High risk coronavirus disease 2019: The primary results of the CoronaHeart multi-center cohort study.

BACKGROUND: Patients with Coronavirus Disease 2019 (COVID-19) may present high risk features during hospitalization, including cardiovascular manifestations. However, less is known about the factors that may further increase the risk of death in these patients. METHODS: We included patients with COVID-19 and high risk features according to clinical and/or laboratory criteria at 21 sites in Brazil from June 10th to October 23rd of 2020. All variables were collected until hospital discharge or in-hospital death. RESULTS: A total of 2546 participants were included (mean age 65 years; 60.3% male). Overall, 70.8% were admitted to intensive care units and 54.2% had elevated troponin levels. In-hospital mortality was 41.7%. An interaction among sex, age and mortality was found (p = 0.007). Younger women presented higher rates of death than men (30.0% vs 22.9%), while older men presented higher rates of death than women (57.6% vs 49.2%). The strongest factors associated with in-hospital mortality were need for mechanical ventilation (odds ratio [OR] 8.2, 95% confidence interval [CI] 5.4-12.7), elevated C-reactive protein (OR 2.3, 95% CI 1.7-2.9), cancer (OR 1.8, 95 %CI 1.2-2.9), and elevated troponin levels (OR 1.8, 95% CI 1.4-2.3). A risk score was developed for risk assessment of in-hospital mortality. CONCLUSIONS: This cohort showed that patients with COVID-19 and high risk features have an elevated rate of in-hospital mortality with differences according to age and sex. These results highlight unique aspects of this population and might help identifying patients who may benefit from more careful initial surveillance and potential subsequent interventional therapies.

Atypical chest pain due to multiple coronary arteries fistulas occluded with percutaneous interlock coils: A case report.

Coronary artery fistulas, although rare, should be included in the differential diagnosis of atypical chest pain, generally unveiled by cardiac catheterization or multidetector computed tomography. Such anatomical findings in conjunction with detectable ischemia and severe symptoms should prompt their closure. Transcatheter closure of fistulas is an attractive alternative to surgery, especially with the novel devices such as the interlock fibered detachable coils, which can be safely and effectively performed in a variety of circumstances, including the coronary arteries with tortuous anatomies. We present a case of atypical chest pain and large burden of ischemia in the stress scintigraphy, due to multiple coronary fistulas to the bronchial arteries successfully occluded with percutaneous interlock coils. .

The Clinical Course of Takotsubo Syndrome Diagnosed According to the InterTAK Criteria

Abstract Background There has been an increase in the number of cases of Takotsubo syndrome (TTS) and of scientific publications on the theme over the last years. However, little is known about the status of this disease in Brazilian hospitals. Objective To assess mortality and major adverse cardiovascular events (MACE) during hospitalization and follow-up of TTS patients seen in a tertiary hospital in Brazil. Methods This was a retrospective, observational study on 48 patients. Clinical data, signs and symptoms, complementary tests, MACE and all-cause mortality were assessed on admission and during follow-up. Kaplan-Meier curves were used for analysis of all-cause mortality and risk for MACE at median follow-up. The 95% confidence interval was also calculated for a significance level of 5%. Results Mean age of patients was 71 years (SD±13 years), and most patients were women (n=41; 85.4%). During hospitalization, four patients (8.3%) died and five (10.4%) developed MACE. At median follow-up of 354.5 days (IQR of 81.5-896.5 days), the risk of all-cause mortality and MACE was 11.1% (95% CI= 1.8-20.3%) and 12.7% (95% CI= 3.3-22.3%), respectively. Conclusion TTS was associated with high morbidity and mortality rates in a tertiary hospital in Brazil, which were comparable to those observed in acute coronary syndrome. Therefore, the severity of TTS should not be underestimated, and new therapeutic strategies are required. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

Aspirin-Free Prasugrel Monotherapy Following Coronary Artery Stenting in Patients With Stable CAD: The ASET Pilot Study.

OBJECTIVES: The aim of this study was to evaluate the hypothesis that prasugrel monotherapy following successful everolimus-eluting stent implantation is feasible and safe in patients with stable coronary artery disease (CAD). BACKGROUND: Recent studies have suggested that short dual-antiplatelet therapy strategies may provide an adequate balance between ischemic and bleeding risks. However, the complete omission of aspirin immediately after percutaneous coronary intervention (PCI) has not been tested so far. METHODS: The study was a multicenter, single-arm, open-label trial with a stopping rule based on the occurrence of definite stent thrombosis (if >3, trial enrollment would be terminated). Patients undergoing successful everolimus-eluting stent implantation for stable CAD with SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores <23 were included. All participants were on standard dual-antiplatelet therapy at the time of index PCI. Aspirin was discontinued on the day of the index procedure but given prior to the procedure; prasugrel was administered in the catheterization laboratory immediately after the successful procedure, and aspirin-free prasugrel became the therapy regimen from that moment. Patients were treated solely with prasugrel for 3 months. The primary ischemic endpoint was the composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis, and the primary bleeding endpoint was Bleeding Academic Research Consortium types 3 and 5 bleeding up to 3 months. RESULTS: From February 22, 2018, to May 7, 2019, 201 patients were enrolled. All patients underwent PCI for stable CAD. Overall, 98.5% of patients were adherent to prasugrel at 3-month follow-up. The primary ischemic and bleeding endpoints occurred in 1 patient (0.5%). No stent thrombosis events occurred. CONCLUSIONS: Aspirin-free prasugrel monotherapy following successful everolimus-eluting stent implantation demonstrated feasibility and safety without any stent thrombosis in selected low-risk patients with stable CAD. These findings may help underpin larger randomized controlled studies to evaluate the aspirin-free strategy compared with traditional dual-antiplatelet therapy following PCI. (Acetyl Salicylic Elimination Trial: The ASET Pilot Study [ASET]; NCT03469856).

Left Atrial Myxoma Hypervascularized from the Right Coronary Artery: An Interesting Cath Lab Finding.

Primary cardiac tumors are rare and approximately half of them are atrial myxomas. They rarely remain asymptomatic, especially if large. The imaging of a myxoma by contrast dye during coronary angiography is an infrequent sign, which clarifies the vascular supply of the tumor. We report herein an interesting and rare case of a left atrial myxoma hypervascularized from the right coronary artery.

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? – Analysis of 568 Patients / Intervenção Coronariana Ad Hoc Reduz a Exposição Radiológica? - Análise em 568 Pacientes

Background:Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention.Objective:To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedureMethods:The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated.Results:A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm2, while the staged group, to 139.2 ± 75.3 Gycm2 (p < 0.001).Conclusion:Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.

Fundamento:Uma série de vantagens e desvantagens tem sido descrita para a intervenção coronária percutânea ad hoc, como a realizada ao mesmo tempo que o cateterismo diagnóstico, porém pouco se sabe sobre a exposição radiológica desse procedimento, comparado com a intervenção estadiada, ou seja, em dois momentos.Objetivo:Comparar a dose de radiação utilizada na angioplastia ad hoc com a angioplastia estadiada.Métodos:O produto de dose por área e o Kerma total foram mensurados, somando-se ambas as fases de diagnóstico e terapêutica. Além disso, foram computados o tempo total de fluoroscopia e o número de filmagens.Resultados:Um total de 568 pacientes consecutivos foram tratados com intervenção coronária percutânea ad hoc (n = 320) ou estadiada (n = 248). À admissão, o grupo do ad hoc apresentava menos hipertensão (74,1% vs. 81,9%; p = 0,035), dislipidemia (57,8% vs. 67,7%; p = 0,02) e doença triarterial (38,8% vs. 50,4%; p = 0,015). O grupo ad hoc foi exposto a doses significativamente menores de radiação, mesmo após ajuste para as diferenças basais entre os grupos. O grupo ad hoc foi exposto a uma dose de produto de dose por área total de 119,7 ± 70,7 Gycm2 enquanto que os pacientes estadiados foram expostos a uma dose de 139,2 ± 75,3 Gycm2 (p < 0,001).Conclusão:A intervenção coronária percutânea ad hoc reduziu a exposição radiológica, em comparação com procedimentos diagnósticos e terapêuticos realizados em tempos separados.

Extensa dissecção coronária espontânea com boa evolução clínica mantida sob tratamento conservador / Extensive spontaneous coronary dissection with favorable evolution maintained under conservative treatment

A dissecção coronária espontânea é uma entidade rara e, por conseguinte, de etiologia, fisiopatologia e tratamento ainda não estabelecidos. Acomete, em geral, mulheres jovens, sem os clássicos fatores de risco cardiovascular, comumente ao longo do ciclo gravídico-puerperal. Vários fatores influenciam na estratégia de tratamento, como quadro clínico, status hemodinâmico, topografia da dissecção, número de artérias afetadas e fluxo coronário distal. Como no caso relatado, em pacientes estáveis, com dissecções bem delimitadas e, sobremodo, quando o fluxo coronário é reestabelecido, pode-se optar por uma abordagem conservadora, em razão da alta incidência de resolução espontânea e da baixa incidência de eventos adversos a longo prazo

Spontaneous coronary dissection is a rare entity and, therefore, its etiology, pathophysiology, and treatment are not yet established. It affects mainly young women without the classic cardiovascular risk factors, commonly during the pregnancy-childbirth cycle. Several factors influence the treatment strategy, such as clinical presentation, hemodynamic status, topography, number of affected arteries, and distal coronary flow. As in the reported case, in stable patients with well-defined dissections and mainly when the coronary flow has been re-established, one can choose a conservative approach, due to the high incidence of spontaneous resolution and low incidence of long-term adverse events

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? - Analysis of 568 Patients.

BACKGROUND: Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention. OBJECTIVE: To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedureMethods:The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated. RESULTS: A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm2, while the staged group, to 139.2 ± 75.3 Gycm2 (p < 0.001). CONCLUSION: Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.

Segurança e preditores de sucesso da alta hospitalar no mesmo dia apósintervenção coronária percutânea eletiva / Safety and predictors of same day discharge after elective percutaneous coronary intervention

Apesar de a alta hospitalar no mesmo dia (AHMD) após intervenção coronária percutânea(ICP) eletiva não complicada ser adotada mundialmente, ela permanece pouco estudada em nosso meio.Objetivamos, assim, avaliar nossa experiência inicial com a AHMD após ICP eletiva, em relação à suas egurança e aos preditores de sucesso. Métodos: Foram incluídos 161 pacientes consecutivos para AHMD, de único centro, selecionados em ambulatório especializado. Para a identificação dos fatores associados ao sucesso da AHMD, foram ajustados modelos de regressão logística simples e múltipla. Resultados: A AHMD foi realizada com sucesso em 114 pacientes (70,8%), tendo os 47 pacientes restantes permanecido internados (45 com alta na manhã seguinte e 2 pacientes após 2 dias). Nenhum paciente com AHMD apresentou evento cardíaco adverso maior ou complicação vascular importante aos 30 dias e no seguimento mediano de 12 meses. No grupo internação, ocorreu apenas um caso de infarto agudo do miocárdio por oclusão de ramo lateral e dois hematomas > 5 cm relacionados ao sítio de punção. Os preditores de sucesso da AHMD foram: via de acesso radial (OR = 5,92; IC95% 1,73-20,21; p = 0,005), presença de lesões tipo A/B1 (OR = 14,09; IC95% 1,70-116,49; p = 0,01) e volume de contraste (OR = 0,76;IC95% 0,65-0,88; p < 0,001). Conclusões: A AHMD foi segura e pôde ser realizada com sucesso na maioria dos pacientes selecionados para ICP eletiva, sendo seus preditores de sucesso o acesso radial, as lesões menos complexas e um volume menor de contraste...

Background: Although same-day discharge (SDD) after elective uncomplicated percutaneous coronary intervention (PCI) be adopted worldwide, it remains poorly studied in our country. We aim to evaluate our initial experience with SDD after elective PCI, regarding its safety and predictors of success. Methods: A hundred and sixty-one single-center consecutive patients, selected in a specialized out patient clinic, were included for SDD. To identify the factors associated with SDD, single and multiple logistic regression models were adjusted. Results: SDD was successfully performed in 114 patients (70.8%) and the remaining 47 patients remained hospitalized (45 with discharge in the following morning and 2 patients after 2 days). No patient with SDD presented major adverse cardiac events or major vascular complications at 30 days or at a median follow-up of 12 months. In the inpatient group, there was only one case of acute myocardial infarction due to a lateral branch occlusion and two patients with > 5 cm hematoma related to the access site. The SDD predictors were radial access route (OR = 5.92; 95%CI 1.73-20.21; p = 0.005), presence of type A/B1 lesions(OR = 14.09; 95%CI 1.70-116.49%; p = 0.01) and contrast volume (OR = 0.76; 95%CI 0.65-0.88; p < 0.001). Conclusions: SDD was safe and could be successfully performed in most patients selected for elective PCI, and its predictors were the radial access, less complex coronary lesions and a and lower contrast volume...

Resultados clínicos tardios do stent farmacológico liberador de sirolimus firebird® no tratamento de pacientes com doença arterial coronária na prática diária: seguimento de 24 Meses do registro CLARIFIRE / Late clinical outcomes of firebird™ sirolimus-eluting stent for the treatment of coronary artery disease in daily practice – 24-month follow-up of the CLARIFIRE registry

Introdução: O stent farmacológico liberador de sirolimus Firebird® já demonstrou eficácia na inibição de hiperplasia neointimal em pacientes selecionados submetidos à intervenção coronária percutânea. Nosso objetivo foi avaliar o desempenho e o resultado clínico tardio do dispositivo Firebird® em pacientes submetidos à intervenção coronária percutânea na prática diária nacional. Métodos: O Registro CLARIFIRE foi um estudo prospectivo, não randomizado, multicêntrico, que incluiu 455 pacientes (536 lesões) em 14 centros no Brasil entre dezembro de 2008 e maio de 2011. O seguimento clínico foi realizado aos 1, 6, 12 e 24 meses, e os eventos adversos foram adjudicados por um Comitê de Eventos Clínicos independente. Resultados: A média das idades foi de 61,1 ± 10,4 anos, 30,8% eram do sexo feminino, 41,9% tinham diabetes e 58,2% apresentaram-se com angina estável. O vaso-alvo mais prevalente foi a artéria descendente anterior (46,5%), 29,9% eram lesões reestenóticas e 8% lesões em bifurcação. Foram implantados 613 stents e as médias de extensão e diâmetro nominal dos stents foram 22,0 ± 6,4 mm e 2,90 ± 0,40 mm, respectivamente. O sucesso do procedimento foi de 97,6%. A taxa cumulativa de eventos cardíacos adversos maiores aos 12 meses (desfecho primário) foi 8,1%. Considerando-se os eventos pós-hospitalização até 24 meses (409/455), observaram-se eventos cardíacos adversos maiores em 9,8%, morte cardíaca em 3,9% e revascularização do vaso-alvo em 7,6%. Já a trombose de stent (definitiva/provável) ocorreu em nove casos (2%) até 30 dias, sem ocorrências subsequentes. Conclusões: O stent farmacológico liberador de sirolimus Firebird ® demonstrou desempenho favorável, Além de segurança e eficácia sustentadas no tratamento de pacientes da prática diária, conforme evidenciado pela elevada taxa de sucesso do procedimento e pela ocorrência relativamente baixa de eventos adversos ao final de 2 anos...

Background: The Firebird™ sirolimus-eluting stent has proven to be effective in inhibiting neointimal hyperplasia in selected patients undergoing percutaneous coronary intervention. Our objective was to evaluate the performance and long-term outcomes of Firebird ™ in patients undergoing percutaneous coronary intervention in daily practice in Brazil. Methods: The CLARIFIRE Registry was a prospective, non-randomized, multicenter study enrolling 455 patients (536 lesions) in 14 Brazilian sites between December 2008 and May 2011. Clinical follow-up was performed at 1, 6, 12, and 24 months, and adverse events were adjudicated by the independent Clinical Events Committee. Results: Mean age was 61.1 ± 10.4 years, 30.8% were women, 41.9% had diabetes, and 58.2% had stable angina. The left anterior descending artery was the most prevalent target vessel (46.5%), 29.9% were restenotic lesions, and 8% were bifurcations. Six hundred and thirteen stents were implanted, and the mean nominal stent length and diameter were 22.0 ± 6.4 mm and 2.90 ± 0.40 mm, respectively. Procedural success was 97.6%. The cumulative major adverse cardiac events rate at 12 months (primary endpoint) was 8.1%. Considering post-discharge events up to 24 months (409/455), major adverse cardiac events were observed in 9.8%, cardiac death in 3.9%, and target vessel revascularization in 7.6% of the patients. Definite/probable stent thrombosis was observed in nine cases (2%) up to 30 days, and no further occurrences were found. Conclusions: The Firebird ™ sirolimus-eluting stent has demonstrated good performance and sustained safety and efficacy for patients treated in daily practice, as evidenced by the high procedural success rates and relatively low adverse event rates after 2 years...

Resultados angiográficos e do seguimento clínico de 5 Anos após implante de stents farmacológicos com revestimento biodegradável em pacientes com alto risco de reestenose: análise de subgrupo do estudo randomizado PAINT / Angiographic and 5-year clinical follow-up after implantation of drug-eluting stents with biodegradable coating in patients at high risk of restenosis: the PAINT randomized trial

Introdução: Polímeros biodegradáveis foram desenvolvidos para reduzir a reação de hipersensibilidade associada aos polímeros duráveis dos stents farmacológicos de primeira geração, mantendo sua eficácia antiproliferativa e aumentado sua segurança. Avaliamos os resultados angiográficos de 9 meses e os resultados clínicos de longo prazo dos stents farmacológicos com polímeros biodegradáveis em pacientes com alto risco de reestenose. Métodos: Pacientes com diâmetro de referência ≤ 2,5 mm, extensão da lesão ≥ 15 mm, diabetes, ou uma combinação dessas características foram selecionados da população do estudo PAINT. Esses pacientes foram previamente randomizados e alocados para intervenção coronária percutânea recebendo os stents farmacológicos com polímeros biodegradáveis com sirolimus ou com paclitaxel ou stents metálicos, na razão 2:2:1. Resultados: Cento e setenta e oito pacientes foram tratados com stents farmacológicos com polímeros biodegradáveis (n = 142) ou stents metálicos (n = 36). No acompanhamento angiográfico de 9 meses, os primeiros mostraram menor perda tardia (0,40 ± 0,42 mm vs. 0,90 ± 0,47 mm; p < 0,01) e reestenose binária (7,4% vs. 25%; p < 0,01). No acompanhamento clínico de 5 anos, o grupo com stents farmacológicos com polímeros biodegradáveis mostrou menores taxas do desfecho combinado de morte cardíaca, infarto do miocárdio e revascularização do vaso-alvo (16,2% vs. 38,0%; p = 0,03), principalmente devido à redução da revascularização do vaso-alvo (9,9% vs. 36,1%; p < 0,01). Morte total, morte cardíaca e infarto do miocárdio não foram diferentes entre os grupos. A trombose do stent, provável ou definitiva, ocorreu em 2,8% vs. 0% (p = 0,30). Conclusões: Os stents farmacológicos com polímeros biodegradáveis eluidores de paclitaxel ou sirolimus foram eficazes na redução de reestenose angiográfica aos 9 meses e na necessidade de reintervenção por reestenose clínica em 5 anos, sem aumentar o risco de...

Background: Biodegradable polymers were developed to reduce the hypersensitivity reaction associated to durable polymers found with the first generation drug-eluting stents, while maintaining antiproliferative efficacy and increasing safety. This study evaluated the 9-month angiographic follow-up and long-term clinical outcomes of biodegradable polymer-coated drug-eluting stents compared with identical platform metallic stents in patients with high-risk for restenosis. Methods: Patients with a reference diameter ≤ 2.5 mm, lesion length ≥ 15 mm, diabetes, or a combination of these characteristics were selected from the population of the PAINT trial. These patients were previously randomized and allocated for percutaneous coronary intervention with either a sirolimus-eluting biodegradable polymer-coated stent, a paclitaxel-eluting biodegradable polymer-coated stent, or an identical metallic platform stent, at a ratio of 2:2:1. Results: One hundred and seventy-eight patients were treated with biodegradable polymer-coated drug-eluting stents (n = 142) or bare metal stents (n = 36). At the 9-month angiographic follow-up, biodegradable polymercoated drug-eluting stents had lower rates of late loss (0.40 ± 0.42 mm vs. 0.90 ± 0.47 mm; p < 0.01) and binary restenosis (7.4% vs. 25%; p <0.01). In the 5-year clinical follow-up, the group with biodegradable polymer-coated drug-eluting stents had lower rates of the composite endpoint of cardiac death, myocardial infarction, and target vessel revascularization (16.2% vs. 38.0%; p = 0.03), especially due to the reduction of target vessel revascularization (9.9% vs. 36.1%; (p 0.01). Total death, cardiac death and myocardial infarction were not different among groups. 0% (p = 0.30). Conclusions: Paclitaxel or sirolimus-eluting biodegradable polymer-coated stents were effective in reducing angiographic restenosis at 9 months and the need of reintervention for clinical restenosis in 5...

Intravascular ultrasound guidance to minimize the use of iodine contrast in percutaneous coronary intervention: the MOZART (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy) randomized controlled trial.

OBJECTIVES: The aim of this study was to evaluate the impact of intravascular ultrasound (IVUS) guidance on the final volume of contrast agent used in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: To date, few approaches have been described to reduce the final dose of contrast agent in PCIs. We hypothesized that IVUS might serve as an alternative imaging tool to angiography in many steps during PCI, thereby reducing the use of iodine contrast. METHODS: A total of 83 patients were randomized to angiography-guided PCI or IVUS-guided PCI; both groups were treated according to a pre-defined meticulous procedural strategy. The primary endpoint was the total volume contrast agent used during PCI. Patients were followed clinically for an average of 4 months. RESULTS: The median total volume of contrast was 64.5 ml (interquartile range [IQR]: 42.8 to 97.0 ml; minimum, 19 ml; maximum, 170 ml) in the angiography-guided group versus 20.0 ml (IQR: 12.5 to 30.0 ml; minimum, 3 ml; maximum, 54 ml) in the IVUS-guided group (p < 0.001). Similarly, the median volume of contrast/creatinine clearance ratio was significantly lower among patients treated with IVUS-guided PCI (1.0 [IQR: 0.6 to 1.9] vs. 0.4 [IQR: 0.2 to 0.6, respectively; p < 0.001). In-hospital and 4-month outcomes were not different between patients randomized to angiography-guided and IVUS-guided PCI. CONCLUSIONS: Thoughtful and extensive use of IVUS as the primary imaging tool to guide PCI is safe and markedly reduces the volume of iodine contrast compared with angiography-alone guidance. The use of IVUS should be considered for patients at high risk of contrast-induced acute kidney injury or volume overload undergoing coronary angioplasty. (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy [MOZART]; NCT01947335).

Long term follow-up of drug eluting versus bare metal stents in the treatment of saphenous vein graft lesions.

INTRODUCTION: The safety and effectiveness of drug-eluting stent (DES) compared with bare metal stents (BMS) for the treatment of saphenous vein graft (SVG) disease is controversial, especially because of the lack of long-term follow-up. The aim of this study was to address the late outcome of DES versus BMS for the treatment of SVG lesions. METHODS: A matched, case-control study included 82 patients in each group. Patients groups were matched by gender, age, clinical presentation, and diabetes. The primary study end point was occurrence of major adverse cardiovascular events (MACE). Secondary end points included death, cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). RESULTS: Clinical and angiographic characteristics were similar between the groups. At 6 months, TVR (hazard ratio [HR] 6.12, 95% confidence interval [CI] 1.39 to 26.93, P = 0.05), and MACE (HR 2.54, 95% CI 1.08 to 5.98, P = 0.04) were higher in the BMS group. At 4 years the risks of MI (P = 0.21), TVR (P = 0.99), and MACE (P = 0.21) were similar between both groups. However, the rates of death (HR 2.74, 95% CI 1.11 to 6.74, P = 0.04) and cardiac death (HR 4.26, 95% CI 1.59 to 11.35, P = 0.01) were significantly higher in the BMS group. CONCLUSIONS: These results suggest that the use of DES compared with BMS in the treatment of SVG lesions reduces TVR and MACE at 6 months of follow-up, a benefit that was lost over the next 3-4 years.

Utilidade clínica da angiografia coronária e da ressonância nuclear magnética no diagnóstico da cardiomiopatia isquêmica / Clinical use of coronary angiography and magnetic resonance imaging in the diagnosis of ischemic cardiomyopathy

INTRODUÇÃO: O diagnóstico da cardiomiopatia isquêmica é frequentemente difícil. A angiografia coronária (AC) é limitada, por ser invasiva e de avaliação exclusivamente anatômica. A ressonância nuclear magnética cardíaca (RNM) com realce tardio pelo gadolínio (RTG) pode mensurar padrões de fibrose miocárdica ocasionados pela isquemia. Porém, o RTG pode não detectar isquemia que não resultou em fibrose. Assim, uma avaliação clínica meticulosa pelo cardiologista parece ser a maneira mais eficaz para definir o diagnóstico. O objetivo deste estudo foi avaliar a AC e o RTG como métodos complementares para o diagnóstico de cardiomiopatia isquêmica em pacientes com insuficiência cardíaca sistólica sem etiologia definida. MÉTODOS: Pacientes com insuficiência cardíaca sistólica, fração de ejeção do ventrículo esquerdo < 45% e etiologia indefinida após avaliação não invasiva inicial foram submetidos à AC e à RNM com RTG para definição etiológica. A análise dos casos por dois cardiologistas foi o padrão-ouro para o diagnóstico de cardiomiopatia isquêmica. RESULTADOS: Foram incluídos 24 pacientes. A sensibilidade para detecção de cardiomiopatia isquêmica foi de 0,45 para AC vs. 0,81 do RTG. A especificidade da AC foi de 1,0 vs. 0,84 do RTG. O valor preditivo positivo foi de 1,0 vs. 0,81, e o valor preditivo negativo foi 0,68 vs. 0,84 para AC e do RTG, respectivamente. A acurácia do RTG foi superior a da AC (0,83 vs. 0,75). CONCLUSÕES: O RTG foi mais sensível do que a AC na avaliação etiológica da disfunção ventricular, enquanto a AC foi mais específica. A definição de cardiomiopatia isquêmica utilizando cada um dos métodos em separado apresentou limitações.

BACKGROUND: The diagnosis of ischemic cardiomyopathy is frequently difficult. Coronary angiography (CA) is limited because it is invasive and the evaluation is exclusively anatomic. Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) measures patterns of myocardial fibrosis caused by ischemia. However, LGE does not detect ischemia that does not result in fibrosis. Thus, a thorough clinical evaluation by a cardiologist seems to be the most effective option for diagnosis. The aim of this study was to evaluate CA and LGE as complementary methods for the diagnosis of ischemic cardiomyopathy in patients with systolic heart failure of unknown etiology. METHODS: Patients with systolic heart failure, left ventricle ejection fraction < 45% and unknown etiology after initial non-invasive evaluation were submitted to CA and MRI with LGE to define the etiology of the disease. Patient evaluation by two cardiologists was the gold standard for the diagnosis of ischemic cardiomyopathy. RESULTS: Twenty-four patients were included. The sensitivity to detect ischemic cardiomyopathy was 0.45 for CA vs. 0.81 for LGE. The specificity was 1.0 for CA vs. 0.84 for LGE. The positive predictive value was 1.0 vs. 0.81 and the negative predictive value was 0.68 vs. 0.84 for CA and LGE, respectively. LGE accuracy was superior to CA accuracy (0.83 vs. 0.75). CONCLUSIONS: LGE was more sensitive than CA to evaluate the etiology of ventricular dysfunction, whereas CA was more specific. The diagnosis of ischemic cardiomyopathy using each one of the methods separately presented limitations.

Hypotheses, rationale, design, and methods for prognostic evaluation of cardiac biomarker elevation after percutaneous and surgical revascularization in the absence of manifest myocardial infarction. A comparative analysis of biomarkers and cardiac magnetic resonance. The MASS-V Trial.

BACKGROUND: Although the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis. METHODS/DESIGN: The study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR. DISCUSSION: The MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.

Prognóstico tardio em jovens com coronariopatia estável: evolução em 10 anos após intervenção coronária percutânea / Late prognosis in young patients with stable coronary disease: 10-years follow-up of percutaneous coronary intervention

Introdução: Atualmente são ainda desconhecidas as implicaçõesprognósticas tardias da doença arterial coronária (DAC) estável em pacientes jovens. O objetivo deste trabalho foiavaliar o prognóstico de pacientes adultos jovens com diagnóstico de DAC estável, tratados por meio de intervenção coronária percutânea (ICP) e acompanhados por até 10 anos.Métodos: A população do estudo foi constituída por pacientes jovens (idade abaixo do 10o percentil) de um grupo de 1.394 pacientes consecutivos tratados para DAC estável por via percutânea.As características dos pacientes foram coletadas prospectivamente. Após o procedimento foi realizado seguimentoambulatorial, com análise do prontuário hospitalar eletrônico e contato telefônico, quando necessário. O desfecho primário foi a mortalidade geral e o desfecho secundário, a mortalidade cardiovascular. Resultados: Foram selecionados 140 pacientes, com média de idade de 43,7 ± 4 anos (mínimo de 26 anos e máximo de 48 anos), predominantemente do sexo masculino (76,4%). Diabetes melito estava presente em aproximadamenteum quinto dos pacientes e metade apresentava infarto prévio. Os pacientes foram seguidos por uma média de 94,6 ±36,2 meses e a mortalidade geral no seguimento de 10 anos foi de 6%, com mortalidade cardíaca de 5,3%. Todos ospacientes que morreram obtiveram sucesso no procedimento inicial e apenas um dos casos não apresentava infarto prévio. Conclusões: Em nossa prática clínica, pacientes jovens com coronariopatia crônica tratados com ICP mostraram ter bom prognóstico tardio.