RESUMO
Embolic stroke is the most dangerous complication of atrial fibrillation (AF). Oral anticoagulation represents the treatment of choice for thromboembolic (TE) prophylaxis in patients with a CHADS2VASc score ≥ 1 but is associated with a significant increase in haemorrhagic events. Almost 90 % of thrombi originate in the left atrial appendage. Registries have shown that percutaneous occlusion of this appendage reduces embolic risk and may be considered for TE prophylaxis in patients with a high TE (CHADS2VASc score ≥ 2) and haemorrhagic (HAS-BLED score ≥ 3) risk. However, available randomized trials of this technique did not include patients with contraindication to oral anticoagulants.
L'embolie cérébrale est la complication la plus sévère de la fibrillation auriculaire (FA). L'anticoagulation orale représente le traitement de choix pour la prophylaxie thromboembolique (TE) chez les patients avec un score CHADS2VASc ≥ 1 mais s'accompagne d'une augmentation significative des événements hémorragiques. Environ 90 % des thrombi se forment au niveau de l'auricule gauche. Différents registres ont montré que la fermeture percutanée de cet appendice par une prothèse permet de diminuer le risque TE chez les patients qui présentent un haut risque TE (score CHADS2VASc ≥ 2) et hémorragique (score HAS-BLED ≥ 3). Cependant, les études randomisées actuellement disponibles concernant cette technique n'ont pas inclus des patients avec une contre-indication aux anticoagulants oraux.
Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Humanos , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/prevenção & controleRESUMO
Coronary angioplasty has undergone several technological revolutions: starting with balloon angioplasty, then with bare metal stent and finally with drug eluting stent (DES), this technique is now mature. However, once we thought the problem of instent restenosis solved with DES, new concerns arise with late and very late stent thrombosis. Should we therefore proscribe DES? How long should be the duration of dual antiplatelet therapy? And how should we manage the patients who need a surgery and are at high risk of bleeding? Are bioresorbable stents the final solution with their initial mechanical properties, then with their drug eluting effect against intra-stent restenosis, and finally with their complete resorption which leaves the artery free of any foreign material?
Assuntos
Implantes Absorvíveis , Stents Farmacológicos , Stents , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/métodos , Reestenose Coronária/etiologia , Reestenose Coronária/prevenção & controle , Trombose Coronária/etiologia , Trombose Coronária/prevenção & controle , Humanos , Inibidores da Agregação Plaquetária/administração & dosagem , Fatores de TempoRESUMO
The role of the sympathetic nervous system (SNS) in the control of blood pressure and the occurrence of hypertension has been established both in animal models and in clinical practice. Patients resistant to treatment are common in clinical practice and require a new approach to optimize blood pressure control. The development of a catheter-based technique to denervate the kidneys for the treatment of high blood pressure was introduced recently. The concept was based on old data of surgical renal denervation which was effective but associated with important morbidity. Recent data shows that catheter-based renal denervation is feasible and safe in humans and preliminary clinical studies are very promising. These data need confirmation in larger randomised controlled trials with longer-term follow-up.
Assuntos
Ablação por Cateter/métodos , Denervação/métodos , Resistência a Medicamentos , Hipertensão/cirurgia , Rim/inervação , Animais , Anti-Hipertensivos/uso terapêutico , Ablação por Cateter/instrumentação , Denervação/instrumentação , Resistência a Medicamentos/fisiologia , Humanos , Hipertensão/tratamento farmacológico , Rim/fisiopatologia , Rim/cirurgia , Modelos Biológicos , Sistema Nervoso Simpático/fisiopatologia , Sistema Nervoso Simpático/cirurgiaRESUMO
INTRODUCTION AND OBJECTIVES: A substantial proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) have a late presentation. There is a lack of temporal trends drawn from large real-word scenarios in these patients. METHODS: All STEMI patients included in the AMIS Plus registry from January 1997 to December 2017 were screened and patient-related delay was assessed. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or> 12hours, respectively). RESULTS: A total of 27 231 STEMI patients were available for the analysis. During the study period, the prevalence of late presentation decreased from 22% to 12.3% (P <.001). In latecomer STEMI patients, there was a gradual uptake of evidence-based pharmacological treatments (rate of P2Y12 inhibitors at discharge, from 6% to 90.6%, P <.001) and a marked increase in the use of percutaneous coronary intervention (PCI), particularly in 12- to 48-hour latecomers (from 11.9%-87.9%; P <.001). In-hospital mortality was reduced from 12.4% to 4.5% (P <.001). On multivariate analysis, PCI had a strong independent protective effect on in-hospital mortality in 12- to 48-hour latecomers (OR, 0.29; 95%CI, 0.15-0.55). CONCLUSIONS: During the 20-year study period, there was a progressive reduction in the prevalence of late presentation, a gradual uptake of main evidence-based pharmacological treatments, and a marked increase in PCI rate in latecomer STEMI patients. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%); in 12- to 48-hour latecomers, this reduction seemed to be mainly associated with the increasing implementation of PCI.
Assuntos
Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Mortalidade Hospitalar , Humanos , Alta do Paciente , Sistema de Registros , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Resultado do TratamentoRESUMO
BACKGROUND: The long-term incidence of stent thrombosis (ST) and complications after sirolimus-eluting stents (SES) implantation is still a matter of debate. METHOD: We conducted a systematic follow-up on the day of their 5-year SES implantation anniversary, in a series of consecutive real-world patients treated with a SES. The use of SES implantation was not restricted to "on-label" indications, and target lesions included in-stent restenosis, vein graft, left main stem locations, bifurcations, and long lesions. The Academic Research Consortium criteria were used for ST classification. RESULTS: Three hundred fifty consecutive patients were treated with SES between April and December 2002 in 3 Swiss hospitals. Mean age was 63 +/- 6 years, 78% were men, 20% presented with acute coronary syndrome, and 19% were patients with diabetes. Five-year follow-up was obtained in 98% of eligible patients. Stent thrombosis had occurred in 12 patients (3.6%) [definite 6 (1.8%), probable 1 (0.3%) and possible 5 (1.5%)]. Eighty-one percent of the population was free of complications. Major adverse cardiac events occurred in 74 (21%) patients and were as follows: cardiac death 3%, noncardiac death 4%, myocardial infarction 2%, target lesion revascularization 8%, non-target lesion revascularization target vessel revascularization 3%, coronary artery bypass graft 2%. Non-TVR was performed in 8%. CONCLUSION: Our data confirm the good long-term outcome of patients treated with SES. The incidence of complications and sub acute thrombosis at 5 years in routine clinical practice reproduces the results of prospective randomized trials.
Assuntos
Síndrome Coronariana Aguda/cirurgia , Trombose Coronária/epidemiologia , Stents Farmacológicos , Oclusão de Enxerto Vascular/epidemiologia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica/instrumentação , Síndrome Coronariana Aguda/diagnóstico por imagem , Angiografia Coronária , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/etiologia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Suíça/epidemiologia , Fatores de TempoRESUMO
The use of drug-eluting stents has brought considerable change to the treatment of coronary artery disease. However, recent reports have suggested that they may be associated with an increase risk of late thrombosis. A current analysis of the available data suggests that the risk of late thrombosis is indeed probably higher with drug-eluting stents than with bare metal stents. However, this risk appears low, and does not justify withholding the device from the patients who would benefit from their use, especially when they suffer from complex disease (long lesions, small vessels, diabetes, etc) with a known higher risk of recurrent stenosis. Based on the information available to us today, appropriate patient selection, meticulous implantation technique and uninterrupted dual antiplatelet therapy (aspirin and clopidogrel) for six to twelve months after angioplasty appear to be the main ingredients for a successful and uncomplicated procedure.
Assuntos
Doença da Artéria Coronariana/terapia , Sistemas de Liberação de Medicamentos/efeitos adversos , Stents/efeitos adversos , HumanosRESUMO
At present, vascular brachytherapy is the only efficient therapy for in-stent restenosis. Nevertheless, edge restenosis often related to geographical miss has been identified as a major limitation of the technique. The non-slippery cutting balloon has the potential to limit vascular barotraumas, which, together with low-dose irradiation at both ends of the radioactive source, are the prerequisite for geographical miss. This prospective study aimed to examine the efficacy of combining cutting balloon angioplasty and brachytherapy for in-stent restenosis. The Radiation in Europe NOvoste (RENO) registry prospectively tracked all patients who had been treated by coronary beta-radiation with the Beta-Cath System (Novoste Corporation, Brussels, Belgium) but were not included in a randomized radiation trial. A subgroup of patients with in-stent restenosis treated by cutting balloon angioplasty and coronary beta-radiation (group 1, n = 166) was prospectively defined, and clinical outcomes of patients at 6 months were compared with those of patients treated by conventional angioplasty and coronary beta-radiation (group 2, n = 712). At 6-month follow-up, there was a significant difference between groups 1 and 2 in target vessel revascularization (10.2% versus 16.6% respectively; p = 0.04) and in the incidence of major adverse clinical events (MACE) including death, myocardial infarction, and revascularization (10.8% versus 19.2%; p = 0.01). This observation was confirmed by a multivariate analysis indicating a lower risk for MACE at 6 months (odds ratio: 0.49; confidence intervals: 0.27 0.88; p = 0.02). Compared to conventional angioplasty, cutting balloon angioplasty prior to coronary beta-radiation with the Beta-Cath System seems to improve the 6-month clinical outcome in patients with in-stent restenosis.
Assuntos
Angioplastia Coronária com Balão , Braquiterapia , Reestenose Coronária/terapia , Idoso , Partículas beta/uso terapêutico , Terapia Combinada , Angiografia Coronária , Reestenose Coronária/diagnóstico , Reestenose Coronária/epidemiologia , Europa (Continente) , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Resultado do TratamentoRESUMO
Churg-Strauss syndrome (CSS) is a rare multisystemic disorder of unknown origin and cardiac involvement is one of the most serious manifestations of the disease, accounting for approximately one-half of deaths attributable to CSS. Cardiac manifestation can be acute and mimic acute coronary syndrome (ACS). In this setting checking the blood leucocyte count can reveal hypereosinophilia and lead to a diagnosis of CSS.
Assuntos
Síndrome Coronariana Aguda/diagnóstico , Síndrome de Churg-Strauss/diagnóstico , Eosinofilia/etiologia , Miocardite/etiologia , Miocárdio/patologia , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Biópsia , Angiografia Coronária , Diagnóstico Diferencial , Ecocardiografia , Eletrocardiografia , Eosinofilia/diagnóstico , Eosinofilia/tratamento farmacológico , Feminino , Seguimentos , Glucocorticoides/administração & dosagem , Humanos , Injeções Intravenosas , Contagem de Leucócitos , Imagem Cinética por Ressonância Magnética , Miocardite/diagnóstico , Miocardite/tratamento farmacológico , Prednisolona/administração & dosagemAssuntos
Infarto do Miocárdio/terapia , Antagonistas Adrenérgicos beta/uso terapêutico , Angioplastia Coronária com Balão , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Humanos , Infarto do Miocárdio/tratamento farmacológico , Nitratos/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Terapia TrombolíticaAssuntos
Infarto do Miocárdio/terapia , Antagonistas Adrenérgicos beta/uso terapêutico , Angioplastia Coronária com Balão , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Humanos , Infarto do Miocárdio/tratamento farmacológico , Nitratos/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Choque Cardiogênico/terapia , Terapia TrombolíticaAssuntos
Angioplastia Coronária com Balão , Ponte Cardiopulmonar , Fármacos Cardiovasculares/uso terapêutico , Infarto do Miocárdio/terapia , Choque Cardiogênico/terapia , Terapia Trombolítica , Fármacos Cardiovasculares/efeitos adversos , Humanos , Infarto do Miocárdio/mortalidade , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Resultado do TratamentoAssuntos
Infarto do Miocárdio/terapia , Antagonistas Adrenérgicos beta/uso terapêutico , Angioplastia Coronária com Balão , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Quimioterapia Combinada , Humanos , Infarto do Miocárdio/tratamento farmacológico , Nitratos/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Terapia TrombolíticaRESUMO
Restenosis has long remained the major limitation of intracoronary stenting, but several randomized trials have recently shown that the use of drug-eluting stents appear to reduce markedly the risk of recurrence following treatment of de novo lesions. To evaluate whether the results of randomized trials can be generalized to routine clinical practice, all patients receiving at least one sirolimus-eluting stent (SES) in two Swiss hospitals were entered into a prospective registry. Only target vessels with a reference diameter > 3.5 mm were excluded. Clinical follow-up was obtained after 6 months. A total of 183 patients were included. The procedural success was 97.8% and the incidence of in-hospital MACE was 2.2%. At 7 +/- 2 months, 95.6% of the patients were event-free, and target lesion revascularization was required in only three patients (1.6%). The excellent medium-term results obtained with the SES in randomized trials can be replicated in routine clinical practice.
Assuntos
Materiais Revestidos Biocompatíveis/uso terapêutico , Doença das Coronárias/terapia , Imunossupressores/uso terapêutico , Sirolimo/uso terapêutico , Stents , Idoso , Angioplastia Coronária com Balão , Implante de Prótese Vascular , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/etiologia , Reestenose Coronária/cirurgia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica , Estudos Prospectivos , Reoperação , Suíça , Resultado do TratamentoRESUMO
More than 70% of percutaneous coronary interventions are followed by a stent implantation. In-stent restenosis still occurs in 20-30% of patients and remains a therapeutic challenge. At present only vascular brachytherapy has been shown to be an effective treatment option. We report here one case of recurrent in-stent restenosis after vascular brachytherapy that was successfully treated by a second beta radiation treatment.
Assuntos
Partículas beta , Braquiterapia , Reestenose Coronária/etiologia , Reestenose Coronária/radioterapia , Stents , Idoso , Implante de Prótese Vascular/instrumentação , Feminino , Humanos , RecidivaRESUMO
IVUS is considered as the most accurate tool for the assessment of optimal stent deployment. Direct stenting has shown to be a safe, efficient, and resource-saving procedure in selected patients. In a prospective 1-month feasibility trial, a new combined IVUS-coronary stent delivery platform (Josonics Flex, Jomed, Helsingborn, Sweden) was evaluated during direct stenting in consecutive patients considered eligible for direct stenting. The feasibility endpoint was successful stent deployment without any clinical adverse event, while the efficacy endpoint was strategic adaptation according to standard IVUS criteria for optimal stent deployment at the intermediate phase (after a result considered angiographically optimal) and at the end of the intervention (after optimization according to IVUS standards). A total of 16 patients were successfully treated with this device without any major clinical complication. At the intermediate phase, optimal stent deployment was achieved in four patients only, while at the end only one patient had nonoptimal IVUS stent deployment. In particular, the minimal in-stent cross-section area increased from 6.3 +/- 1.2 to 8.3 +/- 2.5 mm(2). These preliminary data demonstrate the feasibility of direct stenting with a combined IVUS-stent catheter in selected patients and confirm the results from larger randomized trials on the impact of IVUS on strategic adaptations during coronary stent placement.