RESUMO
Myocardial infarction remains a major healthcare problem. Reperfusion therapy has been shown to influence favourably short- and long-term patient survival. The authors reviewed the data of early recognition of STEMI (ST Elevation Myocardial Infarction), the reperfusion modalities including a flowchart management, as proposed by the Belgian working groups (BIWAC and BWGIC), and the lessons learned from European and American registries. Primary PCI often remains the treatment of choice. A national policy is still required to implement the guidelines and improve clinical practice for our STEMI patients.
Assuntos
Infarto do Miocárdio/terapia , Reperfusão Miocárdica , Bélgica , Árvores de Decisões , Serviços Médicos de Emergência , Humanos , Transporte de PacientesRESUMO
Myocardial infarction remains a major healthcare problem. Reperfusion therapy has been shown to influence favourably short- and long-term patient survival. The authors reviewed the data of early recognition of STEMI (ST Elevation Myocardial Infarction), the reperfusion modalities including a flowchart management, as proposed by the Belgian working groups (BIWAC and BWGIC), and the lessons learned from European and American registries. Primary PCI often remains the treatment of choice. A national policy is still required to implement the guidelines and improve clinical practice for our STEMI patients.
Assuntos
Infarto do Miocárdio/terapia , Reperfusão Miocárdica/métodos , Bélgica/epidemiologia , Europa (Continente)/epidemiologia , Humanos , Infarto do Miocárdio/classificação , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/cirurgia , Qualidade de Vida , Sistema de Registros , Reperfusão , Sociedades Médicas , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Because heterogeneous results have been reported, we assessed coronary flow velocity changes in individuals who underwent percutaneous transluminal coronary angioplasty (PTCA) and examined their impact on clinical outcome. METHODS AND RESULTS: As part of the Doppler Endpoints Balloon Angioplasty Trial Europe (DEBATE) II study, 379 patients underwent Doppler flow-guided angioplasty. All patients were evaluated according to their coronary flow velocity reserve (CFVR) results (> or =2.5 or < 2.5) at the end of the procedure. A CFVR < 2.5 after angioplasty was associated with an elevated baseline blood flow velocity in both the target artery and reference artery. CFVR before PTCA and CFVR in the reference artery were independent predictors of an optimal CFVR after balloon angioplasty (CFVR before PTCA: odds ratio [OR], 2.26; 95% confidence interval [CI], 1.57 to 3.24; CFVR in reference artery: OR, 1.90; 95% CI, 1.21 to 2.98; both P<0.001) and stent implantation (before PTCA: OR, 2.54; 95% CI, 1.47 to 4.36; reference artery: OR, 1.97; 95% CI, 1.07 to 3.87; both P<0.05). A low CFVR at the end of the procedure was an independent predictor of major adverse cardiac events (MACE) at 30 days (OR, 4.71; 95% CI, 1.14 to 25.92; P=0.034) and at 1 year (OR, 2.06; 95% CI, 1.16 to 3.66; P=0.014). After excluding MACE at 30 days, no difference in MACE at 1 year was observed between the patients with and without a CFVR < 2.5 at the end of the procedure. CONCLUSIONS: A low postprocedural CFVR was associated with a worse periprocedural outcome (which was related to microcirculatory disturbances), but there was no significant difference at late follow-up.
Assuntos
Angioplastia Coronária com Balão , Circulação Coronária , Ecocardiografia Doppler/métodos , Velocidade do Fluxo Sanguíneo , Angiografia Coronária , Intervalo Livre de Doença , Feminino , Seguimentos , Previsões , Humanos , Masculino , Microcirculação , Pessoa de Meia-Idade , Análise Multivariada , Miocárdio/enzimologia , Stents , Resultado do TratamentoRESUMO
BACKGROUND: We have previously reported a virtual absence of neointimal hyperplasia 4 months after implantation of sirolimus-eluting stents. The aim of the present investigation was to determine whether these results are sustained over a period of 1 year. METHODS AND RESULTS: Forty-five patients with de novo coronary disease were successfully treated with the implantation of a single sirolimus-eluting Bx VELOCITY stent in São Paulo, Brazil (n=30, 15 fast release [group I, GI] and 15 slow release [GII]) and Rotterdam, The Netherlands (15 slow release, GIII). Angiographic and volumetric intravascular ultrasound (IVUS) follow-up was obtained at 4 and 12 months (GI and GII) and 6 months (GIII). In-stent minimal lumen diameter and percent diameter stenosis remained essentially unchanged in all groups (at 12 months, GI and GII; at 6 months, GIII). Follow-up in-lesion minimal lumen diameter was 2.28 mm (GIII), 2.32 mm (GI), and 2.48 mm (GII). No patient approached the >/=50% diameter stenosis at 1 year by angiography or IVUS assessment, and no edge restenosis was observed. Neointimal hyperplasia, as detected by IVUS, was virtually absent at 6 months (2+/-5% obstruction volume, GIII) and at 12 months (GI=2+/-5% and GII=2+/-3%). CONCLUSIONS: This study demonstrates a sustained suppression of neointimal proliferation by sirolimus-eluting Bx VELOCITY stents 1 year after implantation.
Assuntos
Implante de Prótese Vascular/instrumentação , Doença das Coronárias/cirurgia , Oclusão de Enxerto Vascular/prevenção & controle , Sirolimo/administração & dosagem , Stents , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Brasil , Estudos de Coortes , Angiografia Coronária , Doença das Coronárias/diagnóstico , Doença das Coronárias/tratamento farmacológico , Preparações de Ação Retardada/administração & dosagem , Implantes de Medicamento/administração & dosagem , Endossonografia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Sirolimo/efeitos adversos , Stents/efeitos adversos , Taxa de Sobrevida , Resultado do Tratamento , Túnica Íntima/efeitos dos fármacos , Grau de Desobstrução Vascular/efeitos dos fármacosRESUMO
BACKGROUND: Recently, a novel nonfluoroscopic 3-dimensional electromechanical mapping technique was introduced in the clinical arena. Although initial in vitro and in vivo studies suggested the reliability of the system in volumetric and hemodynamic evaluation of the left ventricle, no validation in human beings has been performed. METHODS: A nonfluoroscopic electromechanical mapping (NOGA, Biosense-Webster) procedure was performed in 44 patients. All patients received a contrast left ventriculogram during the same session. Volumetric (end-diastolic [EDV] and end-systolic volumes [ESV]) and hemodynamic (left ventricular ejection fraction [LVEF] and stroke volume) parameters of both systems were compared. RESULTS: Two uncomplicated pericardial effusions occurred with the first-generation mapping catheters. No procedural complications were noted with the new-generation mapping catheters. Significant correlations were found between mapping-derived and ventriculography-based measurements for both ESV (r = 0.67, P <.001) and LVEF (r = 0.78, P <.001). Absolute volumes, however, were only comparable for ESV (46.6 +/- 25.3 mL vs 48.8 +/- 37.0 mL, respectively; P =.13) but differed greatly for LVEF (35% +/- 13% vs 65% +/- 19%, respectively; P <.001), EDV (69.1 +/- 28.6 mL vs 125.9 +/- 53.4 mL, respectively; P <.001) and stroke volume (22.4 +/- 9.9 mL vs 77.1 +/- 33.7 respirations; P <.001). Moreover, Bland-Altman analysis showed the clinical noninterchangeability between these techniques for the measurement of hemodynamic parameters. CONCLUSION: Measurement of hemodynamic parameters with nonfluoroscopic mapping of the left ventricle is feasible and safe. The system provides data that strongly correlate but that are in clinical disagreement with angiographic data. Therefore the interchangeability of these techniques may be questioned.
Assuntos
Mapeamento Potencial de Superfície Corporal/métodos , Volume Cardíaco/fisiologia , Volume Sistólico/fisiologia , Função Ventricular , Algoritmos , Angiografia , Cateterismo Cardíaco , Estudos de Viabilidade , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do ObservadorRESUMO
Limited data are available regarding the angiographic healing rate and physiologic impact of coronary artery dissections. Therefore, we studied the impact of coronary dissections on coronary flow velocity and outcome as well as their healing rate at 6-month follow-up balloon angioplasty. Of 297 patients who underwent balloon angioplasty, 225 underwent intracoronary Doppler measurements and 184 had Doppler and angiographic assessment at 6-month follow-up. Dissections were scored by an independent core lab (Cardialysis BV) and divided in 4 groups: mild (types A to B), moderate (type C), severe (D to F), and patients without dissections. Severe dissections (types D to F) were excluded from the analysis. Clinical, angiographic, and Doppler data were compared among the remaining 3 patient groups. From the 67 dissections detected after balloon angioplasty, only 3 (4.5%) remained unhealed at follow-up. Immediately after balloon angioplasty, the moderate dissection group was associated with a lower coronary flow velocity reserve than the patients with mild (2.16 +/- 0.60 vs 2.82 +/- 1.00, p = 0.037) or no dissections (2.16 +/- 0.60 vs 2.71 +/- 0.88, p = 0.046), respectively. In addition, higher recurrence of angina at 30 days was observed in the moderate group rather than in the mild group (5 [50%] vs 8 [16%], p = 0.0160) and in the patients without dissections (11 [12%], p = 0.007). After standard balloon angioplasty, the occurrence of unhealed dissections is a rare phenomenon. An impaired coronary flow reserve was observed after the development of nonocclusive type C dissections, which was associated with a worse short-term outcome.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Circulação Coronária , Doença das Coronárias/terapia , Vasos Coronários/lesões , Velocidade do Fluxo Sanguíneo , Angiografia Coronária , Doença das Coronárias/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Ecocardiografia Doppler , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , CicatrizaçãoRESUMO
In 40 patients, we compared linear local shortening assessed with nonfluoroscopic electromechanical mapping as a function of regional wall motion with echocardiographic data in a subset of patients with severe coronary artery disease and subsequently decreased left ventricular function. Our study showed that nonfluoroscopic electromechanical mapping can accurately assess regional wall motion. In addition, this study showed a significant decrease in unipolar voltages among segments with declining regional function.
Assuntos
Mapeamento Potencial de Superfície Corporal , Doença das Coronárias/complicações , Ecocardiografia/métodos , Disfunção Ventricular Esquerda/diagnóstico , Análise de Variância , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Doença das Coronárias/diagnóstico , Eletrodos , Feminino , Fluoroscopia , Humanos , Masculino , Probabilidade , Valores de Referência , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Disfunção Ventricular Esquerda/etiologiaRESUMO
OBJECTIVE: To evaluate the healing of balloon induced coronary artery dissection in individuals who have received beta radiation treatment and to propose a new intravascular ultrasound (IVUS) dissection score to facilitate the comparison of dissection through time. DESIGN: Retrospective study. SETTING: Tertiary referral centre. PATIENTS: 31 patients with stable angina pectoris, enrolled in the beta energy restenosis trial (BERT-1.5), were included. After excluding those who underwent stent implantation, the evaluable population was 22 patients. INTERVENTIONS: Balloon angioplasty and intracoronary radiation followed by quantitative coronary angiography (QCA) and IVUS. Repeat QCA and IVUS were performed at six month follow up. MAIN OUTCOME MEASURES: QCA and IVUS evidence of healing of dissection. Dissection classification for angiography was by the National Heart Lung Blood Institute scale. IVUS proven dissection was defined as partial or complete. The following IVUS defined characteristics of dissection were described in the affected coronary segments: length, depth, arc circumference, presence of flap, and dissection score. Dissection was defined as healed when all features of dissection had resolved. The calculated dose of radiation received by the dissected area in those with healed versus non-healed dissection was also compared. RESULTS: Angiography (type A = 5, B = 7, C = 4) and IVUS proven (partial = 12, complete = 4) dissections were seen in 16 patients following intervention. At six month follow up, six and eight unhealed dissections were seen by angiography (A = 2, B = 4) and IVUS (partial = 7, complete = 1), respectively. The mean IVUS dissection score was 5.2 (range 3-8) following the procedure, and 4.6 (range 3-7) at follow up. No correlation was found between the dose prescribed in the treated area and the presence of unhealed dissection. No change in anginal status was seen despite the presence of unhealed dissection. CONCLUSION: beta radiation appears to alter the normal healing process, resulting in unhealed dissection in certain individuals. In view of the delayed and abnormal healing observed, long term follow up is indicated given the possible late adverse effects of radiation. Although in this cohort no increase in cardiac events following coronary dissections was seen, larger populations are needed to confirm this phenomenon. Stenting of all coronary dissections may be warranted in patients scheduled for brachytherapy after balloon angioplasty.
Assuntos
Angina Pectoris/radioterapia , Angioplastia Coronária com Balão/efeitos adversos , Aneurisma Coronário/fisiopatologia , Vasos Coronários/efeitos da radiação , Cicatrização/efeitos da radiação , Angina Pectoris/terapia , Partículas beta/efeitos adversos , Partículas beta/uso terapêutico , Estudos de Coortes , Aneurisma Coronário/etiologia , Angiografia Coronária , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Cicatrização/fisiologiaRESUMO
A 65-year old patient was referred to our institution for a diagnostic catheterization. 23 years before, a direct surgical myocardial procedure using the Vineberg technique was performed. Currently, the angiogram shows patent left and right internal mammary arteries implanted directly into the myocardium and connecting with the native circulation through collaterals. As the native coronary artery tree shows very severe three vessel disease, it is hypothesized that the major contribution of myocardial perfusion comes from the implanted vessels. This is the first case to show a long-term success of the Vineberg operation, with persistence of myocardial perfusion through newly formed vasculature.
Assuntos
Doença das Coronárias/cirurgia , Revascularização Miocárdica , Idoso , Angiocardiografia , Doença das Coronárias/diagnóstico por imagem , Humanos , Masculino , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate the effectiveness of electively placed heparin-coated stents in the treatment of coronary saphenous vein bypass grafts with de novo lesions less than 15 mm in diameter in a prospective study with all eligible consecutive patients presenting to Middelheim Hospital, Antwerp, Belgium between September 1997 and August 1998. PATIENTS AND METHODS: Fifty patients with 53 lesions were studied. Anginal class, risk factors, quantitative coronary angiographic measurements pre- and postprocedure, procedural outcome, in-hospital events, clinical status on discharge, and six-month clinical and angiographic follow-up (in 48 patients) were recorded. All patients received acetylsalicylic acid and ticlopidine, unless known intolerance was present. RESULTS: On average, 1.1 stents/patient were placed in very old saphenous vein grafts (11. 7+/-3.9 years). Procedural success was 98%. Only two non-Q wave myocardial infarctions (MIs) occurred, with no Q-wave MIs and no deaths during hospital stay. Length of hospital stay was short (2. 4+/-1.7 days), and 96% of patients were free of angina on discharge. At six-months' follow-up, two patients had died, one of whom died of a noncardiac cause. One patient suffered a non-Q wave MI. At six months, 86% of patients were free from angina. Minimal luminal diameter decreased from 1.14 mm before to 3.33 mm after stenting and to 2.52 mm at six months. Restenosis was present in 22% of patients (21.6% of lesions). CONCLUSIONS: In a selected population with coronary saphenous vein bypass graft disease, Wiktor heparin-coated stents can be delivered with an excellent periprocedural outcome. Six-month outcome appears favourable with a low recurrence of angina (18%) and a low rate of angiographic restenosis (21.6%).
Assuntos
Ponte de Artéria Coronária , Oclusão de Enxerto Vascular/terapia , Veia Safena/transplante , Stents , Idoso , Aspirina/uso terapêutico , Angiografia Coronária , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Heparina/administração & dosagem , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Recidiva , Stents/efeitos adversos , Ticlopidina/uso terapêutico , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: We compared initial outcome, peri-procedural complications and long-term clinical follow-up of elective Wiktor GX stent implantation in severely narrowed vein grafts to a historic register of elective angioplasties in saphenous vein grafts in the same center. METHODS: Eighty-one consecutive patients with angina and a history of coronary artery bypass grafting (CABG), all received elective angioplasty (PTCA) of the diseased graft; we described them as group P. The next 38 consecutive patients were treated with elective angioplasty and Wiktor Stent implantation, followed by one month ticlopidine; they were called group S. CONCLUSION: This retrospective study suggests that elective Wiktor stenting in old saphenous vein graft stenosis, in combination with one month ticlopidine, leads to: 1) a better angiographic result, with reduction of peri-procedural complications; and 2) a lower incidence of recurrent angina, need for invasive or surgical re-intervention, myocardial infarction and death during follow-up.
Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Oclusão de Enxerto Vascular/terapia , Veia Safena , Stents , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Estudos Retrospectivos , Ticlopidina/uso terapêutico , Resultado do TratamentoRESUMO
Intravascular ultrasound (IVUS) is a clinically useful tool that provides cross-sectional images of the coronary arterial lumen and wall. Diagnostic applications of IVUS include the evaluation of ambiguous lesions on angiography particularly at the bifurcations. IVUS is also useful in the assessment of coronary vasculopathy in cardiac transplant patients or it can help to diagnose abnormalities such as syndrome X or coronary artery spasm. IVUS can optimize the performing of percutaneous coronary interventions, especially stent implantation. It represents as well an optimal tool for assessing regression of atherosclerosis. Three-dimensional reconstruction, elastography and imaging guide wires are some of the recent advances in the field of intravascular ultrasound.
Assuntos
Doença das Coronárias/diagnóstico , Doença das Coronárias/terapia , Ultrassonografia de Intervenção , Angioplastia Coronária com Balão , HumanosAssuntos
Circulação Coronária , Doença das Coronárias/fisiopatologia , Vasos Coronários/patologia , Processamento de Imagem Assistida por Computador , Stents , Idoso , Angioplastia Coronária com Balão , Velocidade do Fluxo Sanguíneo , Angiografia Coronária , Doença das Coronárias/patologia , Doença das Coronárias/terapia , Vasos Coronários/diagnóstico por imagem , Humanos , Hiperplasia/diagnóstico por imagem , Masculino , Túnica Íntima/patologia , Ultrassonografia de IntervençãoAssuntos
Doença das Coronárias/fisiopatologia , Revascularização Miocárdica/métodos , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Estenose da Valva Aórtica/cirurgia , Doença das Coronárias/etiologia , Implante de Prótese de Valva Cardíaca , Doença Iatrogênica , Complicações Pós-Operatórias/diagnóstico por imagem , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
Although the principle of reducing plaque load in the coronary artery remains very appealing, clinical benefit from debulking devices has not been demonstrated unequivocally. Other approaches to prevent restenosis had been the application of various pharmacological agents. Unfortunately, the majority of clinical studies have not reproduced the promising results observed in the experimental laboratories. New frontiers in improving atherectomy devices and in optimizing concomitant medical treatment are currently being explored. We report on the EUROCARE trial investigating the possible benefit of carvedilol after coronary atherectomy, and the Pullback Atherectomy (PAC) pilot trial using a novel atherectomy device.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Antioxidantes/uso terapêutico , Aterectomia Coronária , Carbazóis/uso terapêutico , Doença da Artéria Coronariana/terapia , Propanolaminas/uso terapêutico , Aterectomia Coronária/instrumentação , Carvedilol , Doença da Artéria Coronariana/tratamento farmacológico , Desenho de Equipamento , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
AIMS: This study was conducted to analyse flow velocity parameters and predictors of a suboptimal coronary flow reserve (<2.5) following balloon angioplasty. METHODS: Two hundred and twenty-five patients underwent sequential intracoronary Doppler as part of the DEBATE I study. Of these, 183, with complete angiography and Doppler at the 6-month follow-up, were included. Univariate and multivariate logistic analysis was performed to identify independent predictors of post-procedural suboptimal coronary flow reserve, defined as coronary flow reserve <2.5. RESULTS: Forty-eight per cent (n=88) of the patients achieved a suboptimal coronary flow reserve. These patients had higher baseline velocities (cm.s(-1)) before balloon angioplasty (18+/-9 vs 14+/-6, P=0.004), after balloon angioplasty (22+/-11 vs 14+/-5, P<0.001) and at follow-up (19+/-9 vs 16+/-6, P=0.011) than the optimal coronary flow reserve group. Although the suboptimal group had lower hyperaemic velocities (cm.s(-1)) after balloon angioplasty than the optimal group (42+/-17 vs 49+/-16, P=0.008), these velocities became similar at follow-up. Increasing age (odds ratio, OR 1.071, P=0.0002), female gender (OR 2.52, P=0.014) and increasing pre-procedural baseline average peak velocities (OR 1.056, P<0.001) were found to be independent predictors of a suboptimal coronary flow reserve following balloon angioplasty. CONCLUSION: A suboptimal coronary flow reserve was associated with (1) a chronically elevated baseline average peak velocity (2) a transient deficit in the hyperaemic average peak velocity (3) the elderly, and female gender.
Assuntos
Angioplastia com Balão , Vasos Coronários/fisiologia , Velocidade do Fluxo Sanguíneo , Angiografia Coronária , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Ultrassonografia DopplerRESUMO
Direct myocardial revascularization (DMR) has been proposed to treat patients with severe coronary artery disease who are not amenable for classical revascularization techniques such as percutaneous coronary intervention (PCI) or bypass surgery (CABG). Although recent reports suggest its benefit in alleviating patients' complaints in the long term, there is still a paucity of data on the immediate impact on regional and global myocardial functioning following this treatment. In this overview we discuss our own experience and provide a summary of other data currently available.
Assuntos
Doença das Coronárias/fisiopatologia , Doença das Coronárias/cirurgia , Revascularização Miocárdica/métodos , Função Ventricular Esquerda , Humanos , Período Pós-Operatório , Resultado do TratamentoRESUMO
Bronchopulmonary sequestrations are malformations that are often congenital; they consist of isolated nonfunctioning lung segments having no communication with functional tracheobronchial elements of the surrounding lung. They are supplied by single or multiple branches from the distal thoracic or proximal abdominal aorta, or from the celiac, splenic, intercostal, subclavian, or pulmonary artery. Due to the absence of ventilation, the lung tissue can become chronically infected. We describe an intralobar pulmonary sequestration with arterial supply from the right coronary artery.