RESUMO
The question of whether to perform percutaneous PFO closure to reduce the risk of recurrent ischemic stroke has been a dilemma for many years. Recent randomized trials have shown the superiority of percutaneous closure compared to medical therapy for large shunts. The indication of PFO closure is based on a multidisciplinary decision involving neurologists, cardiologists and hemostasis specialists. Important points are: PFO anatomy, brain imaging, history of venous thromboembolism and potential thrombophilia. In addition, atrial fibrillation (AF) should systematically be excluded. The intervention is performed under fluoroscopic guidance alone or with additional echocardiographic guidance. The procedural complication rate is low. There is an increased incidence of AF after percutaneous closure compared with medical therapy.
De récentes données randomisées démontrent une supériorité de la fermeture percutanée du foramen ovale perméable (FOP) comparée au traitement médicamenteux lors de shunt de grande taille. La fermeture du FOP repose sur une décision multidisciplinaire lors d'un colloque entre neurologues, cardiologues et spécialistes de l'hémostase. Les points à considérer sont : l'anatomie du FOP, l'imagerie cérébrale, les antécédents de maladie thromboembolique veineuse et la recherche d'une thrombophilie. De plus, il faut systématiquement exclure la fibrillation auriculaire (FA). L'intervention se fait par un accès veineux fémoral sous guidance fluoroscopique seul ou avec également une guidance échocardiographique. Le taux de complications lors de la procédure est faible mais il existe une augmentation de l'incidence de FA après fermeture percutanée.
RESUMO
The post-graduate education course in general internal medicine - which leads to the accreditation as a specialist - is established by l'Institut Suisse de Formation médicale (ISFM), one of the organs of the FMH (Federatio Medicorum Helveticorum) in collaboration with the Swiss Society of General Internal Medicine (SSGIM). This program sets inter alia the necessary learning steps and defines which tools are efficient in monitoring the teaching program. The specific goals defined in the course are not, however, easily reached, specifically in the internal medicine services of hospitals that are subject to organisational constraints. This is strongly highlighted in the assessments made by residents during these training years. It, therefore, seems necessary to implicate the residents more actively in the definition of the goals of their training to maintain and continuously improve the quality of their post-graduate education.
Le programme de formation postgraduée en médecine interne générale, qui permet l'obtention du titre de spécialiste est établi par l'Institut suisse de formation médicale (ISFM), organe de la FMH (Fédération des médecins suisses) en collaboration avec la Société suisse de médecine interne générale (SSMIG). Celui-ci fixe notamment les étapes nécessaires de la formation et définit les outils permettant d'en évaluer la qualité. Toutefois, les objectifs spécifiques décrits ne sont pas toujours aisément atteignables, en particulier dans les services hospitaliers, pour des raisons notamment organisationnelles. Ceci ressort clairement des évaluations effectuées en cours de formation par les médecins assistants, et c'est pourquoi une implication plus active des médecins en formation dans l'organisation de la formation post-graduée en médecine interne paraît indispensable pour le maintien et l'amélioration de sa qualité.
Assuntos
Educação de Pós-Graduação em Medicina , Medicina Interna , Internato e Residência , Medicina Interna/educaçãoRESUMO
Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment for aortic valve disease, including low-risk patients. However, as TAVR usage increases, concerns about long-term durability and the potential for addition interventions have arisen. Transcatheter aortic valve (TAV)-in-TAV procedures have shown promise in selected patients in numerous registries, offering a less morbid alternative to TAVR explantation. In this review, the authors aimed to comprehensively review the experience surrounding TAV-in-TAV, summarize available data, discuss pre-procedural planning, highlight associated challenges, emphasize the importance of coronary obstruction assessment and provide insights into the future of this technique.
RESUMO
OBJECTIVES: The authors sought to compare the differential effects of ultrathin-strut and thicker-strut drug-eluting stents (DES) in patients with chronic (CCS) versus acute (ACS) coronary syndromes. BACKGROUND: Newest-generation ultrathin-strut DES reduce target lesion failure (TLF) compared with thicker-strut second-generation DES in patients undergoing percutaneous coronary intervention. METHODS: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing newer-generation ultrathin-strut (<70 µm) versus thicker-strut (≥70 µm) DES. Patients were divided based on baseline clinical presentation (CCS versus ACS). The primary endpoint was TLF, a composite of cardiac death, target vessel myocardial infarction, or clinically indicated target lesion revascularization (TLR). RESULTS: A total of 22,766 patients from 16 randomized controlled trials were included, of which 9 trials reported TLF rates in ACS patients. At a mean follow-up of 12.2 months, the risk of TLF was lower among patients treated with ultrathin-strut compared with thicker-strut DES (risk ratio [RR]: 0.85; 95% CI: 0.75-0.95; P = 0.006). The difference was driven by a lower risk of clinically-indicated TLR (RR: 0.75; 95% CI: 0.63-0.89; P < 0.001) among patients treated with ultrathin-strut DES. The treatment effect was consistent between patients presenting with CCS and ACS (relative RR: 0.97; 95% CI: 0.73-1.31; P for interaction = 0.854). In patients with ST-segment elevation myocardial infarction, TLF risk was lower among those treated with ultrathin- compared with thicker-strut DES (RR: 0.74; 95% CI: 0.54-0.99; P = 0.049). CONCLUSIONS: Ultrathin-strut DES reduce the risk of TLF compared with thicker-strut second-generation DES in patients undergoing percutaneous coronary intervention, a difference caused by a lower risk of ischemia-driven TLR. The treatment effect was consistent among patients with CCS and ACS.
Assuntos
Síndrome Coronariana Aguda , Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Implantes Absorvíveis , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/etiologia , Síndrome Coronariana Aguda/terapia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/terapia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Desenho de Prótese , Resultado do TratamentoRESUMO
BACKGROUND: Infective endocarditis with paravalvular abscess can be complicated by atrioventricular block (AVB), but junctional ectopic tachycardia (JET) has as yet never been described. CASE SUMMARY: A 68-year-old male recently admitted with Staphylococcal aureus endocarditis of his aortic valve bioprosthesis, presented with a regular tachycardia at 240 b.p.m. with a pre-existent right bundle branch block pattern. Haemodynamic collapse necessitated electrical cardioversion, following which high-grade AVB was observed. Multiple recurrences of the same tachycardia required repeated electrical cardioversions and emergent electrophysiological study, which indicated JET. The tachycardia was unresponsive to overdrive pacing, adenosine and intravenous amiodarone, and external cardioversions. Radiofrequency catheter ablation of the atrioventricular node was performed emergently with interruption of the tachycardia. A temporary external pacemaker was implanted via a jugular route. The tachycardia recurred after 48 h at a slower rate, and the patient underwent redo ablation. Transoesophageal echocardiography revealed a pseudoaneurysm of the right sinus of Valsalva probably corresponding to an evacuated abscess. A permanent pacemaker was implanted after active infection had been ruled out. At 3 months of follow-up, the patient had complete AVB, without arrhythmia recurrence. DISCUSSION: This is the first case report of JET complicating a paravalvular abscess of the aortic valve with concomitant AVB. Junctional ectopic tachycardia is very rare arrhythmia which is usually seen in children as a congenital arrhythmia or following surgical correction of paediatric heart disease. The differential diagnosis is discussed in detail in the article.