RESUMO
Physiologic assessment has become an essential tool to guide revascularization decisions due to the multiple limitations of angiographic and anatomic measures of physiologic significance. However, in certain cases the apparent physiologic measurement may not accurately reflect the severity of coronary disease compared with anatomical measurements. This article will review how anatomy trumps physiology in cases of acute coronary syndromes, left main disease, saphenous vein graft lesions, and myocardial bridging, and how to overcome the limitations of physiologic measurement in these clinical situations.
RESUMO
PURPOSE OF REVIEW: Multivessel coronary artery disease, defined as significant stenosis in two or more major coronary arteries, is associated with high morbidity and mortality. The diagnosis and treatment of multivessel disease have evolved in the PCI era from solely a visual estimation of ischemic risk to a functional evaluation during angiography. This review summarizes the evidence and discusses the commonly used methods of multivessel coronary artery stenosis physiologic assessment. RECENT FINDINGS: While FFR remains the gold standard in coronary physiologic assessment, several pressure-wire-based non-hyperemic indices of functional stenosis have been developed and validated as well as wire-free angiographically derived quantitative flow ratio. Identifying and treating functionally significant coronary atherosclerotic lesions reduce symptoms and major adverse cardiovascular events. Coronary physiologic assessment in multivessel disease minimizes the observer bias in visual estimates of stenosis, changes clinical management, and improves patient outcomes.
Assuntos
Doença da Artéria Coronariana , Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Constrição Patológica , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Valor Preditivo dos TestesRESUMO
Outcomes of deferred PCI based on negative FFR are generally good. This study demonstrated deferred target lesion failure with FFR >0.80 in 7% and related it to coexistent risk factors, such as multivessel disease, diabetes, and SVG lesions. A negative FFR is only one variable on the continuum of ischemic risk, but in general provides an excellent prognostic tool.
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Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Humanos , Revascularização Miocárdica , Intervenção Coronária Percutânea/efeitos adversos , Prognóstico , Resultado do TratamentoRESUMO
The present article examines the right heart (RH) pressures of patients with submassive pulmonary embolism before and after catheter-directed thrombolysis (CDT). 40% of patients had a low cardiac output (CI ≤1.8 L/min/m2 ) despite normally preserved blood pressure. After thrombolysis, CI increased and pulmonary artery pressures decreased. Although routine RH pressure measurements may help in CDT management and possibly serve as a surrogate outcome measure, more comprehensive pulmonary embolism trials are needed to solidify the role of hemodynamics in this setting.
Assuntos
Embolia Pulmonar , Terapia Trombolítica , Catéteres , Hemodinâmica , Humanos , Resultado do TratamentoRESUMO
Angiographically visible collaterals are seen in a minority of STEMI patients, predominantly to the RCA and in patients with delays to reperfusion. Patients with visible collaterals were less likely to have cardiogenic shock and tended to have a longer survival. Further studies will determine the mechanisms of collateral formation and their protective associations.
Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST , Circulação Colateral , Circulação Coronária , Vasos Coronários , Humanos , Prognóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Resultado do TratamentoRESUMO
The axillary artery is a useful alternative access site for large-bore interventions as it is rarely atherosclerotic. This systematic review of percutaneous large-bore axillary artery access suggests that it is as safe and effective as open surgical access. The Society of Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement will soon be convened to provide best practice recommendations on transaxillary access including technique, training, and safety.
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Artéria Axilar , Axila , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/cirurgia , Humanos , Resultado do TratamentoRESUMO
This study compared virtual (residual) post-PCI QFR and actual post-PCI QFR from pre- and post-stent angiograms in predicting post-PCI FFR. While there was no difference in mean values, compared with post-PCI FFR, the post-PCI QFR correlated better than residual QFR. As the CFD algorithms improve, post-PCI QFR can potentially serve as a quality control after PCI to reduce post-PCI angina and adverse outcomes.
Assuntos
Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Angiografia Coronária , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Valor Preditivo dos Testes , Stents , Tomografia de Coerência Óptica , Resultado do TratamentoRESUMO
The intraaortic balloon pump (IABP) provides counterpulsation by displacing a 40-50 cc blood volume during diastole augmenting diastolic pressure. The rapid deflation of the balloon timed to the initiation of systole reduces the afterload of ventricular ejection and thus peak systolic pressure. As a direct result, IABP increases mean arterial pressure (MAP) and peak diastolic pressure while reducing systolic pressure and myocardial work. IABP increases coronary flow velocity in non-obstructed vessels, but does not increase flow across a severe obstruction as shown by intracoronary Doppler flow studies (Kern et al., Circulation, 1993;87:500-511 and Kern et al., Circulation 1991;84:II-485). There are few studies using pressure sensor guidewires to confirm these responses. We present a case illustrating the translesional hemodynamics using an angioplasty sensor pressure wire across a severe stenosis and the unique influence of the IABP.
Assuntos
Angioplastia Coronária com Balão , Estenose Coronária/terapia , Reserva Fracionada de Fluxo Miocárdico , Insuficiência Cardíaca/terapia , Hemodinâmica , Balão Intra-Aórtico , Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Estenose Coronária/diagnóstico , Estenose Coronária/fisiopatologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Transdutores de Pressão , Resultado do TratamentoRESUMO
Compressive pericardial physiology (i.e., cardiac tamponade) reduces ventricular chamber volume/filling and cardiac output, which exacerbates coexisting hemodynamic derangements. In this hemodynamic rounds, we demonstrate the interaction of two hemodynamic conditions in one patient with acute pericardial tamponade in the setting of aortic stenosis (AS). Simultaneous pressures across the aortic valve before and after relief of cardiac tamponade demonstrate an acute and uncommon improvement in the hemodynamics of AS.
Assuntos
Estenose da Valva Aórtica/fisiopatologia , Valva Aórtica/fisiopatologia , Tamponamento Cardíaco/fisiopatologia , Hemodinâmica , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Tamponamento Cardíaco/complicações , Tamponamento Cardíaco/diagnóstico por imagem , Tamponamento Cardíaco/terapia , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Pericardiocentese , Recuperação de Função Fisiológica , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
Transradial angiography and intervention continues to become increasingly common as an access site for coronary procedures. Since the first "Best Practices" paper in 2013, ongoing trials have shed further light onto the safest and most efficient methods to perform these procedures. Specifically, this document comments on the use of ultrasound to facilitate radial access, the role of ulnar artery access, the utility of non-invasive testing of collateral flow, strategies to prevent radial artery occlusion, radial access for primary PCI and topics that require further study.
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Cateterismo Cardíaco/normas , Cateterismo Periférico/normas , Angiografia Coronária/normas , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea/normas , Artéria Radial/diagnóstico por imagem , Ultrassonografia de Intervenção/normas , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/prevenção & controle , Benchmarking , Cateterismo Cardíaco/efeitos adversos , Cateterismo Periférico/efeitos adversos , Consenso , Angiografia Coronária/efeitos adversos , Doença da Artéria Coronariana/fisiopatologia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Valor Preditivo dos Testes , Artéria Radial/fisiopatologia , Fatores de Risco , Resultado do Tratamento , Artéria Ulnar/diagnóstico por imagem , Ultrassonografia de Intervenção/efeitos adversos , Grau de Desobstrução Vascular , VasoconstriçãoRESUMO
The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly infectious, carries significant morbidity and mortality, and has rapidly resulted in strained health care system and hospital resources. In addition to patient-related care concerns in infected individuals, focus must also relate to diminishing community spread, protection of staff, case selection, and concentration of resources. The current document based on available data and consensus opinion addresses appropriate catheterization laboratory preparedness for treating these patients, including procedure-room readiness to minimize external contamination, safe donning and doffing of personal protective equipment (PPE) to eliminate risk to staff, and staffing algorithms to minimize exposure and maximize team availability. Case selection and management of both emergent and urgent procedures are discussed in detail, including procedures that may be safely deferred or performed bedside.
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Cateterismo Cardíaco/estatística & dados numéricos , Angiografia Coronária/estatística & dados numéricos , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto/normas , COVID-19 , Cateterismo Cardíaco/normas , Cardiologia , Angiografia Coronária/métodos , Infecções por Coronavirus/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Laboratórios Hospitalares , Liderança , Masculino , Mentores , Pandemias/estatística & dados numéricos , Equipamento de Proteção Individual/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Sociedades Médicas , Análise de Sobrevida , Estados UnidosRESUMO
The society for cardiovascular angiography and interventions (SCAI) think tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community for high-level field-wide discussions. The 2020 think tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease (CHD). Each session was moderated by a senior content expert and co-moderated by a member of SCAI's emerging leader mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialogue from a broader base, and thereby aid SCAI and the industry community in developing specific action items to move these areas forward.
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Cateterismo Cardíaco/tendências , Cardiologia/tendências , Angiografia Coronária/tendências , Cardiopatias/diagnóstico por imagem , Cardiopatias/terapia , Intervenção Coronária Percutânea/tendências , Difusão de Inovações , Cardiopatias/fisiopatologia , HumanosRESUMO
BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30â¯days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (Pâ¯<â¯.001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, Pâ¯=â¯.24; mortality: 0% vs. 0.07%, Pâ¯=â¯.99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.
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Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Angina Estável/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Idoso , Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Ambulatórios/mortalidade , Redução de Custos , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/mortalidade , Feminino , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Alta do Paciente/tendências , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/tendências , Intervenção Coronária Percutânea/economia , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/mortalidade , Pontuação de Propensão , Fatores de Tempo , Estados Unidos , United States Department of Veterans AffairsRESUMO
FFR/iFR is discordant in 15-20% of cases, at times causing confusion about revascularization decisions. The CONTRAST substudy identifies lesion location, lesion severity, and bradycardia as major predictors for FFR/iFR discordance, with age a minor predictor. Each of these predictors can be explained physiologically through the mechanisms related to resting and hyperemic pressure loss across different patterns of atherosclerotic stenoses. A logical approach to using both resting and hyperemic pressure ratios is proposed.
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Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Angiografia Coronária , Vasos Coronários , Humanos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Patients may have preferences and priorities for their catheterization procedure that may differ from the operator's expectations. This online survey of normal volunteers suggested that patients place the highest value on same-day discharge and lesser values for radiation exposure, bleeding risk, and access site. Patient-centered care needs to increasingly emphasize same-day discharge after PCI for highest patient satisfaction.
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Crowdsourcing , Intervenção Coronária Percutânea , Voluntários Saudáveis , Humanos , Alta do Paciente , Resultado do TratamentoRESUMO
IVUS measurements of luminal area have only modest correlations to FFR. This study used IVUS 3D anatomical data in a computational fluid dynamic model to estimate FFR with a reasonable degree of accuracy. Further studies are needed to refine the models to make them more accurate and practical for routine use.
Assuntos
Reserva Fracionada de Fluxo Miocárdico , Hemodinâmica , Hidrodinâmica , Ultrassonografia , Ultrassonografia de IntervençãoRESUMO
TAVR patients given pacemakers operating in mandatory DDD mode had more ventricular pacing, heart failure hospitalization, and mortality compared with AAI-DDD or VVI modes. AV conduction disturbances are often transient after TAVR. Minimizing ventricular pacing where possible avoids the risk of pacemaker-induced cardiomyopathy. Pacemaker specialists should be consulted for any TAVR patient with mild rhythm abnormalities given the high incidence of AV block.
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Marca-Passo Artificial , Substituição da Valva Aórtica Transcateter , Valva Aórtica , Estimulação Cardíaca Artificial , Catéteres , Eletrônica , Humanos , Pacientes , EspecializaçãoRESUMO
There is limited evidence supporting the preloading of potent oral P2Y12 inhibitors in ST-elevation myocardial infarction (STEMI). This study demonstrates that longer pretreatment times were associated with improved angiographic coronary flow grades and ST-segment resolution. Although larger studies would be needed to prove a clinical benefit, in the absence of harm preloading in STEMI would be the most reasonable strategy.