Comparison of computed tomography venography and intravascular ultrasound in screening and classification of iliac vein obstruction in patients with chronic venous disease.

OBJECTIVE: To investigate power of computed tomography venography (CTV) to identify and characterize iliac vein obstruction (IVO) compared with intravascular ultrasound (IVUS) examination in highly symptomatic patients with chronic venous disease (CVD). METHODS: CVD CEAP C3-6 limbs with visual analog scale for pain score of greater than 3 and/or Venous Clinical Severity Scale of greater than 8 were prospectively investigated with CTV and IVUS examination. The segment of maximum IVO was verified and categorically classified: group I, 0% to 49%; group II, 50% to 79%; and group III, 80% or greater. The CTV's screening power to detect the point and degree of maximum IVO was compared with IVUS. RESULTS: The CTV point of maximum IVO was 80% in the left limb, 10% in the right limb, 10% bilaterally; 2% in the inferior vena cava; 91% in the common iliac vein (CIV) confluence (41.6% below the CIV confluence, 34.5 at the CIV confluence, and 23.9% above the CIV confluence); 7% at the external iliac vein (kappa index 0.841; P < .001, when compared with IVUS). The distal venous segment considered free of obstruction was above inguinal ligament: 68% (CIV, 47%; external iliac vein, 21%) 32% below the inguinal ligament (common femoral vein, 26%; deep femoral vein, 6%) (kappa index 0.671; P = .023, when compared with IVUS). The power of CTV to detect an IVO of 50% or greater (groups II and III) when compared with IVUS achieved a sensitivity and specificity ratio of 94.0% and 79.2%, respectively. The positive predictive value was 94%, the negative predictive value was 79.1%, accuracy was 86.7% (kappa, 0.733), and interobserver agreement was 92.1% (95% confidence interval, 87.1-97.7; kappa, 0.899). CONCLUSIONS: CTV is a powerful screening method in determining the precise point of compression and classifying IVO in limbs with symptomatic CVD when compared with IVUS. The prevalence of an obstruction above the iliac vein confluence is significant and should be considered in iliac vein stenting treatment strategy. The tomographic classification system proposed here may help to define the optimum technique of treatment, prognosis, and comparison of outcome results.

Criteria for detecting significant chronic iliac venous obstructions with duplex ultrasound.

OBJECTIVE: The purpose of this study was to determine the sonographic criteria for diagnosis of iliac venous outflow obstruction by assessing the correlation of this method with intravascular ultrasound (IVUS) in patients with advanced chronic venous insufficiency (CVI). METHODS: The evaluation included 15 patients (30 limbs; age, 49.4 ± 10.7 years; 1 man) with initial CVI symptoms (Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] classification, CEAP1-2) in group I (GI) and 51 patients (102 limbs; age, 50.53 ± 14.5 years; 6 men) with advanced CVI symptoms (CEAP3-6) in group II (GII). Patients from both groups were matched by gender, age, and race. The Venous Clinical Severity Score was considered. All patients underwent structured interviews and duplex ultrasound (DU) examination, measuring the flow phasicity, the femoral volume flows and velocities, and the velocity and obstruction ratios in the iliac vein. The reflux multisegment score was analyzed in both groups. Three independent observers evaluated individuals in GI. GII patients were submitted to IVUS, in which the area of the impaired venous segments was obtained and compared with the DU results and then grouped into three categories: obstructions <50%, obstructions between 50% and 79%, and obstructions ≥80%. RESULTS: The predominant clinical severity CEAP class was C1 in 24 of 30 limbs (80%) in GI and C3 in 54 of 102 limbs (52.9%) in GII. Reflux was severe (reflux multisegment score ≥3) in 3 of 30 limbs (10%) in GI and in 45 of 102 limbs (44.1%) in GII (P < .001). There was a moderately high agreement between DU and IVUS findings when they were grouped into three categories (κ = 0.598; P < .001) and high agreement when they were grouped into two categories (obstructions <50% and ≥50%; κ = 0.784; P < .001). The best cutoff points and their correlation with IVUS were 0.9 for the velocity index (r = -0.634; P < .001), 0.7 for the flow index (r = -0.623; P < .001), 0.5 for the obstruction ratio (r = 0.750; P < .001), and 2.5 for the velocity ratio (r = 0.790; P < .001). Absence of flow phasicity was observed in 62.5% of patients with obstructions ≥80%. An ultrasound algorithm was created using the measures and the described cutoff points with accuracy of 86.7% for detecting significant obstructions (≥50%) with high agreement (κ = 0.73; P < .001). CONCLUSIONS: DU presented high agreement with IVUS for detection of obstructions ≥50%. The velocity ratio in obstructions ≥2.5 is the best criterion for detection of significant venous outflow obstructions in iliac veins.

Treatment of patients with aortic atherosclerotic disease with paclitaxel-associated lipid nanoparticles.

OBJECTIVE: The toxicity of anti-cancer chemotherapeutic agents can be reduced by associating these compounds, such as the anti-proliferative agent paclitaxel, with a cholesterol-rich nanoemulsion (LDE) that mimics the lipid composition of low-density lipoprotein (LDL). When injected into circulation, the LDE concentrates the carried drugs in neoplastic tissues and atherosclerotic lesions. In rabbits, atherosclerotic lesion size was reduced by 65% following LDE-paclitaxel treatment. The current study aimed to test the effectiveness of LDE-paclitaxel on inpatients with aortic atherosclerosis. METHODS: This study tested a 175 mg/m2 body surface area dose of LDE-paclitaxel (intravenous administration, 3/3 weeks for 6 cycles) in patients with aortic atherosclerosis who were aged between 69 and 86 yrs. A control group of 9 untreated patients with aortic atherosclerosis (72-83 yrs) was also observed. RESULTS: The LDE-paclitaxel treatment elicited no important clinical or laboratory toxicities. Images were acquired via multiple detector computer tomography angiography (64-slice scanner) before treatment and at 1-2 months after treatment. The images showed that the mean plaque volume in the aortic artery wall was reduced in 4 of the 8 patients, while in 3 patients it remained unchanged and in one patient it increased. In the control group, images were acquired twice with an interval of 6-8 months. None of the patients in this group exhibited a reduction in plaque volume; in contrast, the plaque volume increased in three patients and remained stable in four patients. During the study period, one death unrelated to the treatment occurred in the LDE-paclitaxel group and one death occurred in the control group. CONCLUSION: Treatment with LDE-paclitaxel was tolerated by patients with cardiovascular disease and showed the potential to reduce atherosclerotic lesion size.

[Left ventricular hypertrophy of athletes: adaptative physiologic response of the heart]. / Hipertrofia ventricular esquerda do atleta: resposta adaptativa fisiológica do coração.

OBJECTIVE: To verify whether left ventricular hypertrophy (LVH) of elite competition athletes (marathoners) represents a purely physiological, adaptative process, or it may involve pathological aspects in its anatomical and functional characteristics. METHODS: From November 1999 to December 2000, consecutive samples from 30 under 50-year-old marathoners in full sportive activity, with previously documented LVH and absence of cardiopathy were selected. They were submitted to clinical exams, electrocardiogram, color Doppler echocardiogram and exercise treadmill test (ETT). Fifteen were assorted to be also submitted to ergoespirometric test and heart magnetic resonance imaging (MRI). RESULTS: In ETT, all of them showed good physical pulmonary capacity, with no evidences of ischemic response to exercise, symptoms or arrhythmias. In Doppler echocardiogram, values of diameter and diastolic thickness of LV posterior wall, interventricular septum, LV mass and left atrium diameter, were significantly higher when compared to non-athlete control group, with similar ages and anthropometric measurements. The mean of LV mass of athletes indexed to body surface (126 g/m2) was significantly greater than the one in control group (70 g/m2) (p < 0.001). Magnetic resonance imaging (MRI) showed there was not impairment of contractile strength or LV performance, and values of end diastolic volume, end systolic volume and EF within limits of normality. On the other hand, average ventricular parietal mass, 162.93 +/- 17.90 g, and LV parietal thickness, 13.67 +/- 2.13 mm, at the end of diastole in athlete group, differed significantly from control group: 110 +/- 14.2 g (p = 0.0001) and 8 +/- 0.9 mm, respectively (p = 0.0001). The same happened to the thickness at the end of systole, which was 18.87 +/- 3.40 mm (control group: 10 +/- 1.80 mm, p = 0.0001). CONCLUSION: Results allowed for concluding that LVH in marathoners in full sportive activity period, assessed by non-invasive methods, represents an adaptative response to intensive and prolonged physical training, with purely physiological characteristics.

Primary coronary angioplasty in 9,434 patients during acute myocardial infarction: predictors of major in- hospital adverse events from 1996 to 2000 in Brazil.

OBJECTIVE: To verify the results after the performance of primary coronary angioplasty in Brazil in the last 4 years. METHODS: During the first 24 hours of acute myocardial infarction onset, 9,434 (12.2%) patients underwent primary PTCA. We analyzed the success and occurrence of major in-hospital events, comparing them over the 4-year period. RESULTS: Primary PTCA use increased compared with that of all percutaneous interventions (1996=10.6% vs. 2000=13.1%; p<0.001). Coronary stent implantation increased (1996=20% vs. 2000=71.9%; p<0.001). Success was greater (1998=89.5% vs. 1999=92.5%; p<0.001). Reinfarction decreased (1998=3.9% vs. 99=2.4% vs. 2000=1.5%; p<0.001) as did emergency bypass surgery (1996=0.5% vs. 2000=0.2%; p=0.01). In-hospital deaths remained unchanged (1996=5.7% vs. 2000=5.1%, p=0.53). Balloon PTCA was one of the independent predictors of a higher rate of unsuccessful procedures (odds ratio 12.01 [CI=95%] 1.58-22.94), and stent implantation of lower mortality rates (odds ratio 4.62 [CI=95%] 3.19-6.08). CONCLUSION: The success rate has become progressively higher with a significant reduction in reinfarction and urgent bypass surgery, but in-hospital death remains nearly unchanged. Coronary stenting was a predictor of a lower death rate, and balloon PTCA was associated with greater procedural failure.

A comparison of rescue and primary percutaneous coronary interventions for acute myocardial infarction: a multicenter registry report of 9,371 patients.

OBJECTIVE: To perform a comparative analysis of in-hospital results obtained from AMI patients who underwent rescue or primary PTCA. METHODS: From the Brazilian Interventional National Registry (CENIC), we selected all consecutive patients who underwent a percutaneous coronary intervention for myocardial infarction (< 24 hours), between 1997 and 2000, analyzing those undergoing a rescue (n=840) or a primary (n=8,531) procedure, and comparing their in-hospital results. RESULTS: Rescue patients were significantly younger males with anterior wall infarctions, associated with left ventricular dysfunction, but had less multivessel disease, compared with those treated with primary intervention. Coronary stents were implanted in at similar rates (56.9% vs. 54.9%; P=0.283). Procedural success were lower for rescue cases (88.1% vs. 91.2%; P<0.001), with higher mortality (7.4% vs. 5.6%; P=0.034), compared with the primary intervention group; target vessel revascularization (< or =0.5%), emergency bypass surgery (< or =0.3%) and reinfarction (< or =2.6%) rates were similar for both strategies. Multivariate analysis identified the rescue procedure as a predictor of in-hospital death [OR(CI=95%) = 1.60 (1.17-2.19); P=0.003]. CONCLUSION: Patients who underwent a rescue coronary intervention had higher in-hospital death rates compared with those who underwent a primary coronary intervention.

Analysis of the sensitivity and specificity of noninvasive imaging tests for the diagnosis of renal artery stenosis.

BACKGROUND: Aging and atherosclerosis are related to renovascular hypertension in elderly individuals. Regardless of comorbidities, renal artery stenosis is itself an important cause of cardiovascular morbidity and mortality. OBJECTIVE: To define the sensitivity, specificity, positive predictive value, and negative predictive value of noninvasive imaging tests used in the diagnosis of renal artery stenosis. METHODS: In a group of 61 patients recruited, 122 arteries were analized, thus permitting the definition of sensitivity, specificity, and the relative contribution of each imaging study performed (Doppler, scintigraphy and computed tomographic angiography in comparison to renal arteriography). RESULTS: The mean age was 65.43 years (standard deviation: 8.7). Of the variables related to the study population that were compared to arteriography, two correlated with renal artery stenosis, renal dysfunction and triglycerides. The median glomerular filtration rate was 52.8 mL/min/m². Doppler showed sensitivity of 82.90%, specificity of 70%, a positive predictive value of 85% and negative predictive value of 66.70%. For tomography, sensitivity was 66.70%, specificity 80%, positive predictive value 87.50% and negative predictive value 55.20%. With these findings, we could identify the imaging tests that best detected stenosis. CONCLUSION: Tomography and Doppler showed good quality and efficacy in the diagnosis of renal artery stenosis, with Doppler having the advantage of not requiring the use of contrast medium for the assessment of a disease that is common in diabetics and is associated with renal dysfunction and severe left ventricular dysfunction.

Uso racional dos exames diagnósticos em cardiologia / Rational use of diagnostic exams in cardiology

O cardiologista dispõe hoje de um amplo arsenal de exames diagnósticos, cada um baseado em diferentes princípios físicos e que tentam atender às necessidades da prática clínica. A falta de trabalhos comparativos entre eles em muitos cenários clínicos pode gerar incertezas quanto à real utilidade de cada um e pode levar à subutilização desses exames, mesmo quando eles são indicados, ou a seu emprego indiscriminado e exagerado. A ecocardiografia pode avaliar a função ventricular e a morfologia cardíaca em casos de cardiopatias congênitas, valvopatias e cardiomiopatias. A ressonância pode complementar esse exame e até ser o único método empregado em casos de coartação da aorta, bem como pode ter grande utilidade na identificação etimológica das cardiomiopatias. Já a medicina nuclear tem seu grande uso na identificação da isquemia miocárdica e a tomografia é fundamental no planejamento do tratamento percutâneo da estenose aórtica, assim como tem sido um exame de grande utilidade em diferentes estágios de doença coronariana. Este artigo tem o objetivo de rever as principais evidências disponíveis em cada condição clínica e apresentar uma sugestão do uso racional e eficaz dos exames de imagem em cardiologia

The cardiologist today has an extensive arsenal of diagnostic exams, each based on different physical principles, aimed at meeting the demands of clinical practice. The lack of comparative works on these exams in many clinical scenarios may generate uncertainties as to the real usefulness of each one, and can lead to their underuse, even when they are indicated, or to their indiscriminate and exaggerated use. Echocardiography can evaluate ventricular function and cardiac morphology in cases of congenital cardiopathies, valvopathies and cardiomyopathies. Magnetic resonance imaging can complement this exam, and may even be the only method used in cases of coarctation of the aorta. It may also be very useful in the etymological identification of cardiomyopathies. Nuclear medicine, meanwhile, is useful in identifying myocardial ischemia, and tomography is fundamental in the planning of percutaneous treatment of aortic stenosis, as well as having been a very useful exam in different stages of coronary disease. The aim of this article is to review the main evidence available in each clinical condition, and to present a suggestion for rational and effective use of imaging exams in cardiology

Avaliação da sensibilidade e especificidade dos exames não invasivos no diagnóstico da estenose de artéria renal / Analysis of the sensitivity and specificity of noninvasive imaging tests for the diagnosis of renal artery stenosis

FUNDAMENTO: O envelhecimento e a aterosclerose estão relacionados à hipertensão renovascular em indivíduos idosos. Independentemente das comorbidades, a estenose de artéria renal é, por si só, importante causa de morbidade e mortalidade cardiovascular. OBJETIVO: Definir a sensibilidade, a especificidade, o valor preditivo positivo e o valor preditivo negativo dos exames não invasivos utilizados no diagnóstico de estenose da artéria renal. MÉTODOS: Um grupo de 61 pacientes recrutados permitiram a análise de 122 artérias e a definição de sensibilidade, especificidade e da contribuição relativa de cada exame realizado (Doppler, cintilografia e angiotomografia, comparados a arteriografia renal). RESULTADOS: A média das idades foi de 65,43 (desvio padrão: 8,7) anos. Das variáveis relacionadas à população do estudo e comparadas à arteriografia, duas estiveram correlacionadas à estenose da artéria renal, à disfunção renal e aos triglicerídeos. A mediana do ritmo de filtração glomerular foi de 52,8 mL/min/m². O Doppler identificou sensibilidade de 82,90%, especificidade de 70%, valor preditivo positivo de 85% e valor preditivo negativo de 66,70%. Para a tomografia, encontraram-se sensibilidade de 66,70%, especificidade de 80%, valor preditivo positivo de 87,50% e valor preditivo negativo de 55,20%. Esses achados permitiram identificar os exames que melhor detectavam a estenose. CONCLUSÃO: A tomografia e o Doppler mostraram qualidade e grande possibilidade no diagnóstico de estenose da artéria renal, com vantagem para o segundo, pois não há necessidade do uso de meio de contraste na avaliação de uma doença que, frequentemente, ocorre em diabéticos e associa-se à disfunção renal e à disfunção ventricular esquerda grave.

BACKGROUND: Aging and atherosclerosis are related to renovascular hypertension in elderly individuals. Regardless of comorbidities, renal artery stenosis is itself an important cause of cardiovascular morbidity and mortality. OBJECTIVE: To define the sensitivity, specificity, positive predictive value, and negative predictive value of noninvasive imaging tests used in the diagnosis of renal artery stenosis. METHODS: In a group of 61 patients recruited, 122 arteries were analized, thus permitting the definition of sensitivity, specificity, and the relative contribution of each imaging study performed (Doppler, scintigraphy and computed tomographic angiography in comparison to renal arteriography). RESULTS: The mean age was 65.43 years (standard deviation: 8.7). Of the variables related to the study population that were compared to arteriography, two correlated with renal artery stenosis, renal dysfunction and triglycerides. The median glomerular filtration rate was 52.8 mL/min/m². Doppler showed sensitivity of 82.90%, specificity of 70%, a positive predictive value of 85% and negative predictive value of 66.70%. For tomography, sensitivity was 66.70%, specificity 80%, positive predictive value 87.50% and negative predictive value 55.20%. With these findings, we could identify the imaging tests that best detected stenosis. CONCLUSION: Tomography and Doppler showed good quality and efficacy in the diagnosis of renal artery stenosis, with Doppler having the advantage of not requiring the use of contrast medium for the assessment of a disease that is common in diabetics and is associated with renal dysfunction and severe left ventricular dysfunction.

Segurança e efetividade da enoxaparina versus heparina não-fracionada no tratamento de pacientes submetidos a implante eletivo de stents não-farmacológicos: resultados imediatos e tardios / Safety and efficacy of enoxaparin versus unfractionated heparin in patients undergoing elective percutaneous coronary intervention with bare-metal stent implantation: immediate and long-term clinical outcomes

A heparina não fracionada (HNF) é terapia anticoagulante clássica na intervenção percutânea, prevenindo complicações trombóticas agudas. Estudos sugerem que as heparinas de baixo peso molecular podem ser uma alternativa segura e eficaz. Objetivos: Avaliar a segurança e a efetividade da enoxaparina (ENO) versus HNF em pacientes tratado por intervenção percutânea eletiva nas fases hospitalar (FH) e tardia (FT). Método: No período de outubro a novembro de 2004, incluímos 57 pacientes consecutivos tratados com ENO 0,75 mg/kg (G2) versus grupo controle de 143 pacientes tratados com UI/kg (G1) nos três meses prévios. Todos receberam stents não-farmacológicos e foram pré-tratados com aspirina mais ticlopidina. Analisamos as complicações vasculares (CV) e hemorrágicas (CH) e os eventos combinados (EC) morte, infarto agudo do miocárdio (IAM), acidente vascular encefálico (AVE) e revascularização de urgência (RU) na FH e EC morte, IAM, AVE e nova revascularização na FT. No G2-ENO, mensuramos o fator anti-Xa 10 minutos após bolus EV e no fim da intervenção percutânea. Resultados: A média de idade foi de 59,8 mais ou menos 9,8 anos, 30 por cento eram diabéticos...

Background: Unfractionated heparin (UFH) is the classic anticoagulant therapy used during percutaneous intervention (PCI) to prevent acute thrombotic events. Preliminary studies with low molecular weight heparin have demonstrated the safety and efficacy of this alternative regimen during PCI. Our objective was to evaluate in-hospital and long-term safety and efficacy of enoxaparin (ENO) compared to UFH in patients (P) undergoing elective PCI. Methods: From 10/2004-11/2004, 57 P treated with ENO 0.75 mg/kg IV (G2) were enrolled and compared to a control group of 143 consecutive P treated with UFH 100 IU/kg IV (G1) during the preceding 3 months. All P received a baremetal stent and were pre-treated with ASA + ticlopidine. We analyzed the in-hospital vascular and bleeding complications as well as in-hospital and long-term composite clinical outcome of death, myocardial infarction (MI), stroke or target-vessel revascularization (TVR). Anti-Xa levels were measured in G2-ENO at the beginning (10 minutes after IV bolus) and at the end of PCI. Results: The mean age was 59.8 ± 9.8 years, 30% were diabetics, and clinical and angiographic characteristics were similar in both groups. Procedure success ocurred in 100% without in-hospital major bleedings nor vascular complications in both groups; a non-significant increase in minor bleedings in G2-ENO (p = 0.15) was observed and CKMB > 3x occurred in 2...

Tratamento do tromboembolismo pulmonar maciço por fragmentação percutânea do trombo / Treatment of massive pulmonary embolism by percutaneous fragmentation of the thrombus

OBJETIVOS: Avaliar a segurança e a eficácia da fragmentação percutânea do trombo (FPT) no tromboembolismo pulmonar (TEP) maciço em pacientes com contra-indicação à administração de trombolíticos. MÉTODOS: Entre julho de 1999 e agosto de 2005, 10 pacientes (7 homens, 3 mulheres, idade média de 57±18 anos) com TEP maciço e contra-indicação à administração de trombolíticos foram submetidos a FPT. A saturação arterial de oxigênio (Sat.O2), índice de Walsh (IW), pressão arterial pulmonar média (PAP), pressão arterial sistêmica média (PAS) e função ventricular direita (FVD) ao ecocardiograma Doppler transtorácico foram avaliados pré e pós-procedimento. Foi realizada análise estatística por meio do teste de Wilcoxon pareado, sendo p significativo quando < 0,05. RESULTADOS: Após o tratamento por FPT houve melhora da Sat. O2 [87,4±1,3 por cento vs 92,3±3,1 por cento (p<0,001)], do IW [6,4±1,07 vs 4,4±1,42 (p=0,003), PAP [31,8±4,6 mmHg vs 25,5±3,4 mmHg (p<0,001)] e PAS [73,9±8,7 vs 85±8,3 (p=0,001). A FVD pré-procedimento percutâneo era grave nos 10 pacientes, porém até o 10° dia após a FPT passou a ser normal ou discreta em 8 e moderada em 1. Não houve complicações técnicas ou do sítio vascular de acesso relacionadas a FPT. Houve 1 óbito hospitalar (10 por cento). O paciente em questão foi o único em quem não se obteve sucesso com o procedimento. CONCLUSÃO: A FPT mostrou-se segura pela ausência de complicações relacionadas ao procedimento. A melhora na Sat.O2, no IW, na PAP, na PAS e na FVD em 90 por cento dos casos, revelaram a eficácia do procedimento, sugerindo ser esse uma alternativa no tratamento do TEP maciço em pacientes com contra-indicação à trombolíticos sistêmicos.

OBJECTIVES: To evaluate the safety and efficacy of percutaneous thrombus fragmentation (PTF) for massive pulmonary embolism (PE) in patients with contraindications to the administration of thrombolytics. METHODS: Between July 1999 and August 2005, 10 patients (7 males, 3 females, age 57±18 years) with massive PE and contraindications to the administration of thrombolytics underwent PTF. A transthoracic doppler echocardiogram was used to evaluate arterial oxygen saturation (Sat O2), the Walsh index (WI), mean pulmonary artery pressure (PAP), mean systemic blood pressure (SBP) and right ventricular function (RVF) before and after the procedure. Statistical analysis was conducted using the paired Wilcoxon test, of which p was significant when < 0.05. RESULTS: After the PTF treatment there was an improvement in Sat. O2 [87.4 ± 1.3 percent vs 92.3 ± 3.1 percent (p < 0.001)], WI [6.4 ± 1.07 vs 4.4 ± 1.42 (p = 0.003)], PAP [31.8 ± 4.6 mmHg vs 25.5 ± 3.4 mmHg (p < 0.001)] and SBP [73.9 ± 8.7 vs 85 ± 8.3 (p = 0.001). The ten patients had severe RVF before the percutaneous treatment; however, within 10 days after PTF, 8 presented normal or discrete function and 1 presented mitigated function. There were no technical or vascular access site complications related to PTF. One patient died in the hospital (10 percent). The procedure was successful for the other nine patients. CONCLUSION: The lack of adverse complications related to the procedure, proves that PTF is safe. The improvement in Sat O2, WI, PAP, SBP and RVF in 90 percent of the cases demonstrates the efficacy of the procedure, indicating that it is an alternative treatment for massive PE in patients with contraindications for the administration of systemic thrombolytics.

Hipertrofia ventricular esquerda do atleta: resposta adaptativa fisiológica do coração / Left ventricular hypertrophy of athletes: adaptative physiologic response of the heart

OBJETIVO: Verificar se a hipertrofia ventricular esquerda (HVE) de atletas competitivos de resistência (maratonistas) representa processo adaptativo, puramente fisiológico, ou se pode envolver aspectos patológicos em suas características anatômicas e funcionais. MÉTODOS: De novembro de 1999 a dezembro de 2000, foram separados consecutivamente de 30 maratonistas em atividade esportiva plena, idade inferior a 50 anos, com HVE, previamente documentada, e sem cardiopatia subjacente. Foram submetidos aos exames: clínico, eletrocardiograma, ecodopplercardiograma, e teste ergométrico (TE). Quinze foram sorteados para realizar, também, teste ergoespirométrico e ressonância magnética (RM) do coração. RESULTADOS: Nos TE, todos apresentavam boa capacidade física cardiopulmonar, sem evidências de resposta isquêmica ao exercício, sintomas ou arritmias. No ecodopplercardiograma, os valores do diâmetro e espessura diastólica da parede posterior do ventrículo esquerdo (VE), do septo interventricular, massa do VE e diâmetro do átrio esquerdo, foram significativamente maiores que os do grupo de não atletas, com idades e medidas antropométricas semelhantes. A média da massa do VE dos atletas indexada à superfície corpórea (126 g/m2) foi significativamente maior que a do grupo controle (70 g/m2) (p<0,001). A RM mostrou que não havia prejuízo da força contrátil ou da performance ventricular esquerda e valores de volume diastólico final, volume sistólico final e fração de ejeção dentro dos limites da normalidade. Por outro lado, a massa do VE média, 162,93±17,90 g, e a espessura parietal ventricular, 13,67±2,13 mm, ao final da diástole no grupo atleta, diferiu significativamente do controle: 110±14,2 g (p=0,0001) e 8±0,9 mm, respectivamente (p=0,0001). O mesmo ocorreu na média da espessura ao final da sístole, que foi 18,87±3,40 mm (controle: 10± 1,80 mm, p=0,0001). CONCLUSAO: Os resultados permitiram concluir que a HVE de maratonistas em período de atividade esportiva plena, avaliada por métodos não invasivos, representa resposta adaptativa ao treinamento físico intensivo e prolongado, com características fisiológicas.

Tomografia computadorizada por múltiplos detectores: nova forma de avaluiaçäo da doença coronária / Multi-slice computed tomography: a new diagnostic techique for the detection of coronary artery disease

Diferentes técnicas têm por objetivo o diagnóstico de doença coronária, mas o imageamento näo-invasivo das artérias coronárias permanece como um desafio. Recentemente a tomografia computa-dorizada por múltiplos detectores, que tem resoluçäo temporal de até 125 ms, foi apresentada comoalternativa para essa finalidade. A experiência internacional vem crescendo no sentido de explorar aspotencial idades dessa técnica. No Hospital do Coraçäo, em Säo Paulo, esse método encontra-sedisponível desde abril de 2000, tendo sido avaliados 1.800 pacientes. Destes, 1.050 tinham comoobjetivo o estudo das artérias nativas e os outros 750, o estudo das pontes de safena e de artériasmamárias usadas como enxertos em cirurgias de revascularizaçäo do miocárdio. A taxa de imagensadequadas para o diagnóstico foi de mais de 85 por cento e nos 150 nos quais foi realizado estudo hemodinâ-mico existiu concordância de resultados em 92 por cento dos casos. As maiores limitações para esse examepermanecem a presença de arritmias, particularmente as arritmias ventriculares. Além disso, a utilida-de do exame para avaliar o resultado tardio de stents coronários ainda é debatida. A despeito disso,porém, a contribuiçäo clínica desse exame vem crescendo e novos desenvolvimentos tecnológicoscontribuiräo ainda mais para sua relevância clínica

Evoluçäo temporal com a utilizaçäo da angioplastia coronariana primária no infarto agudo do miocárdio no Brasil. Análise dos preditores de sucesso e dos eventos adversos hospitalares em 9.434 pacientes / Primary coronary angioplasty in 9, 434 patients during acute myocardial infarction: predictors of major in- hospital adverse events from 1996 to 2000 in Brazil

OBJECTIVE: To verify the results after the performance of primary coronary angioplasty in Brazil in the last 4 years. METHODS: During the first 24 hours of acute myocardial infarction onset, 9,434 (12.2 percent) patients underwent primary PTCA. We analyzed the success and occurrence of major in-hospital events, comparing them over the 4-year period. RESULTS: Primary PTCA use increased compared with that of all percutaneous interventions (1996=10.6 percent vs. 2000=13.1 percent; p<0.001). Coronary stent implantation increased (1996=20 percent vs. 2000=71.9 percent; p<0.001). Success was greater (1998=89.5 percent vs. 1999=92.5 percent; p<0.001). Reinfarction decreased (1998=3.9 percent vs. 99=2.4 percent vs. 2000=1.5 percent; p<0.001) as did emergency bypass surgery (1996=0.5 percent vs. 2000=0.2 percent; p=0.01). In-hospital deaths remained unchanged (1996=5.7 percent vs. 2000=5.1 percent, p=0.53). Balloon PTCA was one of the independent predictors of a higher rate of unsuccessful procedures (odds ratio 12.01 [CI=95 percent] 1.58-22.94), and stent implantation of lower mortality rates (odds ratio 4.62 [CI=95 percent] 3.19-6.08). CONCLUSION: The success rate has become progressively higher with a significant reduction in reinfarction and urgent bypass surgery, but in-hospital death remains nearly unchanged. Coronary stenting was a predictor of a lower death rate, and balloon PTCA was associated with greater procedural failure

Oclusäo de ramos secundários após angioplastia da artéria coronária descendente anterior / Occlusion of secondary branches after angioplasthy of the left descending coronary artery

Avaliar a incidência de oclusäo de ramos secundários em pacientes com lesäo única da artéria descendente anterior, em que a angioplastia coronária foi aplicada pela primeira vez e com sucesso. Duzentos e treze casos com ramos secundários em pacientes com lesäo única da ar considerados " em risco" por estarem envolvidos na lesäo (grupo I - GI; 85 casos - 39,9%); ou por terem sido atingidos pela insuflaçäo do baläo (grupo II - GII, 128 casos - 61,5%). Corresponderam a: GI - 54 ramos septais (S) e 31 ramos diaggonais (Dg), sendo que 36% tinham evidência angiográfica de doença ostial; GII - 77 S e 51 Dg, com 7,8% de doença ostial. Oclusäo de 7 (3,3%) ramos secundários " em "em risco", 4 (4,7%) do GI e 3 (2,3%) do GII. Na evoluçäo clínica destes 7 casos observaram-se angina de peito em 57% e alteraçöes isquêmicas discretas ao eletrocardiograma em 28.6%. Näo houve qualquer alteraçäo enzímica. A oclusäo foi clinicamente silenciosa em 43% dos casos. A oclusäo de ramos secundários é de baixa incidência, ocorre com maior freqüência nos septais, que nascem da lesäo e nos que têm doença ostial, sendo silenciosa em quase metade dos pacientes ou acompanhada de alteraçeos isquêmicas.

Purpose: To evaluate the incidence and clinical presentation of the occlusion of such secondary branches in patients with single vessel coronary artery disease in the left anterior descending artery, who underwent a first elective and successful PTCA. Material and Methods: Two hundred and thirteen side branches of 121 patients considered to be at risk. They were divided into group I (GI85 side branches, 39.9%), if they originated from the atherosclerotic site; and group II (GII120 side branches, 61.5%), if their origin would be involved during the balloon inflation. In the GI there were 54 septal branches and 3.1 diagonal branches, and 36& had angiographic evidence of ostium disease. GII was constituted by 77 septal and 51 diagonal branches, and 7.8% of them had evidence of ostium disease. Results: Seven side branches (3.3%) at risk occluded, 4 from GI (4.7%) and 3 (2.3%) from GII. As for the clinical presentation, 57% of them had angina, where as 28.6% showed minor abnormalities in the ECG. No patient elevated its serum CK-MB, and silent occlusion cccurred in 43% if them. Conclusion: Occlusion of side branches is a low incidence phenomenon, which happens more often in septal branches with ostium disease that originates from the atherosclerotic site; that about half of the patient had silent occlusion (43%) or mild ischemic manifestations

Angioplastia da artéria descendente anterior de origem anômala: aplicaçäo de novo cateter-baläo de baixo perfil; relato de caso / Angioplasty of anterior descending artery from anomalous origin: use of a new low profile catheter baloon: report of a case

Atualmente existe a possibilidade de se realizar angioplastia translumina coronaria em artérias de fino calibre e que apresentem lesöes distais graves. Isto se deve, entre outros fatores, à introduçäo de sistemas dilatadores dotados de inovaçöes tecnológicas que favorecem sua realizaçäo nestas e em outras circunstâncias. Nesta paciente o procedimento foi efetivado em uma artéria coronária com origem anômala e fino calibre, variedade anatômica rara e de acesso problemático à angioplastia, utilizando para tanto, cateter-baläo de baixo perfil do tipo Probe**TM, que apresenta características que diferenciam daqueles convencionalmente utilizados

It is possible to perform transluminal coronary angioplasty (TCA) in thin vessels presenting severe obstructions. One of the achievements that made such procedure possible is the development of a new generation of balloon catheters. In this case report the TCA was performed in a very thin left anterior descending artery with an anomalous origin, a quite rare situation that represents a major problem to the traditional dilator system. The catheter used was a ProbeTM (USCI), which differs of the traditional balloons in a number of characteristics. The authors consider the procedure in detail pointing out the advantages of using of the new generations and discuss the impact that newer technological developments will have in enlarging the indications for TCA and improving the results.

Angioplastia coronária: eficácia dos novos cateteres-baläo de baixo perfil / Coronary angioplasty: efficacy of the new low profile balloon catheter

Os novos cateteres-baläo de baixo perfil têm permitido a realizaçäo da angioplastia coronária (ATC) em lesöes mais complexas. O nosso estudo mostra a experiência inicial com estes novos sistemas em 50 (50%) de 101 pacientes submetidos à ATC entre 15 de março e 15 de maio de 1989 no Instituto Dante Pazzanese de Cardiologia. A idade média foi de 58,6 ñ 10,4 anos, com a maioria (75%) dos pacientes do sexo masculino. Cinqüenta e quatro lesöes foram dilatadas, e a doença uniarterial participou com 84% dos casos. Das lesöes nos vasos, 56% se encontravam nos terços médio ou distal e a média do grau de estenose pré-ATC era de 84 ñ 10,2%. A funçäo ventricular esquerda era normal em 60% dos pacientes. O índice de sucesso primário por paciente foi de 95% e a ultrapassagem das obstruçöes coronárias foi possível em todos os casos. O número médio de insuflaçöes foi de 2,7 ñ 0,6. As médias de pressäo máxima de insuflaçäo e de tempo máximo de insuflaçäo foram de 8 ñ 1,15 atm e 86,1 ñ 29,0 segundos, respectivamente. A lesäo residual média correspondeu a 15,2 ñ 10,6%. Em relaçäo às complicaçöes maiores, ocorreu apenas um episódio de infarto lateral. Cirurgias de emergências näo foram necessárias, assim como näo houve óbitos. Em conclusäo, estes novos cateteres-baläo permitiram ampliar o espectro de indicaçäo da ATC para lesöes mais complexas, com elevada taxa (95%) de sucesso primário, e baixo (2,5%) índice de complicaçöes

Angioplastia coronária de lesöes moderadas (50 a 60%) / Coronary angioplasty of moderate lesions (50 to 60%)

Objetivo - Avaliar a eficácia da angioplastia coronária em pacientes com lesöes moderadas (obstruçäo 50 a 60% da luz arterial). Material e Métodos - Cento e trinta e nove pacientes, sendo 108 (78%) homens, com idades média de 55 anos, submetidos à angioplastia coronária entre agosto de 1983 e janeiro de 1989. O quadro clínico era angina estável em 91 (65%) e angina instável em 48 (35%). Lesäo uniarterial foi observada em 117 pacientes (84%); os restantes 22 (16%) exibiam doença biarterial. Resultados - Obteve-se sucesso primário em 130 (94%) casos. Todos os pacientes biarteriais foram revascularizados de forma completa. Entre os insucessos, houve 2 (1,4%) casos de infarto do miocárdio e 4 (2,8%) de cirurgia de emergência. Näo houve óbitos hospitalares. Cento e dezenove (92%) dos com sucesso foram acompanhados tardiamente (média de 31 meses). Constatamos 85 (71%) assintomáticos e recidiva dos sintomas em 27 (23%). Houve 2 óbitos tardios de causa cardiovascular e 5 por doenças sistêmicas. Em 54 reestudos angiográficos, observamos em 42 (78%) manutençäo do resultado inicíal, e em 12 (22%) reestenose, em grau de obstruçäo médio mais severo que pré-angioplastia. Conclusäo - Angioplastia coronária de lesöes moderadas apresenta elevado percentual de sucesso primário (965); entretanto, os índices de complicaçöes maiores e reestenose assemelham-se aos observados para obstruçöes de grau severo, o que nos leva a reservar sua indicaçäo para os casos de alto risco clínico ou que apresentem evidências objetivas de isquemia miocárdica, apesar de terapêutica medicamentosa

Influência do quadro clínico nos resultados imediatos e tardios após aterectomia rotacional / Influence of the Clinical Presentation in Acute and Long-Term Results After Rotational Atherectomy

PURPOSE: To analyse the influence of unstable coronary syndromes (UCS) in the early and late prognosis after rotational atherectomy (RA). METHODS: We treated 236 patients with RA between Aug/1992 and May/1996. Patients were divided into two groups: A) stable coronary syndromes 120 (51) patients; B) UCS: 116 (49) patients. Definitions: 1) procedure success (PS)--lesion success in all locations were RA use was attempted, without a major complication; 2) late coronary events (LCE)--angina, MI, additional revascularization or death. RESULTS: There was a significant predominance of age > 70 (A = 14x B = 24, p = 0.03) in B and previous MI (A = 32x B = 11, p = 0.0001) in A. Other characteristics were similar in both groups, including complex lesions (type B2/C), which were observed in 77A stenosis and 80B lesions. PS was 95in A and 92in B (p = NS). In-hospital major complications were observed in 2.5A and 4.3B patients, (p = NS). One patient died in each group. A and B patients had similar time of follow-up. LCE occurred in 25A and 39B patients (p = 0.002). Recurrence of angina (36x 23; p = 0.01) and target lesion revascularization (29x 18; p = 0.03) were also more frequently required in B cases. CONCLUSION: This study suggests that UCS (group A) does not implicate in worse acute results after RA. However, UCS patients present greater incidence of late coronary events, particularly recurrence of angina and target-lesion revascularization.