RESUMEN
AIMS: To test a decision model for non-invasive estimation of left ventricular filling pressure (LVFP) in patients with left ventricular (LV) dysfunction and a wide range of ejection fractions (EF). METHODS AND RESULTS: In patients with LV dysfunction (n = 270; EF = 42 +/- 16%), classification and regression tree (CART) analysis was used to generate a model for the prediction of elevated LVFP, defined as pulmonary capillary wedge pressure (PCWP) >15 mmHg, in a derivation cohort (n = 178). At each step of the decision tree, nodes including single or multiple criteria connected by Boolean operators were tested to achieve the best information entropy gain. Averaged mitral-to-myocardial early velocities ratio (E/e') > or =13 OR E-wave deceleration time <150 ms was closely associated with elevated LVFP. Alternatively, prediction of PCWP >15 mmHg needed the following criteria to be satisfied: (i) intermediate E/e' (13 > E/e' > 8); (ii) left atrial volume index >40 mL/m(2) OR ratio of mitral E-wave and colour M-mode propagation velocity >2 OR difference in duration of pulmonary vein and mitral flow at atrial contraction >30 ms; (iii) estimated pulmonary artery systolic pressure >35 mmHg. Patients were correctly allocated according to PCWP with an 87% sensitivity and a 90% specificity. Compared with the best single parameter estimating LVFP, a 17% relative increase in accuracy was achieved in patients with EF >50%. The model was prospectively validated in a testing group (n = 92): 80% sensitivity, 78% specificity. CONCLUSION: This sequential testing is useful to non-invasively predict LVFP in patients with LV dysfunction, especially in those with preserved EF.
Asunto(s)
Ecocardiografía Doppler , Insuficiencia Cardíaca/patología , Ventrículos Cardíacos/patología , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular Izquierda , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Técnicas de Apoyo para la Decisión , Árboles de Decisión , Femenino , Insuficiencia Cardíaca/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Análisis de Regresión , Sensibilidad y Especificidad , Factores de Tiempo , Disfunción Ventricular Izquierda/patologíaRESUMEN
AIMS: It has been demonstrated that, in comparison with bare-metal stents (BMS), sirolimus-eluting stents (SES) reduce restenosis after the percutaneous revascularization of small coronary arteries, but the long-term clinical outcomes of this treatment have not yet been investigated. METHODS AND RESULTS: The long-term SES-SMART clinical study was a multicentre, prospective, randomized, single-blind study of 257 patients receiving a SES or BMS in a small coronary artery, who were evaluated at discharge, 30 days, 8 and 24 months after stenting. The clinical endpoint of the study was a 24 months composite of major adverse cardiac and cerebrovascular events, which included death, non-fatal myocardial infarction, ischaemia-driven target lesion revascularization (TLR), and cerebrovascular accident. The 24 months follow-up was completed by 254 patients (98.8%). The use of SES was associated with a significantly lower incidence of the clinical endpoint (12.6% vs. 33.1%; HR 0.30, 95% CI: 0.17-0.55; P < 0.0001), which was not only due to a reduction in TLR (7.9% vs. 29.9%; HR 0.30, 95% CI: 0.16-0.59; P < 0.0001), but also to a reduction in myocardial infarction (1.6% vs. 10.2%; HR 0.09, 95% CI: 0.01-0.66; P = 0.018). CONCLUSION: In comparison with BMS, the use of SES in the percutaneous revascularization of small coronary arteries is associated with improved clinical outcomes after 2 years follow-up.
Asunto(s)
Reestenosis Coronaria/terapia , Stents Liberadores de Fármacos , Sirolimus/administración & dosificación , Moduladores de Tubulina/administración & dosificación , Anciano , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/mortalidad , Reestenosis Coronaria/mortalidad , Muerte Súbita Cardíaca/etiología , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Infarto del Miocardio/mortalidad , Revascularización Miocárdica/mortalidad , Estudios Prospectivos , Factores de Riesgo , Método Simple Ciego , Resultado del TratamientoAsunto(s)
Enfermedad de la Arteria Coronaria/etiología , Enfermedades Vasculares Periféricas/etiología , Enfermedad de Tangier/complicaciones , Adulto , Aterosclerosis/etiología , Colesterol/metabolismo , Enfermedad de la Arteria Coronaria/patología , Humanos , Masculino , Tonsila Palatina/patología , Enfermedades Vasculares Periféricas/patología , Esplenomegalia , Enfermedad de Tangier/diagnósticoRESUMEN
BACKGROUND: Introduction of the modified Bentall procedure with the button technique has reduced but not eliminated anastomotic complications in patients receiving a composite aortic conduit. Particularly the true incidence of coronary ostial complications such as stenosis, kinking or pseudoaneurysm formation needs to be assessed. METHODS: We reviewed 71 patients receiving a composite aortic conduit from November 1993 to November 1999 for chronic aneurysms (n = 51) or aortic dissection (n = 20), 12 of whom had Marfan syndrome. Patients were divided into two groups according to variations in the surgical technique. In group 1 (30 patients; 42%) the classic modified Bentall operation with the button technique was employed whereas in group 2 (41 patients; 58%) some technical modifications were added mainly consisting of a reinforcement suture joining the cut edge of the aortic wall and the prosthetic sewing ring and suture of the coronary buttons with an "endo-button" technique. To detect potential procedure-related complications particularly at the coronary ostia anastomoses follow-up included transthoracic two-dimensional echocardiography every 6 months and computerized tomographic angiography at 12 months or whenever indicated; in 20 patients a magnetic resonance imaging angiography and standard aortography with selective coronary angiography were also added. RESULTS: At a mean follow-up of 49 +/- 19 months anastomotic complications occurred in 4 patients (6%): in 2 a pseudoaneurysm developed at the distal aortic suture line and in 1 a pseudoaneurysm developed at the right coronary ostium after repair of acute aortic dissection; in 1 Marfan patient an aneurysm of the left coronary ostium developed. Such complications were unrelated to the two surgical techniques used in this series for reimplantaion of the coronary ostia. CONCLUSIONS: The modified Bentall operation is associated with an extremely low incidence of anastomotic complications particularly at the coronary ostia. More extensive use of new imaging techniques is desirable to assess the true incidence of such complications in patients receiving a composite aortic conduit.