RESUMO
OBJECTIVES: Cardiac surgery for coronary artery disease was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with disease ordinarily treated with coronary artery bypass grafting (CABG) instead underwent percutaneous coronary intervention (PCI). We sought to describe 12-month outcomes following PCI in patients who would typically have undergone CABG. METHODS: Between March 1 and July 31, 2020, patients who received revascularization with PCI when CABG would have been the primary choice of revascularization were enrolled in the prospective, multicenter UK-ReVasc Registry. We evaluated the following major adverse cardiovascular events at 12 months: all-cause mortality, myocardial infarction, repeat revascularization, stroke, major bleeding, and stent thrombosis. RESULTS: A total of 215 patients were enrolled across 45 PCI centers in the United Kingdom. Twelve-month follow up data were obtained for 97% of the cases. There were 9 deaths (4.3%), 5 myocardial infarctions (2.4%), 12 repeat revascularizations (5.7%), 1 stroke (0.5%), 3 major bleeds (1.4%), and no cases of stent thrombosis. No difference in the primary endpoint was observed between patients who received complete vs incomplete revascularization (residual SYNTAX score £ 8 vs > 8) (P = .22). CONCLUSIONS: In patients with patterns of coronary disease in whom CABG would have been the primary therapeutic choice outside of the pandemic, PCI was associated with acceptable outcomes at 12 months of follow-up. Contemporary randomized trials that compare PCI to CABG in such patient cohorts may be warranted.
RESUMO
A woman in her 70s presented with chest pain, which was initially thought to be an acute coronary syndrome but subsequently felt to be pericarditis. Chest radiography and echocardiography demonstrated striking cardiomegaly and marked biatrial dilatation, likely secondary to undiagnosed restrictive cardiomyopathy. The patient remained well on the ward for some days with only mild discomfort and stable haemodynamics. CT of the thorax went on to unexpectedly demonstrate a Stanford type A aortic dissection. The patient was promptly transferred for emergent surgery but sadly died intraoperatively.Delayed or missed diagnosis of acute aortic dissection (AAD) is common. The dual-processing theory (DPT) of human judgement can be applied to medical decision making and used to explain this potential for diagnostic error in AAD diagnosis. A greater awareness of DPT and the role of heuristics and biases in medical decision making may help to reduce medical diagnostic error.
Assuntos
Dissecção Aórtica , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Dor no Peito , Erros de Diagnóstico , Ecocardiografia , Feminino , HumanosRESUMO
OBJECTIVES: To describe outcomes following percutaneous coronary intervention (PCI) in patients who would usually have undergone coronary artery bypass grafting (CABG). BACKGROUND: In the United Kingdom, cardiac surgery for coronary artery disease (CAD) was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with "surgical disease" instead underwent PCI. METHODS: Between 1 March 2020 and 31 July 2020, 215 patients with recognized "surgical" CAD who underwent PCI were enrolled in the prospective UK-ReVasc Registry (ReVR). 30-day major cardiovascular event outcomes were collected. Findings in ReVR patients were directly compared to reference PCI and isolated CABG pre-COVID-19 data from British Cardiovascular Intervention Society (BCIS) and National Cardiac Audit Programme (NCAP) databases. RESULTS: ReVR patients had higher incidence of diabetes (34.4% vs 26.4%, P = .008), multi-vessel disease with left main stem disease (51.4% vs 3.0%, P < .001) and left anterior descending artery involvement (94.8% vs 67.2%, P < .001) compared to BCIS data. SYNTAX Score in ReVR was high (mean 28.0). Increased use of transradial access (93.3% vs 88.6%, P = .03), intracoronary imaging (43.6% vs 14.4%, P < .001) and calcium modification (23.6% vs 3.5%, P < .001) was observed. No difference in in-hospital mortality was demonstrated compared to PCI and CABG data (ReVR 1.4% vs BCIS 0.7%, P = .19; vs NCAP 1.0%, P = .48). Inpatient stay was half compared to CABG (3.0 vs 6.0 days). Low-event rates in ReVR were maintained to 30-day follow-up. CONCLUSIONS: PCI undertaken using contemporary techniques produces excellent short-term results in patients who would be otherwise CABG candidates. Longer-term follow-up is essential to determine whether these outcomes are maintained over time.
Assuntos
COVID-19 , Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Ponte de Artéria Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Hirudinas , Humanos , Pandemias , Estudos Prospectivos , Proteínas Recombinantes , Sistema de Registros , SARS-CoV-2 , Resultado do TratamentoRESUMO
OBJECTIVES: Recent improvements in coronary stent design have focussed on thinner struts, different alloys and architecture, more biocompatible polymers, and shorter drug absorption times. This study evaluates safety and efficacy of a newer generation thin-strut cobalt chromium sirolimus-eluting coronary stent (SES, Ultimaster) in comparison with a second-generation thicker strut stainless steel biolimus-eluting stent (BES, Nobori) in percutaneous coronary intervention (PCI) practice. METHODS: A propensity score analysis was performed to adjust for differences in baseline characteristics of 8137 SES patients and 2738 BES patients of two PCI registries (e-Ultimaster and NOBORI 2). An independent clinical event committee adjudicated all endpoint-related adverse events. RESULTS: The use of SES, as compared with BES was associated with a significantly lower rate of myocardial infarction (MI) (1.2% vs 2.2%; P = 0.0006) and target vessel-related MI (1.1% vs 1.8%; P = 0.002) at 1 year. One-year composite endpoints of all predefined endpoints were lower in patients undergoing SES implantation (target lesion failure: 3.2% vs 4.1%; P = 0.03, target vessel failure: 3.7% vs 5.0%; P = 0.003, patient-oriented composite endpoint 5.7% vs 6.8%; P = 0.03). No significant differences between SES and BES were observed in all-cause death (2.0% vs 1.6%; P = 0.19), cardiac death (1.2% vs 1.2%; P = 0.76) or stent thrombosis (0.6% vs 0.8%; P = 0.43). CONCLUSIONS: These findings suggest an improved clinical safety and efficacy of a newer generation thin-strut SES as compared with a second-generation thicker strut BES.
Assuntos
Ligas de Cromo/farmacologia , Doença da Artéria Coronariana/cirurgia , Reestenose Coronária , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Complicações Pós-Operatórias , Sirolimo/análogos & derivados , Sirolimo/farmacologia , Idoso , Materiais Biocompatíveis/farmacologia , Reestenose Coronária/diagnóstico , Reestenose Coronária/etiologia , Reestenose Coronária/mortalidade , Stents Farmacológicos/efeitos adversos , Stents Farmacológicos/classificação , Análise de Falha de Equipamento , Feminino , Humanos , Imunossupressores/farmacologia , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Desenho de Prótese , Sistema de Registros/estatística & dados numéricos , Análise de SobrevidaRESUMO
A 44-year-old woman presented to the emergency department with central crushing chest pain and dynamic anterior ST elevation on a background of a known left bundle-branch block on her electrocardiogram. Past medical history included insulin-dependent diabetes, asthma, fibromyalgia, and a gradually failing kidney transplant. This case demonstrates the rarely utilized niche role for intracoronary thrombolysis in STEMI treatment in the modern angioplasty era.
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Doença da Artéria Coronariana , Vasos Coronários , Rejeição de Enxerto/complicações , Insuficiência Renal Crônica , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Cateterismo Cardíaco/métodos , Meios de Contraste/administração & dosagem , Meios de Contraste/efeitos adversos , Angiografia Coronária/efeitos adversos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Transplante de Rim/efeitos adversos , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/etiologia , Risco Ajustado/métodos , Tenecteplase , Trombose/diagnóstico por imagem , Trombose/terapia , Resultado do TratamentoAssuntos
Síndrome Coronariana Aguda , Assistência Ambulatorial/estatística & dados numéricos , Procedimentos Cirúrgicos Ambulatórios , Angioplastia Coronária com Balão/efeitos adversos , Emergências , Síndrome Coronariana Aguda/terapia , Algoritmos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Seguimentos , Humanos , Readmissão do Paciente/estatística & dados numéricos , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
Iatrogenic coronary ostial stenosis after aortic valve replacement is a rare, life-threatening complication, which may follow implantation of either a mechanical or a biological prosthesis. Historically, this condition has been treated by urgent coronary bypass surgery but is associated with high morbidity and mortality, due to the hazards of early repeat sternotomy. We report a case of iatrogenic coronary ostial stenosis successfully treated with stenting and discuss the advantages of percutaneous intervention over coronary bypass surgery.
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Valva Aórtica/cirurgia , Estenose Coronária/terapia , Stents Farmacológicos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Próteses Valvulares Cardíacas/efeitos adversos , Angioplastia Coronária com Balão/métodos , Estenose da Valva Aórtica/cirurgia , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/etiologia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Undilatable coronary lesions, due to coronary calcification, are encountered with increasing frequency. Percutaneous intervention of such lesions comes with the risk of stent underexpansion, which increases the risk of stent thrombosis and restenosis. A variety of techniques and devices are available to assist the interventionist in the treatment of calcified lesions. The OPN NC (SIS-Medical AG, Winterthur, Switzerland) is a high-pressure balloon (rated burst pressure 35 atm) that uses a novel, twin-layer balloon technology to ensure uniform balloon expansion, eliminating "dog-boning." We report four cases of successful treatment of calcified lesions with the OPN NC balloon after dilatation with standard noncompliant balloons to high-pressure failed.
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Angioplastia Coronária com Balão/instrumentação , Calcinose/terapia , Estenose Coronária/terapia , Idoso , Calcinose/diagnóstico por imagem , Complacência (Medida de Distensibilidade) , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Desenho de Equipamento , Feminino , Humanos , Masculino , Pressão , Stents , Resultado do TratamentoRESUMO
BACKGROUND: Cardiac surgery is the reference treatment for patients with left main (LM) disease, although percutaneous coronary intervention with drug-eluting stents is emerging as a possible alternative. The objective of this registry was to evaluate the 2-year outcome of elective percutaneous coronary intervention for unprotected LM disease with paclitaxel-eluting stents. METHODS AND RESULTS: A total of 291 patients were prospectively included from 4 centers. Acute myocardial infarction and cardiogenic shock were the only exclusion criteria. Patients were 69+/-11 years old, 29% were diabetic, and 25% had 3-vessel disease. For distal LM lesions (78%), the provisional side-branch T-stenting approach was used in 92% of cases and final kissing balloon inflation in 97%. Angiographic success was obtained in 99.7% of cases. At 2-year follow-up, the total cardiac death rate was 5.4% (1 EuroSCORE point was associated with a 15% [95% confidence interval 2.9% to 28.2%, P=0.013] higher risk of cardiac death), target-lesion revascularization was 8.7%, and incidence of Q-wave or non-Q-wave myocardial infarction was 0.9% and 3.1%, respectively. The combined end point occurred in 15.8% of cases and stroke in 0.7%. The incidence of definite and probable LM stent thrombosis was 0.7%, whereas the incidence of any stent thrombosis was 3.8%, with a higher risk in patients with side-branch stenting in the presence of LM bifurcation lesions (hazard ratio 9.6, 95% confidence interval 1.2 to 77.7, P=0.035). CONCLUSIONS: Unprotected LM stenting with paclitaxel-eluting stents, with a strategy of provisional side-branch T-stenting for distal lesions, provides excellent acute angiographic results and good mid-term clinical outcomes, with a 15.8% rate of major adverse cardiac events at 2-year follow-up.
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Estenose Coronária/cirurgia , Stents Farmacológicos , Paclitaxel/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/etiologia , Angiografia Coronária , Estenose Coronária/complicações , Estenose Coronária/mortalidade , Stents Farmacológicos/efeitos adversos , Feminino , Seguimentos , França , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Análise de Sobrevida , Trombose/etiologia , Resultado do TratamentoRESUMO
We present three patients with angulated ostial lesions beyond the insertion point of coronary artery bypass grafts. Use of the Venture Catheter, a deflectable tip 3.5F wire control catheter, facilitated successful percutaneous coronary intervention after prolonged, unsuccessful attempts at conventional guidewire passage.
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Cateterismo Cardíaco/instrumentação , Ponte de Artéria Coronária/métodos , Doença das Coronárias/terapia , Idoso , Doença das Coronárias/diagnóstico por imagem , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , RadiografiaRESUMO
Aortic stenosis is the most common valvular heart disease in the Western world and its prevalence is increasing with an aging population. Although medical therapy has little to offer in terms of prognosis or symptomatic relief, at least one-third of patients with severe aortic stenosis are denied valve surgery as a result of age and comorbidities. This review describes the development of the percutaneous aortic valve as an alternative therapy for such patients. The technique, initial results and the current limitations of the procedure are explained alongside the ongoing trials necessary in order that such therapy may eventually be made widely available.