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The 2021 Coronary Artery Disease revascularization guidelines of the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI) provide recommendations for managing nonculprit arteries in ST-segment elevation myocardial infarction (STEMI). Although staged revascularization is preferred, at times same-setting intervention, coronary artery bypass surgery, or medical therapy may be preferable. These cases exemplify clinical scenarios for treating nonculprit arteries in STEMI. (Level of Difficulty: Intermediate.).
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AIM: The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Cardiologia/normas , Doença da Artéria Coronariana/terapia , Revascularização Miocárdica/normas , American Heart Association , Humanos , Revascularização Miocárdica/métodos , Estados UnidosRESUMO
AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
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Doença da Artéria Coronariana/terapia , Revascularização Miocárdica/normas , Algoritmos , American Heart Association , Tomada de Decisão Compartilhada , Diabetes Mellitus , Terapia Antiplaquetária Dupla , Humanos , Revascularização Miocárdica/métodos , Equipe de Assistência ao Paciente , Medição de Risco , Estados UnidosRESUMO
AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
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Cardiologia/normas , Ponte de Artéria Coronária/normas , Revascularização Miocárdica/normas , Intervenção Coronária Percutânea/normas , Procedimentos Cirúrgicos Vasculares/normas , American Heart Association/organização & administração , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Vasos Coronários/cirurgia , Humanos , Estados Unidos , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
Pluripotent stem cell-derived cardiomyocyte grafts can remuscularize substantial amounts of infarcted myocardium and beat in synchrony with the heart, but in some settings cause ventricular arrhythmias. It is unknown whether human cardiomyocytes can restore cardiac function in a physiologically relevant large animal model. Here we show that transplantation of â¼750 million cryopreserved human embryonic stem cell-derived cardiomyocytes (hESC-CMs) enhances cardiac function in macaque monkeys with large myocardial infarctions. One month after hESC-CM transplantation, global left ventricular ejection fraction improved 10.6 ± 0.9% vs. 2.5 ± 0.8% in controls, and by 3 months there was an additional 12.4% improvement in treated vs. a 3.5% decline in controls. Grafts averaged 11.6% of infarct size, formed electromechanical junctions with the host heart, and by 3 months contained â¼99% ventricular myocytes. A subset of animals experienced graft-associated ventricular arrhythmias, shown by electrical mapping to originate from a point-source acting as an ectopic pacemaker. Our data demonstrate that remuscularization of the infarcted macaque heart with human myocardium provides durable improvement in left ventricular function.
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Diferenciação Celular/genética , Células-Tronco Embrionárias Humanas/transplante , Infarto do Miocárdio/terapia , Miócitos Cardíacos/transplante , Animais , Criopreservação , Modelos Animais de Doenças , Humanos , Macaca , Infarto do Miocárdio/patologia , Miocárdio/patologia , Miócitos Cardíacos/citologia , Células-Tronco Pluripotentes/transplante , PrimatasRESUMO
Thrombotic aortic valve restenosis following transcatheter aortic valve replacement (TAVR) has not been extensively reported and the rates of TAVR valve thrombosis are not known. We present three cases of valve-in-valve (VIV) restenosis following TAVR with the balloon expandable transcatheter heart valves, presumably due to valve thrombosis that improved with anticoagulation. © 2016 Wiley Periodicals, Inc.
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Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Trombose/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Valvuloplastia com Balão/efeitos adversos , Ecocardiografia Doppler , Ecocardiografia Transesofagiana , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Trombose/fisiopatologia , Resultado do TratamentoRESUMO
A 71-year-old man presented with New York Heart Association (NYHA) class IV heart failure. He had undergone transapical mitral valve replacement for mixed mitral stenosis and mitral regurgitation. At the 1 month follow-up, the patient reported symptom resolution. An echocardiogram revealed a low gradient and no regurgitation. Our case shows that with careful multidisciplinary evaluation, preoperative planning, and patient selection, percutaneous mitral intervention can become an alternative therapy for high-risk patients who cannot undergo conventional surgical therapy.
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Angioplastia/métodos , Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Estenose da Valva Mitral/cirurgia , Idoso , Cateterismo Cardíaco/métodos , Ponte Cardiopulmonar/métodos , Ecocardiografia Doppler , Seguimentos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/diagnóstico por imagem , Desenho de Prótese , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Aortic pseudoaneurysms (APSAs) are an uncommon but serious complication of aortic surgery with potentially fatal complications if left untreated. Operative repair is associated with significant morbidity and mortality. Percutaneous APSA repair may reduce the risk of these complications and represents an alternative option for patients. We report our experience with percutaneous intervention for the treatment of APSAs. METHODS AND RESULTS: We retrospectively reviewed all patients at our institution who underwent percutaneous APSA repair with Amplatzer septal occluders and vascular plugs between January 2004 and September 2014. Ten patients are included in this study, representing our first cases of percutaneous APSA repair. Follow-up was performed with serial computed tomographic angiography. The primary outcome was the success rate of device deployment. Secondary outcomes included success rate of complete APSA exclusion, postprocedural symptoms, and periprocedural and postprocedural complications. Mean clinical follow-up time was 12 months (range, 5-30 months) and mean imaging follow-up time was 29 months (range, 14-52 months). Device deployment was successful in all patients, although 2 patients required reintervention due to device malposition and the discovery of additional defects on postprocedure CT angiography. There were no periprocedural or postprocedure complications. Long-term follow-up imaging was available for 7 patients and revealed complete APSA exclusion in 4 patients. One out of the remaining 3 patients ultimately required operative intervention. CONCLUSIONS: Percutaneous APSA repair can be performed safely with a good procedural success, albeit with variable long-term results. This procedure may be considered as an alternative to surgical repair in select patients.
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Falso Aneurisma , Angioplastia , Aorta Torácica , Aneurisma Aórtico , Implante de Prótese Vascular , Complicações Pós-Operatórias/prevenção & controle , Dispositivo para Oclusão Septal , Adulto , Assistência ao Convalescente , Idoso , Idoso de 80 Anos ou mais , Falso Aneurisma/diagnóstico , Falso Aneurisma/fisiopatologia , Falso Aneurisma/cirurgia , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Angioplastia/métodos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/fisiopatologia , Aneurisma Aórtico/cirurgia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/métodos , Angiografia por Tomografia Computadorizada/métodos , Ecocardiografia/métodos , Feminino , Humanos , Efeitos Adversos de Longa Duração/diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Instrumentos Cirúrgicos , Resultado do Tratamento , Estados Unidos , Dispositivos de Acesso VascularRESUMO
BACKGROUND: This study describes short-term and mid-term outcomes of nonagenarian patients undergoing transfemoral or transapical transcatheter aortic valve replacement (TAVR) in the Placement of Aortic Transcatheter Valve (PARTNER)-I trial. METHODS: From April 2007 to February 2012, 531 nonagenarians, mean age 93 ± 2.1 years, underwent TAVR with a balloon-expandable prosthesis in the PARTNER-I trial: 329 through transfemoral (TF-TAVR) and 202 transapical (TA-TAVR) access. Clinical events were adjudicated and echocardiographic results analyzed in a core laboratory. Quality of life (QoL) data were obtained up to 1 year post-TAVR. Time-varying all-cause mortality was referenced to that of an age-sex-race-matched US population. RESULTS: For TF-TAVR, post-procedure 30-day stroke risk was 3.6%; major adverse events occurred in 35% of patients; 30-day paravalvular leak was greater than moderate in 1.4%; median post-procedure length of stay (LOS) was 5 days. Thirty-day mortality was 4.0% and 3-year mortality 48% (44% for the matched population). By 6 months, most QoL measures had stabilized at a level considerably better than baseline, with Kansas City Cardiomyopathy Questionnaire (KCCQ) 72 ± 21. For TA-TAVR, post-procedure 30-day stroke risk was 2.0%; major adverse events 32%; 30-day paravalvular leak was greater than moderate in 0.61%; and median post-procedure LOS was 8 days. Thirty-day mortality was 12% and 3-year mortality 54% (42% for the matched population); KCCQ was 73 ± 23. CONCLUSIONS: A TAVR can be performed in nonagenarians with acceptable short- and mid-term outcomes. Although TF- and TA-TAVR outcomes are not directly comparable, TA-TAVR appears to carry a higher risk of early death without a difference in intermediate-term mortality. Age alone should not preclude referral for TAVR in nonagenarians.
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Substituição da Valva Aórtica Transcateter , Fatores Etários , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoRESUMO
Pluripotent stem cells provide a potential solution to current epidemic rates of heart failure by providing human cardiomyocytes to support heart regeneration. Studies of human embryonic-stem-cell-derived cardiomyocytes (hESC-CMs) in small-animal models have shown favourable effects of this treatment. However, it remains unknown whether clinical-scale hESC-CM transplantation is feasible, safe or can provide sufficient myocardial regeneration. Here we show that hESC-CMs can be produced at a clinical scale (more than one billion cells per batch) and cryopreserved with good viability. Using a non-human primate model of myocardial ischaemia followed by reperfusion, we show that cryopreservation and intra-myocardial delivery of one billion hESC-CMs generates extensive remuscularization of the infarcted heart. The hESC-CMs showed progressive but incomplete maturation over a 3-month period. Grafts were perfused by host vasculature, and electromechanical junctions between graft and host myocytes were present within 2 weeks of engraftment. Importantly, grafts showed regular calcium transients that were synchronized to the host electrocardiogram, indicating electromechanical coupling. In contrast to small-animal models, non-fatal ventricular arrhythmias were observed in hESC-CM-engrafted primates. Thus, hESC-CMs can remuscularize substantial amounts of the infarcted monkey heart. Comparable remuscularization of a human heart should be possible, but potential arrhythmic complications need to be overcome.
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Células-Tronco Embrionárias/citologia , Coração , Infarto do Miocárdio/patologia , Infarto do Miocárdio/terapia , Miócitos Cardíacos/citologia , Regeneração , Animais , Arritmias Cardíacas/fisiopatologia , Cálcio/metabolismo , Sobrevivência Celular , Vasos Coronários/fisiologia , Criopreservação , Modelos Animais de Doenças , Eletrocardiografia , Humanos , Macaca nemestrina , Masculino , Camundongos , Medicina Regenerativa/métodosRESUMO
Human embryonic stem cells (hESCs) can be differentiated into structurally and electrically functional myocardial tissue and have the potential to regenerate large regions of infarcted myocardium. One of the key challenges that needs to be addressed towards full-scale clinical application of hESCs is enhancing survival of the transplanted cells within ischaemic or scarred, avascular host tissue. Shortly after transplantation, most hESCs are lost as a result of multiple mechanical, cellular and host factors, and a large proportion of the remaining cells undergo apoptosis or necrosis shortly thereafter, as a result of loss of adhesion-related signals, ischaemia, inflammation or immunological rejection. Blocking the apoptotic signalling pathways of the cells, using pro-survival cocktails, conditioning hESCs prior to transplant, promoting angiogenesis, immunosuppressing the host and using of bioengineered matrices are among the emerging techniques that have been shown to optimize cell survival. This review presents an overview of the current strategies for optimizing cell and host tissue to improve the survival and efficacy of cardiac cells derived from pluripotent stem cells.
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Sobrevivência Celular , Cardiopatias/terapia , Células-Tronco Pluripotentes/fisiologia , Animais , Vasos Coronários/fisiopatologia , Células-Tronco Embrionárias/fisiologia , Células-Tronco Embrionárias/transplante , Sobrevivência de Enxerto , Humanos , Miocárdio/imunologia , Miocárdio/patologia , Células-Tronco Pluripotentes/transplante , Medicina RegenerativaRESUMO
OBJECTIVE: In an effort to expand the cardiac donor pool, we tested the hypothesis that hemoadsorption of cytokines attenuates brain death-induced ventricular dysfunction. METHODS: Eighteen Yorkshire pigs (50-60 kg) were instrumented with a left ventricular conductance catheter. Cytokine expression, preload recruitable stroke work, and the diastolic relaxation constant tau were measured at baseline and at hourly intervals for 6 hours after induction of brain death by intracranial balloon inflation (brain death, n = 6) or sham operation (control, n = 6). In a third group (brain death + hemoadsorption, n = 6), 3 hours after induction of brain death, animals were placed on an extracorporeal circuit containing a cytokine-hemoadsorption device for the remaining 3 hours of the experiment. Myocardial water content was measured after the animals were killed. RESULTS: Six hours after induction of brain death, tumor necrosis factor and interleukin-6 were highest in the brain death group (106 ± 13.1 pg/mL and 301 ± 181 pg/mL, respectively), lowest in controls (68.3 ± 8.55 pg/mL and 37.8 ± 11 pg/mL, respectively), and intermediate in the brain death + hemoadsorption group (81.2 ± 35.2 pg/mL and 94.6 ± 20 pg/mL, respectively). Compared with controls, preload recruitable stroke work was significantly reduced in the brain death group 4 hours after the induction of brain death and was 50% of baseline by 5 hours. In the brain death + hemoadsorption group, preload recruitable stroke work was relatively preserved at 80% of baseline at similar time points. Tau remained unchanged in the control and brain death + hemoadsorption groups, whereas in the brain death group it was significantly elevated versus baseline 5 (139.3% ± 21.5%) and 6 (172% ± 16.1%) hours after induction of brain death. Myocardial water content was significantly greater in the brain death group than in the other 2 groups. CONCLUSIONS: Hemoadsorption of cytokines using an extracorporeal circuit attenuates brain death-induced ventricular dysfunction in a porcine model. Improvement in function generally correlates with trends in cytokine expression, but this relationship requires further investigation.
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Morte Encefálica , Citocinas/sangue , Oxigenação por Membrana Extracorpórea , Hemadsorção , Disfunção Ventricular Esquerda/prevenção & controle , Função Ventricular Esquerda , Animais , Biópsia , Cateterismo Cardíaco , Diástole , Modelos Animais de Doenças , Interleucina-6/sangue , Masculino , Volume Sistólico , Sus scrofa , Fatores de Tempo , Fator de Necrose Tumoral alfa/sangue , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/imunologia , Disfunção Ventricular Esquerda/fisiopatologia , Pressão VentricularRESUMO
BACKGROUND: Previous studies indicated that patients undergoing coronary artery bypass graft (CABG) surgery are less likely to receive guideline-based secondary prevention therapy than are those undergoing percutaneous coronary intervention (PCI) after an acute myocardial infarction. We aimed to evaluate whether these differences have persisted after the implementation of public reporting of hospital metrics. METHODS AND RESULTS: The Clinical Outcomes Assessment Program (COAP) database was analyzed retrospectively to evaluate adherence to secondary prevention guidelines at discharge in patients who underwent coronary revascularization after an acute ST-elevation myocardial infarction in Washington State. From 2004 to 2007, 9260 patients received PCI and 692 underwent CABG for this indication. Measures evaluated included prescription of aspirin, ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, or lipid-lowering medications; cardiac rehabilitation referral; and smoking-cessation counseling. Composite adherence was lower for CABG than for PCI patients during the period studied (79.6% versus 89.7%, P<0.01). Compared to patients who underwent CABG, patients who underwent PCI were more likely to receive each of the pharmacological therapies. There was no statistical difference in smoking-cessation counseling (91.7% versus 90.3%, P=0.63), and CABG patients were more likely to receive referral for cardiac rehabilitation (70.9% versus 48.3%, P<0.01). Adherence rates improved over time among both groups, with no significant difference in composite adherence in 2006 (85.6% versus 87.6%, P=0.36). CONCLUSIONS: Rates of guideline-based secondary prevention adherence in patients with ST-elevation myocardial infarction who underwent CABG surgery have been improving steadily in Washington State. The improvement possibly is associated with the implementation of public reporting of quality measures.
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Ponte de Artéria Coronária/reabilitação , Fidelidade a Diretrizes , Cooperação do Paciente , Intervenção Coronária Percutânea/reabilitação , Prevenção Secundária/normas , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Feminino , Humanos , Hipolipemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Avaliação de Resultados em Cuidados de Saúde , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos , WashingtonRESUMO
OBJECTIVES: We describe characteristics associated with use of endarterectomy (CEA) versus stenting (CAS) in patients before urgent cardiac surgery. BACKGROUND: The optimal modality of carotid revascularization preceding cardiac surgery is unknown. METHODS: Retrospective evaluation of the CARE (Carotid Artery Revascularization and Endarterectomy) registry from January 2005 to April 2010 was performed on patients undergoing CEA or CAS preceding urgent cardiac surgery within 30 days. Baseline characteristics were compared, and multivariate adjustment was performed. RESULTS: Of 451 patients who met study criteria, 255 underwent CAS and 196 underwent CEA. Both procedures increased over time to a similar degree (p = 0.18). Patients undergoing CAS had more frequent history of peripheral artery disease (38.2% vs. 26.5%, p < 0.01), neck surgery (5.5% vs. 1.0%, p = 0.01), neck radiation (4.3% vs. 1.0%, p = 0.04), left-main coronary disease (34.8% vs. 23.5%, p < 0.01), neurological events (45.8% vs. 31.3%, p < 0.01), carotid intervention (20.8% vs. 7.6%, p < 0.01), and higher baseline creatinine (1.3 vs. 1.1 mg/dl, p = 0.02). The target carotid arteries of CAS patients were more likely to be symptomatic in the 6 months before revascularization and have restenosis from prior CEA. Patients undergoing CAS had a lower American Society of Anesthesiology grade. Midwest hospitals were less likely to perform CAS than CEA, whereas in the other regions CAS was more common (p < 0.01). Non-Caucasian race, a history of heart failure, previous carotid procedures, prior stroke, left main coronary artery stenosis, lower American Society of Anesthesiology grade, and teaching hospital were independent predictors of patients who would receive CAS. CONCLUSIONS: Carotid artery stenting and CEA have increased among patients undergoing urgent cardiac surgery. Patients who underwent CAS had more vascular disease but lower acute pre-surgical risk. Significant regional variation in procedure selection exists.
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Angioplastia/instrumentação , Procedimentos Cirúrgicos Cardíacos , Doenças das Artérias Carótidas/terapia , Endarterectomia das Carótidas , Cardiopatias/cirurgia , Padrões de Prática Médica , Stents , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Feminino , Disparidades em Assistência à Saúde , Cardiopatias/complicações , Cardiopatias/diagnóstico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Sistema de Registros , Características de Residência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: There is speculation that the volume of percutaneous coronary interventions (PCIs) has been decreasing over the past several years. Published studies of PCI volume have evaluated regional or hospital trends, but few have captured national data. This study describes the use of coronary angiography and revascularization methods in Medicare patients from 2001 to 2009. METHODS AND RESULTS: This retrospective study used data from the Centers for Medicare & Medicaid Services from 2001 to 2009. The annual number of coronary angiograms, PCI, intravascular ultrasound, fractional flow reserve, and coronary artery bypass graft (CABG) surgery procedures were determined from billing data and adjusted for the number of Medicare recipients. From 2001 to 2009, the average year-to-year increase for PCI was 1.3% per 1000 beneficiaries, whereas the mean annual decrease for CABG surgery was 5%. However, the increase in PCI volume occurred primarily from 2001 to 2004, as there was a mean annual rate of decline of 2.5% from 2004 to 2009; similar trends were seen with diagnostic angiography. The use of intravascular ultrasound and fractional flow reserve steadily increased over time. CONCLUSIONS: This study confirms recent speculation that PCI volume has begun to decrease. Although rates of CABG have waned for several decades, all forms of coronary revascularization have been declining since 2004.
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Angioplastia Coronária com Balão/estatística & dados numéricos , Angioplastia Coronária com Balão/tendências , Doença da Artéria Coronariana/terapia , Angiografia Coronária/estatística & dados numéricos , Angiografia Coronária/tendências , Ponte de Artéria Coronária/estatística & dados numéricos , Ponte de Artéria Coronária/tendências , Doença da Artéria Coronariana/epidemiologia , Humanos , Medicare/estatística & dados numéricos , Estudos Retrospectivos , Ultrassonografia de Intervenção/estatística & dados numéricos , Ultrassonografia de Intervenção/tendências , Estados Unidos/epidemiologiaRESUMO
Percutaneous balloon aortic valvuloplasty (PBAV) is a procedure used for palliation, bridging to surgery, and as an integral step in the procedure for percutaneous aortic valve replacement. Older patients with severe aortic stenosis are thought to have greater risk for adverse perioperative events than younger patients. The aim of this study was to evaluate the outcomes of patients aged >80 years and those aged < or =80 years who underwent PBAV to identify factors associated with adverse clinical outcomes. This was a retrospective study of 111 consecutive patients with severe symptomatic aortic stenosis who underwent retrograde PBAV at Massachusetts General Hospital from December 2004 to December 2008. Forty-nine patients (44%) were men, and the mean age for the whole group was 82 +/- 8 years. Patients were divided into 2 age groups: those aged >80 years (n = 73) and those aged < or =80 years (n = 38). Procedural outcomes, complications, and in-hospital adverse events were compared. Multivariate logistic regression was used for the adjusted analysis. Nearly 90% of patients were in New York Heart Association class III or IV. Patients aged >80 years had lower baseline ejection fractions (43.5% vs 56.1%, p <0.01) and smaller aortic valve areas (0.59 vs 0.73 cm(2), p <0.01). Although the 2 age groups had a similar percentage of aortic valve area increase (55.5% vs 45.2%, p = 0.28), those aged >80 years had smaller post-PBAV aortic valve areas (0.89 vs 1.02 cm(2), p <0.05). Overall, in-hospital mortality was 8.1%, with no significant differences between the groups. Advanced age was not an independent predictor of in-hospital death, myocardial infarction, stroke, cardiac arrest, or tamponade; however, patients aged >80 years had a significantly higher incidence of intraprocedural emergent intubation and cardiopulmonary resuscitation compared to the younger group. New York Heart Association class was the only independent predictor of worse in-hospital outcomes. In conclusion, compared to younger patients, those aged >80 years had less favorable preprocedural characteristics for PBAV but similar overall in-hospital clinical outcomes. Patients aged >80 years had significantly higher incidence of emergent intubation and cardiopulmonary resuscitation during PBAV.
Assuntos
Estenose da Valva Aórtica/terapia , Oclusão com Balão , Reanimação Cardiopulmonar/estatística & dados numéricos , Cateterismo/métodos , Pacientes Internados , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Ecocardiografia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Massachusetts/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The use of the Rotablator rotational atherectomy device in the body of saphenous vein coronary grafts is currently contraindicated by the manufacturer (Boston Scientific Corp., Natick, Massachusetts). While rotational atherectomy in soft lesions in friable vein grafts would likely lead to complications, for severely calcified lesions that are non-dilatable, rotational atherectomy can arguably be performed safely. We present a case in which a non-dilatable, calcified saphenous vein coronary graft is successfully treated with rotational atherectomy.
Assuntos
Aterectomia Coronária/métodos , Ponte de Artéria Coronária/métodos , Veia Safena/cirurgia , Idoso , Constrição Patológica/cirurgia , Humanos , Masculino , Infarto do Miocárdio/terapia , Veia Safena/transplante , Resultado do TratamentoRESUMO
The no-reflow phenomenon is a poorly understood complication of percutaneous coronary intervention in which diminished blood flow to distal microvascular beds persists despite the successful treatment of the occlusive lesion from the epicardial coronary artery or arteries. In this contemporary review we endeavour to discuss the pathophysiology of coronary no-reflow, understand the predictors and describe current pharmacological and mechanical strategies to prevent and treat coronary no-reflow.
Assuntos
Circulação Coronária , Fenômeno de não Refluxo/tratamento farmacológico , Fenômeno de não Refluxo/fisiopatologia , Adenosina/uso terapêutico , Animais , Diltiazem/uso terapêutico , Humanos , Nicardipino/uso terapêutico , Nicorandil/uso terapêutico , Nitroprussiato/uso terapêutico , Fenômeno de não Refluxo/terapia , Próteses e Implantes , Vasodilatadores/uso terapêutico , Verapamil/uso terapêuticoRESUMO
BACKGROUND AND PURPOSE: Findings on transesophageal echocardiography (TEE) after ischemic stroke predict recurrent embolic events and prompt therapy; however, the additive predictive power of TEE findings on long-term mortality is unknown. Our goal was to study the impact of TEE findings on all cause mortality in ischemic stroke patients referred for TEE. METHODS: We reviewed 245 consecutive patients who underwent TEE for ischemic stroke of undetermined origin (2000 to 2003). Long-term survival was assessed using the Social Security Death Index. RESULTS: In a mean follow-up period of 3.0 (1.4 to 4.8) years, death occurred in 19.2% of patients. TEE findings included patent foramen ovale (18.8%), left atrium/left ventricle thrombus (2.4%), spontaneous echo contrast (3.7%), atrial septal aneurysm (3.3%), valve vegetation/mass/tumor (7.8%), complex aortic atheroma ([CAA]; 14.7%), and the composite of any cardiac source of embolus (39.2%). A total atherosclerotic burden (TAB) score was also recorded. On Cox hazard regression analysis, measures of aortic atherosclerosis (CAA [hazard ratio (HR), 2.7; 95% CI, 1.4 to 5.3] or TAB score [HR, 1.4; 95% CI, 1.2 to 1.6]) were independent predictors of death, whereas other TEE findings were not. CONCLUSIONS: In patients with ischemic stroke of undetermined origin referred for TEE, measures of aortic atherosclerosis, including CAA, represent the only TEE findings that predict long-term mortality after all other clinical factors are considered. Further study is needed to determine whether treatments for CAA effect long-term survival in patients with ischemic stroke.