RESUMO
STUDY OBJECTIVE: We examined the diagnostic performance of a recalibrated History, Electrocardiogram, Age, Risk factors, Troponin (HEART), and Thrombolysis in Myocardial Infarction (TIMI) score in patients with suspected acute cardiac syndrome (ACS). Recalibration of troponin thresholds was performed, including shifting from the 99th percentile to the limit of detection (LOD) or to the limit of quantification (LOQ) We compared the discharge potential and safety of the recalibrated composite scores using a single presentation high-sensitivity cardiac troponin (hs-cTn) T to the conventional scores and with a LOD/LOQ troponin strategy alone. METHODS: We undertook a 2-center prospective cohort study in the United Kingdom (UK) (2018) (Clinicaltrials.gov NCT03619733) to specifically assess recalibrated risk scores (shifting the troponin subset scoring from 99th percentile to LOD [UK]) and combined the results of this with secondary analyses of 2 prospective cohort studies in the UK (2011) and the United States (2018, using LOQ rather than LOD). The primary outcome was major adverse cardiovascular events (MACE), defined as adjudicated type 1 myocardial infarction (MI), urgent coronary revascularization, and all-cause death, at 30 days. We evaluated the original scores using hs-cTn below the 99th percentile and recalibrated scores using hs-cTn Assuntos
Síndrome Coronariana Aguda
, Infarto do Miocárdio
, Humanos
, Feminino
, Pessoa de Meia-Idade
, Masculino
, Troponina T
, Estudos Prospectivos
, Troponina
, Infarto do Miocárdio/diagnóstico
, Infarto do Miocárdio/complicações
, Síndrome Coronariana Aguda/diagnóstico
, Biomarcadores
, Serviço Hospitalar de Emergência
RESUMO
The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Adulto , Humanos , Procedimentos Cirúrgicos Cardíacos/métodos , Circulação Extracorpórea/métodos , Perfusão , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , CoraçãoRESUMO
Acute myocardial infarction (AMI) is one of the major causes of morbidity and mortality worldwide. The inflammation response during and after AMI is common and seems to play a key role in the peri-AMI period, related with ischaemia-reperfusion injury, adverse cardiac remodelling, infarct size and poor prognosis. In this article, we provide an updated and comprehensive overview of the most important cytokines and adipokines involved in the complex pathophysiology mechanisms in AMI, summarizing their prognostic role post-AMI. Data so far support that elevated levels of the major proinflammatory cytokines TNFα, IL-6 and IL-1 and the adipokines adiponectin, visfatin and resistin, are linked to high mortality and morbidity. In contrary, there is evidence that anti-inflammatory cytokines and adipokines as IL-10, omentin-1 and ghrelin can suppress the AMI-induced inflammatory response and are correlated with better prognosis. Mixed data make unclear the role of the novel adipokines leptin and apelin. After all, imbalance of pro-inflammatory and anti-inflammatory cytokines may result in worst AMI prognosis. The incorporation of these inflammation biomarkers in established prognostic models could further improve their prognostic power improving overall the management of AMI patients.
Assuntos
Adipocinas , Infarto do Miocárdio , Adipocinas/metabolismo , Anti-Inflamatórios , Citocinas/metabolismo , Humanos , Inflamação , PrognósticoRESUMO
BACKGROUND: Primary percutaneous coronary intervention (PPCI) is the standard reperfusion treatment in ST-segment elevation myocardial infarction (STEMI). Intracoronary thrombolysis (ICT) may reduce thrombotic burden in the infarct-related artery, which is often responsible for microvascular obstruction and no-reflow. METHODS: We conducted, according to the PRISMA statement, the largest meta-analysis to date of ICT as adjuvant therapy to PPCI. All relevant studies were identified by searching the PubMed, Scopus, Cochrane Library, and Web of Science. RESULTS: Thirteen randomized controlled trials (RCTs) involving a total of 1876 patients were included. Compared to the control group, STEMI ICT-treated patients had fewer major adverse cardiac events (MACE) (OR 0.65, 95% CI, 0.48-0.86, P = 0.003) and an improved 6-month left ventricular ejection fraction (MD 3.78, 95% CI, 1.53-6.02, P = 0.0010). Indices of enhanced myocardial microcirculation were better with ICT (Post-PCI corrected thrombolysis in myocardial infarction (TIMI) frame count (MD - 3.57; 95% CI, - 5.00 to - 2.14, P < 0.00001); myocardial blush grade (MBG) 2/3 (OR 1.76; 95% CI, 1.16-2.69, P = 0.008), and complete ST-segment resolution (OR 1.97; 95% CI, 1.33-2.91, P = 0.0007)). The odds for major bleeding were comparable between the 2 groups (OR 1.27; 95% CI, 0.61-2.63, P = 0.53). CONCLUSIONS: The present meta-analysis suggests that ICT was associated with improved MACE and myocardial microcirculation in STEMI patients undergoing PPCI, without significant increase in major bleeding. However, these findings necessitate confirmation in a contemporary large RCT.
RESUMO
Accessory mitral valve tissue is a rare congenital cardiac abnormality that sometimes can cause left ventricular outflow tract obstruction. We herein present the case of a 55-year-old male with an incidental finding of accessory mitral valve tissue on transthoracic echocardiography. The patient was managed conservatively as accessory tissue was not causing left ventricular outflow obstruction and there were no hemodynamic consequences.
Assuntos
Cardiopatias Congênitas , Obstrução do Fluxo Ventricular Externo , Adulto , Ecocardiografia , Cardiopatias Congênitas/diagnóstico por imagem , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologiaRESUMO
We present the case of a 70-year-old man with a history of haemophilia B, who presented to our hospital with a non-ST-elevation myocardial infarction. The patient, following consultation by a haemophilia expert, was revascularized with percutaneous coronary intervention (PCI) under adequate clotting factor administration. Patients with haemophilia and acute coronary syndrome, are susceptible to periprocedural bleeding and thrombotic events during PCI, and therefore a balanced management plan should always be implemented by a multidisciplinary team.
Assuntos
Síndrome Coronariana Aguda , Hemofilia A , Infarto do Miocárdio sem Supradesnível do Segmento ST , Intervenção Coronária Percutânea , Trombose , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/terapia , Idoso , Hemofilia A/complicações , Hemofilia A/tratamento farmacológico , Humanos , Masculino , Resultado do TratamentoRESUMO
Papillary muscle (PM) rupture can usually complicate inferior or posterior myocardial infarctions, but selective PM infarction is extremely rare, and the exact underlying pathophysiological mechanism is not entirely clear. We present a case of PM rupture due to isolated PM infarction in a patient with unobstructed coronary arteries, which could be misdiagnosed as a vegetation or other mass given the absence of regional wall motion abnormalities (RWMAs) on transthoracic echocardiogram. Our case highlights that in patients with severe mitral regurgitation and associated mitral valve mass, the absence of RWMAs should not exclude ischemic PM rupture from differential diagnosis.
Assuntos
Doença da Artéria Coronariana , Ruptura Cardíaca Pós-Infarto , Insuficiência da Valva Mitral , Infarto do Miocárdio , Ruptura Cardíaca Pós-Infarto/diagnóstico por imagem , Humanos , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico por imagem , Infarto do Miocárdio/diagnóstico por imagem , Músculos Papilares/diagnóstico por imagemRESUMO
We present a case of a 70-year-old woman with exertional shortness of breath. A transthoracic echocardiogram showed a large mass on the ventricular side of the pulmonary valve. The anatomy of the mass was additionally investigated with a transesophageal echocardiogram, which delineated the anatomical details of the structure. The mass was surgically excised, and histopathology confirmed a cardiac papillary fibroelastoma.
Assuntos
Fibroelastoma Papilar Cardíaco , Fibroma , Neoplasias Cardíacas , Valva Pulmonar , Idoso , Ecocardiografia Transesofagiana , Feminino , Fibroma/diagnóstico por imagem , Fibroma/cirurgia , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Humanos , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/cirurgiaAssuntos
Estimulação Cardíaca Artificial , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Parada Cardíaca/etiologia , Marca-Passo Artificial/efeitos adversos , Fibrilação Ventricular/etiologia , Idoso de 80 Anos ou mais , Humanos , Masculino , Complicações Pós-Operatórias , Telemetria , Resultado do TratamentoRESUMO
We present the case of a 54-year-old man who had an unusual finding in contrast echocardiography with agitated saline. Partition of the right atrium in two compartments, an opacified and a non-opacified one, was noted. Further assessment with a transesophageal echocardiogram revealed the presence of a membrane in the right atrium, with the final diagnosis being cor triatriatum dexter.
Assuntos
Meios de Contraste , Coração Triatriado/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Comunicação Interatrial/diagnóstico por imagem , Aumento da Imagem/métodos , Solução Salina , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
We present a case of a 68-year-old man with calciphylaxis, who was found to have a floating thrombus in the descending aorta on a transesophageal echocardiogram. The use of 3D echocardiography demonstrated nicely the free motion of the thrombus, emerging from an atherosclerotic plaque in the descending aorta. Anticoagulation was started for thromboembolism prevention.
Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/complicações , Doenças da Aorta/diagnóstico por imagem , Calciofilaxia/complicações , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagem , Idoso , Diagnóstico Diferencial , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Evolução Fatal , Humanos , MasculinoRESUMO
Contrast echocardiography with agitated saline is used to assess mainly the existence of interatrial communication. We report a case of a 26-year-old woman, with a "port-a-cath" central venous line, who had an unusual finding in agitated saline contrast echocardiography. Multimodality imaging revealed occlusion of superior vena cava and a systemic-to-pulmonary venous shunt.
Assuntos
Ecocardiografia/métodos , Comunicação Interatrial/diagnóstico , Veias Pulmonares/diagnóstico por imagem , Cloreto de Sódio/farmacologia , Veia Cava Superior/diagnóstico por imagem , Adulto , Feminino , Humanos , Veias Pulmonares/anormalidades , Veia Cava Superior/anormalidadesRESUMO
We present the case of a 34-year-old female who was admitted to our hospital due to community-acquired pneumonia and had a transthoracic echocardiogram which revealed an aneurysm of the membranous interventricular septum. This was further investigated with a transesophageal echocardiogram which showed in detail the anatomical features of this very rare condition.
Assuntos
Ecocardiografia/métodos , Aneurisma Cardíaco/diagnóstico por imagem , Achados Incidentais , Septo Interventricular/diagnóstico por imagem , Adulto , Ecocardiografia Transesofagiana , Feminino , HumanosRESUMO
A 73-year-old man, with a previous long drug-eluting stent (DES) from the mid-portion of the left main stem artery (LMS) to proximal left anterior descending artery (LAD), underwent elective coronary angiogram due to worsening anginal symptoms and an abnormal myocardial perfusion single photon emission computed tomography (SPECT) showing ischemia in the LAD territory.
Assuntos
Angioplastia Coronária com Balão , Angiografia Coronária , Stents Farmacológicos , Humanos , Idoso , Masculino , Angioplastia Coronária com Balão/métodos , Angioplastia Coronária com Balão/instrumentação , Falha de Equipamento , Tomografia Computadorizada de Emissão de Fóton Único , Vasos Coronários/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/cirurgiaRESUMO
An emergency transradial coronary angiography in a 68-year-old woman demonstrated sub-total occlusion of the proximal left anterior descending artery.
Assuntos
Intervenção Coronária Percutânea , Feminino , Humanos , Idoso , Arteríolas , Intervenção Coronária Percutânea/efeitos adversos , Angiografia Coronária , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgiaRESUMO
A 58-year-old male with a medical history of arterial hypertension, dyslipidemia, and psoriasis was admitted for a scheduled surgical removal of the thyroid gland. During the surgery, the patient suffered severe blood loss caused by vascular complications. After the operation, his electrocardiogram showed diffuse ST segment elevation along with high-sensitivity cardiac troponin T elevation and severe left ventricular systolic dysfunction. An emergency coronary angiography showed unobstructed coronary arteries. However, the left ventriculography demonstrated akinesia of the apical segments and hyperkinesia of the basal segments during systole. The patient was diagnosed with Takotsubo syndrome and he was successfully stabilized over the course of the next few days. Takotsubo cardiomyopathy is characterized by transient left ventricular systolic dysfunction and although the clinical and electrocardiographical presentation is similar to an acute coronary syndrome, the coronary arteries are unobstructed. Stressful events, both physical or psychological, could trigger an excessive catecholaminergic response which can cause the syndrome. Repetitive echocardiograms in our patient demonstrated complete recovery of the systolic function after a few days.
RESUMO
Engaging intracoronary imaging (IC) techniques such as intravascular ultrasound or optical coherence tomography enables the precise description of vessel architecture. These imaging modalities have well-established roles in providing guidance and optimizing percutaneous coronary intervention (PCI) outcomes. Furthermore, IC is increasingly recognized for its diagnostic capabilities, as it has the unique capacity to reveal vessel wall characteristics that may not be apparent through angiography alone. This manuscript thoroughly reviews the contemporary landscape of IC in clinical practice. Focused on current methodologies, the review explores the utility and advancements in IC techniques. Emphasizing their role in clarifying coronary pathophysiology, guiding PCI, and optimizing patient outcomes, the manuscript critically evaluates the strengths and limitations of each modality. Additionally, the integration of IC into routine clinical workflows and its impact on decision-making processes are discussed. By synthesizing the latest evidence, this review provides valuable insights for clinicians, researchers, and healthcare professionals involved in the dynamic field of interventional cardiology.
RESUMO
Background/Objectives: Radial artery occlusion (RAO) is the most common complication of transradial coronary catheterization. In this study, we aimed to evaluate the incidence of RAO and identify the risk factors that predispose patients to it. Methods: We conducted an investigator-initiated, prospective, multicenter, open-label study involving 1357 patients who underwent cardiac catheterization via the transradial route for angiography and/or a percutaneous coronary intervention (PCI). Univariate and multivariate logistic regression analyses were performed to identify potential predictors of RAO occurrence. Additionally, a subgroup analysis only for patients undergoing PCIs was performed. Results: The incidence of RAO was 9.5% overall, 10.6% in the angiography-only group and 6.2% in the PCI group. Independent predictors of RAO were as follows: (i) the female gender (aOR = 1.72 (1.05-2.83)), (ii) access site cross-over (aOR = 4.33 (1.02-18.39)), (iii) increased total time of the sheath in the artery (aOR = 1.01 (1.00-1.02)), (iv) radial artery spasms (aOR = 2.47 (1.40-4.36)), (v) the presence of a hematoma (aOR = 2.28 (1.28-4.06)), (vi) post-catheterization dabigatran use (aOR = 5.15 (1.29-20.55)), (vii) manual hemostasis (aOR = 1.94 (1.01-3.72)) and (viii) numbness at radial artery ultrasound (aOR = 8.25 (1.70-40)). Contrariwise, two variables were independently associated with increased odds for radial artery patency (RAP): (i) PCI performance (aOR = 0.19 (0.06-0.63)), and (ii) a higher dosage of intravenous heparin per patient weight (aOR = 0.98 (0.96-0.99)), particularly, a dosage of >50 IU/kg (aOR = 0.56 (0.31-1.00)). In the PCI subgroup, independent predictors of RAO were as follows: (i) radial artery spasms (aOR = 4.48 (1.42-14.16)), (ii) the use of intra-arterial nitroglycerin as a vasodilator (aOR = 7.40 (1.67-32.79)) and (iii) the presence of symptoms at echo (aOR = 3.80 (1.46-9.87)), either pain (aOR = 2.93 (1.05-8.15)) or numbness (aOR = 4.66 (1.17-18.57)). On the other hand, the use of intra-arterial verapamil as a vasodilator (aOR = 0.17 (0.04-0.76)) was independently associated with a greater frequency of RAP. Conclusions: The incidence of RAO in an unselected, all-comers European population after transradial coronary catheterization for angiography and/or PCIs is similar to that reported in the international literature. Several RAO prognostic factors have been confirmed, and new ones are described. The female gender, radial artery trauma and manual hemostasis are the strongest predictors of RAO. Our results could help in the future identification of patients at higher risk of RAO, for whom less invasive diagnostic procedures maybe preferred, if possible.
RESUMO
BACKGROUND: Elderly patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) frequently exhibit high platelet reactivity (HPR) while on clopidogrel. In the elderly cohort, either prasugrel is not recommended or, if used, halving of the dose has been suggested. We aimed to test the hypothesis that in elderly patients exhibiting HPR after standard treatment with clopidogrel, prasugrel-reduced dose (5 mg) could be more effective than high-dose (150 mg) clopidogrel. METHODS: Consecutive elderly (≥75 years old) patients with ACS undergoing PCI and loaded with clopidogrel were considered for platelet reactivity (PR) assessment at 24 hours after PCI with the VerifyNow assay (Accumetrics Inc, San Diego, CA), measured in P2Y12 reaction units (PRU). Of 63 screened patients, 30 (47.6%) were found with HPR (defined as PRU ≥230) and 27 of them participated in a prospective, randomized, single-center, single-blind, investigator-initiated, crossover study of platelet inhibition by prasugrel 5 mg/d vs clopidogrel 150 mg/d, with a 15-day treatment period. RESULTS: The primary end point of PR at the end of the 2 study periods was lower in patients receiving low-dose prasugrel than those receiving high-dose clopidogrel (least squares estimates 190.8 [95% CI 161.5-220.1] and 240.8 [95% CI 211.0-270.6], respectively; P = .008). The secondary end point of HPR rate at the end of treatment periods was lower for prasugrel (8/24; 33.3%) compared with clopidogrel (16/24; 66.7%), P = .02. CONCLUSIONS: In elderly patients with ACS undergoing PCI and exhibiting HPR after standard clopidogrel treatment, prasugrel 5 mg/d is significantly more efficacious than clopidogrel 150 mg/d in reducing PR and HPR rate.
Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Intervenção Coronária Percutânea/métodos , Piperazinas/farmacologia , Inibidores da Agregação Plaquetária/farmacologia , Agregação Plaquetária/efeitos dos fármacos , Tiofenos/farmacologia , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/cirurgia , Idoso , Clopidogrel , Feminino , Humanos , Masculino , Piperazinas/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Testes de Função Plaquetária , Cloridrato de Prasugrel , Estudos Prospectivos , Tiofenos/efeitos adversos , Ticlopidina/efeitos adversos , Ticlopidina/farmacologia , Resultado do TratamentoRESUMO
In this difficult case of an 80-year-old woman with an acute coronary syndrome and extremely calcified and tortuous left anterior descending artery, the operators were unable to insert the stent into the distal cylinder of the Telescope after encountering strong resistance. Assuming the stent was stuck at the level of the distal cylinder entry pot, they decided to remove both the guide catheter extension (GCE) and the stent as a single unit to prevent complications. Since the first GCE was introduced in 2009, many other GCE systems have been developed and there is accumulating experience with their use. To our knowledge, this is the first description of stent damage occurring during the insertion in the distal cylinder of the Telescope GCE (Medtronic). Interventional cardiologists should always be prepared to face unexpected complications related to sophisticated devices such as GCE.