RESUMEN
There does not appear to be a difference in patient outcomes of percutaneous coronary intervention for unprotected left main coronary artery stenosis whether using first- or second-generation drug elutting stent. This is despite increase in patients having more adjunctive procedures such as intravascular imaging and newer generation antiplatelet agents. This single-center study provokes questions as to why there has not been improvement in outcomes.
Asunto(s)
Estenosis Coronaria , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Composición Familiar , Humanos , Pacientes , Stents , Resultado del TratamientoRESUMEN
The use of mechanical thrombectomy in STEMI with large amount of jeopardized myocardium may preserve regional wall motion When appropriate and done with proper removal technique, there does not appear to be any increased incidence of neurologic complications The guideline recommendation that mechanical thrombectomy should not be done routinely is supported by these authors.
Asunto(s)
Infarto del Miocardio , Infarto del Miocardio con Elevación del ST , Humanos , Miocardio , Sistema de Registros , TrombectomíaRESUMEN
The learning curve for TAVR is determined based on technical (procedural) data from PARTNER-1 Trial The number of cases needed to reach a learning curve for TAVR in PARTNER-1 was 50 for original sites and fell to 25 for late entering sites Analyses such as this is important in developing guidelines for other emerging technologies.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Educación de Postgrado en Medicina/normas , Prótesis Valvulares Cardíacas , Curva de Aprendizaje , Enseñanza/normas , Reemplazo de la Válvula Aórtica Transcatéter/educación , Arteria Femoral , Humanos , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/métodosRESUMEN
Current guidelines indicate that routine aspiration thrombectomy (AT) has a level III indication and AT is only indicated for "bail-out" indications. "Bail-out" situations are not well defined. The AT catheter may still be necessary and have other uses such as distal contrast or drug delivery.
Asunto(s)
Succión , Trombectomía , Catéteres , Humanos , Resultado del TratamientoRESUMEN
With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.
Asunto(s)
Cateterismo Cardíaco/normas , Cardiología/normas , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/normas , Guías de Práctica Clínica como Asunto , Válvula Pulmonar/cirugía , Sociedades Médicas , American Heart Association , Humanos , Estados UnidosAsunto(s)
Válvula Aórtica/cirugía , Medicina Basada en la Evidencia/normas , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas/normas , Pautas de la Práctica en Medicina/normas , Reemplazo de la Válvula Aórtica Transcatéter/normas , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Técnicas de Imagen Cardíaca/normas , Competencia Clínica/normas , Toma de Decisiones Clínicas , Consenso , Habilitación Profesional/normas , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/fisiopatología , Hemodinámica , Humanos , Curva de Aprendizaje , Selección de Paciente , Valor Predictivo de las Pruebas , Diseño de Prótesis/normas , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Resultado del Tratamiento , Carga de Trabajo/normasAsunto(s)
Infarto del Miocardio/terapia , Intervención Coronaria Percutánea , Electrocardiografía , Medicina Basada en la Evidencia , Humanos , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Trombectomía/métodos , Resultado del TratamientoRESUMEN
As the prevalence of asymptomatic COVID-19 continues to increase, there is an increasing possibility that patients with COVID-19 may presen with ST-segment elevation myocardial infarction (STEMI). With social distancing and restricted access to preventive healthcare and emergency services, the management of acute cardiac emergencies such as myocardial infarction has suffered collateral damage. Thus far, global trends suggest a decrease in STEMI activations with possible worse outcomes due to delayed presentation and management. In this review, we discuss the challenges to STEMI management in the COVID-19 era and provide potential solutions for adherence to evidence-based therapies as the pandemic progresses into the year 2021.
Asunto(s)
COVID-19/complicaciones , Control de Infecciones/organización & administración , Infarto del Miocardio con Elevación del ST/terapia , COVID-19/epidemiología , COVID-19/prevención & control , Humanos , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/etiologíaRESUMEN
OBJECTIVES: The aim of this study was to evaluate 1-year outcomes of valve-in-mitral annular calcification (ViMAC) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. BACKGROUND: The MITRAL trial is the first prospective study evaluating the feasibility of ViMAC using balloon-expandable aortic transcatheter heart valves. METHODS: A multicenter prospective study was conducted, enrolling high-risk surgical patients with severe mitral annular calcification and symptomatic severe mitral valve dysfunction at 13 U.S. sites. RESULTS: Between February 2015 and December 2017, 31 patients were enrolled (median age 74.5 years [interquartile range (IQR): 71.3 to 81.0 years], 71% women, median Society of Thoracic Surgeons score 6.3% [IQR: 5.0% to 8.8%], 87.1% in New York Heart Association functional class III or IV). Access was transatrial (48.4%), transseptal (48.4%), or transapical (3.2%). Technical success was 74.2%. Left ventricular outflow tract obstruction (LVOTO) with hemodynamic compromise occurred in 3 patients (transatrial, n = 1; transseptal, n = 1; transapical, n = 1). After LVOTO occurred in the first 2 patients, pre-emptive alcohol septal ablation was implemented to decrease risk in high-risk patients. No intraprocedural deaths or conversions to open heart surgery occurred during the index procedures. All-cause mortality at 30 days was 16.7% (transatrial, 21.4%; transseptal, 6.7%; transapical, 100% [n = 1]; p = 0.33) and at 1 year was 34.5% (transatrial, 38.5%; transseptal, 26.7%; p = 0.69). At 1-year follow-up, 83.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.1 mm Hg (IQR: 5.6 to 7.1 mm Hg), and all patients had ≤1+ mitral regurgitation. CONCLUSIONS: At 1 year, ViMAC was associated with symptom improvement and stable transcatheter heart valve performance. Pre-emptive alcohol septal ablation may prevent transcatheter mitral valve replacement-induced LVOTO in patients at risk. Thirty-day mortality of patients treated via transseptal access was lower than predicted by the Society of Thoracic Surgeons score. Further studies are needed to evaluate safety and efficacy of ViMAC.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco , Femenino , Humanos , Masculino , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to assess 1-year clinical outcomes among high-risk patients with failed surgical mitral bioprostheses who underwent transseptal mitral valve-in-valve (MViV) with the SAPIEN 3 aortic transcatheter heart valve (THV) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. BACKGROUND: The MITRAL trial is the first prospective study evaluating transseptal MViV with the SAPIEN 3 aortic THV in high-risk patients with failed surgical mitral bioprostheses. METHODS: High-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis due to failed surgical mitral bioprostheses were prospectively enrolled. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). RESULTS: Thirty patients were enrolled between July 2016 and October 2017 (median age 77.5 years [interquartile range (IQR): 70.3 to 82.8 years], 63.3% women, median Society of Thoracic Surgeons score 9.4% [IQR: 5.8% to 12.0%], 80% in New York Heart Association functional class III or IV). The technical success rate was 100%. The primary performance endpoint in survivors was achieved in 96.6% (28 of 29) at 30 days and 82.8% (24 of 29) at 1 year. Thirty-day all-cause mortality was 3.3% and was unchanged at 1 year. The only death was due to airway obstruction after swallowing several pills simultaneously 29 days post-MViV. At 1-year follow-up, 89.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.6 mm Hg (interquartile range: 5.5 to 8.9 mm Hg), and all patients had MR grade ≤1+. CONCLUSIONS: Transseptal MViV in high-risk patients was associated with 100% technical success, low procedural complication rates, and very low mortality at 1 year. The vast majority of patients experienced significant symptom alleviation, and THV performance remained stable at 1 year.
Asunto(s)
Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Estudios Prospectivos , Diseño de Prótesis , Resultado del TratamientoRESUMEN
OBJECTIVES: The authors report 1-year outcomes of high-risk patients with failed surgical annuloplasty rings undergoing transseptal mitral valve-in-ring (MViR) with the SAPIEN 3 aortic transcatheter heart valve (THV). BACKGROUND: The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective study evaluating transseptal MViR with the SAPIEN 3 aortic THV in high-risk patients with failed surgical annuloplasty rings. METHODS: Prospective enrollment of high-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis and failed annuloplasty rings at 13 U.S. sites. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). RESULTS: Thirty patients were enrolled between January 2016 and October 2017 (median age 71.5 years [interquartile range: 67.0 to 76.8 years], 36.7% women, median Society of Thoracic Surgeons score 7.6% [interquartile range: 5.1% to 11.8%], 76.7% in New York Heart Association functional class III or IV). Technical success was 66.7% (driven primarily by need for a second valve in 6 patients). There was no intraprocedural mortality or conversion to surgery. The primary performance endpoint was achieved in 85.7% of survivors at 30 days (24 of 28) and 89.5% of patients alive at 1 year with echocardiographic data available (17 of 19). All-cause mortality at 30 days was 6.7% and at 1 year was 23.3%. Among survivors at 1-year follow-up, 84.2% were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.0 mm Hg (interquartile range: 4.7 to 7.3 mm Hg), and all had ≤1+ MR. CONCLUSIONS: Transseptal MViR was associated with a 30-day mortality rate lower than predicted by the Society of Thoracic Surgeons score. At 1 year, transseptal MViR was associated with symptom improvement and stable THV performance.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral , Anciano , Cateterismo Cardíaco/efectos adversos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Estudios Prospectivos , Diseño de Prótesis , Resultado del TratamientoRESUMEN
BACKGROUND: Transcatheter mitral valve replacement using aortic transcatheter heart valves has recently become an alternative for patients with degenerated mitral bioprostheses, failed surgical repairs with annuloplasty rings or severe mitral annular calcification who are poor surgical candidates. Outcomes of these procedures are collected in the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry. A comprehensive analysis of mitral valve-in-valve (MViV), mitral valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) outcomes has not been performed. We sought to evaluate short-term outcomes of early experience with MViV, MViR, and ViMAC in the United States. METHODS: Retrospective analysis of data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. RESULTS: Nine hundred three high-risk patients (median Society of Thoracic Surgeons score 10%) underwent MViV (n=680), MViR (n=123), or ViMAC (n=100) between March 2013 and June 2017 at 172 hospitals. Median age was 75 years, 59.2% female. Technical and procedural success were higher in MViV. Left ventricular outflow tract obstruction occurred more frequently with ViMAC (ViMAC=10%, MViR=4.9%, MViV=0.7%; P<0.001). In-hospital mortality (MViV=6.3%, MViR=9%, ViMAC=18%; P=0.004) and 30-day mortality (MViV=8.1%, MViR=11.5%, ViMAC=21.8%; P=0.003) were higher in ViMAC. At 30-day follow-up, median mean mitral valve gradient was 7 mm Hg, most patients (96.7%) had mitral regurgitation grade ≤1 (+) and were in New York Heart Association class I to II (81.7%). CONCLUSIONS: MViV using aortic balloon-expandable transcatheter heart valves is associated with a low complication rate, a 30-day mortality lower than predicted by the Society of Thoracic Surgeons score, and superior short-term outcomes than MViR and ViMAC. At 30 days, patients in all groups experienced improvement of symptoms, and valve performance remained stable. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02245763.
Asunto(s)
Calcinosis/cirugía , Cateterismo Cardíaco/instrumentación , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral/instrumentación , Válvula Mitral/cirugía , Falla de Prótesis , Anciano , Anciano de 80 o más Años , Calcinosis/etiología , Calcinosis/mortalidad , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Femenino , Enfermedades de las Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Anuloplastia de la Válvula Mitral/efectos adversos , Anuloplastia de la Válvula Mitral/mortalidad , Diseño de Prótesis , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosAsunto(s)
Infarto del Miocardio/terapia , Reperfusión Miocárdica/métodos , Intervención Coronaria Percutánea , Medición de Riesgo , Terapia Trombolítica , American Heart Association , Cardiología/métodos , Cardiología/normas , Protocolos Clínicos/clasificación , Protocolos Clínicos/normas , Técnicas de Diagnóstico Cardiovascular , Manejo de la Enfermedad , Electrocardiografía , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/organización & administración , Medicina Basada en la Evidencia/métodos , Medicina Basada en la Evidencia/normas , Humanos , Administración del Tratamiento Farmacológico/normas , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Selección de Paciente , Estados UnidosAsunto(s)
Cateterismo Cardíaco/normas , Cardiología/normas , Implantación de Prótesis de Válvulas Cardíacas/normas , Insuficiencia de la Válvula Mitral/terapia , Cirugía Torácica/normas , Cateterismo Cardíaco/efectos adversos , Cardiología/educación , Protocolos Clínicos , Diagnóstico por Imagen , Educación de Postgrado en Medicina , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico , Selección de Paciente , Valor Predictivo de las Pruebas , Factores de Riesgo , Cirugía Torácica/educación , Resultado del TratamientoRESUMEN
Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.
Asunto(s)
Atención Ambulatoria/normas , Angioplastia Coronaria con Balón/normas , Tiempo de Internación , Alta del Paciente/normas , Calidad de la Atención de Salud/normas , Atención Ambulatoria/economía , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/economía , Competencia Clínica , Protocolos Clínicos , Costos de la Atención en Salud , Instituciones de Salud/normas , Humanos , Reembolso de Seguro de Salud , Tiempo de Internación/economía , Observación , Alta del Paciente/economía , Calidad de la Atención de Salud/economía , Medición de Riesgo , Terminología como Asunto , Resultado del TratamientoAsunto(s)
Cateterismo Cardíaco/normas , Cardiología/normas , Certificación/normas , Competencia Clínica/normas , Instituciones de Salud/normas , Enfermedades de las Válvulas Cardíacas/terapia , Implantación de Prótesis de Válvulas Cardíacas/normas , Válvula Mitral , Cateterismo Cardíaco/efectos adversos , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/fisiopatología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Privilegios del Cuerpo Médico/normas , Válvula Mitral/fisiopatología , Grupo de Atención al Paciente/normas , Formulación de Políticas , Desarrollo de Programa/normas , Resultado del TratamientoRESUMEN
UNLABELLED: Doctor: "Ma'am you need an angioplasty". PATIENT: "Doctor, the newspaper says that medicine is as good as angioplasty". Doctor: "Ma'am you're having a heart attack". The COURAGE trial was published 1 year ago and received attention from the media, patients, and other medical specialties concerning the value of percutaneous coronary intervention. Now, 1 year later there has been time to reflect on COURAGE, and some newer data have emerged. The purpose of this article is to put into perspective the issues surrounding the COURAGE trial and suggest different approaches for future trials of stable coronary artery disease.