}: 1.05 to 1.12]) and major amputation (5.2% vs 3.8%, aOR: 1.05 [95% CI: 1.02 to 1.08]), compared with non-AF group. Among patients who had endovascular intervention (EVI), AF was associated with a higher rates of in-hospital mortality (3.8% vs 1.6%, aOR: 1.29 [95% CI: 1.24 to 1.33]) and major amputation (5.2% vs 3.9%, aOR: 1.07 [95% CI: 1.04 to 1.10]), compared with non-AF group. Within study period, EVI utilization increased in patients with and without AF (Ptrend <0.001); whereas, surgical revascularization utilization decreased in patients with and without AF (Ptrend <0.001). In conclusion, among patients with PAD who undergo limb revascularization, AF appears to be associated with poor in-hospital outcomes.
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Fibrilação Atrial/complicações , Procedimentos Endovasculares/métodos , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Medição de Risco/métodos , Idoso , Fibrilação Atrial/epidemiologia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Doença Arterial Periférica/complicações , Doença Arterial Periférica/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
Studies have shown an association between left ventricular (LV) geometry and complex ventricular ectopic activity. Increased transmural dispersion of repolarization (TDR), which correlates to the interval from the peak to the end of the T wave (Tpe) on the surface electrocardiogram, is linked to ventricular tachyarrhythmias. The relation between LV geometry and TDR is unknown. The mean Tpe interval, measured from leads V(1) to V(3) of the surface electrocardiogram, was assessed in 300 patients (50% men) who had normal LV systolic function and QRS duration and were categorized into 3 equal groups, which were matched by age and gender, according to echocardiographically determined LV geometry (normal structure, concentric remodeling, and LV hypertrophy). The Tpe interval was corrected for the QT interval using Tpe/QTc and was compared among the 3 groups. Compared with those who had normal LV structure, the Tpe interval was significantly prolonged in those who had LV hypertrophy and significantly shortened in those who had concentric remodeling (p = <0.0001 for the 2 comparisons). Correcting for the QT interval using Tpe/QTc yielded similar results. Thus, TDR was increased in patients who had LV hypertrophy but decreased in concentric remodeling compared with those who had normal cardiac structure. Although LV hypertrophy represents a maladaptive geometric process that results in an unfavorable electrical substrate, concentric remodeling may represent a structural adaptation that has a more favorable electrical milieu.
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Eletrocardiografia , Hipertrofia Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Remodelação Ventricular , Arritmias Cardíacas/fisiopatologia , Ecocardiografia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: The left renal vein (LRV) entrapment syndrome is a rare condition. Here, we present a 22-year-old female presenting with recurrent nausea, vomiting, weight loss and evidence of the LRV compression by the superior mesenteric artery and the abdominal aorta. Hemodynamic assessment confirmed a pressure gradient of >3 mmHg between the LRV and the inferior vena cava. A self-expandable stent was then deployed in the LRV. Subsequent clinical follow-ups ensure full resolution of the patient's symptoms. METHODS: Multilingual search was performed in PubMed, Google scholar, Scielo, Korea Med and EMBASE with the medical subheadings "nutcracker syndrome", "nutcracker phenomenon" and "compression vein syndrome" from January 1983 to September 2013. RESULTS: Review of the literature exhibited a plethora of individual case reports (291 citations). Importantly, few retrospective case series [5] comprising a total of 157 patients included successful endovascular interventions. CONCLUSION: Endovascular therapy for nutcracker syndrome represents a safe and suitable treatment option, but prospective studies are needed to confirm these data.
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Aorta Abdominal/cirurgia , Síndrome do Quebra-Nozes/cirurgia , Veias Renais/cirurgia , Aorta Abdominal/diagnóstico por imagem , Procedimentos Endovasculares , Humanos , Masculino , Radiografia , Síndrome do Quebra-Nozes/diagnóstico , Estudos Retrospectivos , Risco , Adulto JovemRESUMO
BACKGROUND: Revascularization of the peripheral arteries remains technically challenging. By decreasing the volume of the atherosclerotic plaque, debulking procedures may confer superior primary patency after revascularization. AIMS: To assess the impact of atherectomy on primary patency rates at 12 months compared to balloon angioplasty and/or stent placement alone in patients with infrainguinal arterial disease. METHODS: A database search for "directional," "orbital," "rotational," and "laser atherectomy" in peripheral arterial disease (PAD) was performed. Studies were screened according to the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) critical appraisal tool and summarized by population, methodology, and outcomes (primary patency and major adverse events). RESULTS: Only two randomized studies were found. Most of the data were obtained from single-arm studies and registries. The primary patency with directional atherectomy approaches 60% at 12 months as a stand-alone technique, whereas orbital atherectomy in conjunction with balloon angioplasty and stenting achieved primary patency rates of 90%. Laser atherectomy is universally employed with balloon angioplasty and stenting for in-stent restenosis lesions with a primary patency rate of 64%. Although there are data for the safe use of rotational atherectomy, robust data to support its effectiveness are lacking. The combination of drug-coated balloons and atherectomy for the treatment of heavily calcified lesions in patients with critical limb ischemia is under evaluation. CONCLUSION: Despite the successful procedural outcomes reported in clinical registries, the available data do not support the use of atherectomy alone in PAD. Larger randomized controlled studies are warranted to define its role in contemporary endovascular practice.
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Aterectomia/métodos , Canal Inguinal/irrigação sanguínea , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/terapia , Grau de Desobstrução Vascular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão , Terapia Combinada , Bases de Dados Factuais , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do TratamentoAssuntos
Falso Aneurisma/complicações , Aneurisma Infectado/complicações , Aneurisma Aórtico/complicações , Ruptura Aórtica/etiologia , Tosse/etiologia , Tontura/etiologia , Hematoma/etiologia , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/microbiologia , Falso Aneurisma/cirurgia , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/microbiologia , Aneurisma Infectado/cirurgia , Antibacterianos/uso terapêutico , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/microbiologia , Aneurisma Aórtico/cirurgia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/cirurgia , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Hematoma/diagnóstico por imagem , Hematoma/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do TratamentoRESUMO
Off-label "double-wire" technique for closure of large-bore vascular access has been reported in the setting of percutaneous aortic valvuloplasty. We present 5 cases of high-risk percutaneous coronary intervention (HRPCI) supported by a 2.5 LP Impella assist device with 13 and 14 Fr size femoral access. Following successful HRPCI, vessel closure was complicated by unsuccessful deployment of a suture-mediated closure device. Subsequently, deployment of two successive collagen-based closure devices with a "double-wire" technique was performed. Our cases warrant further studies to test the feasibility of using double-closure device as an alternative for vessel closure when left ventricular assist devices are needed to support HRPCI.