RESUMO
The interventional treatment of high-risk patients remains challenging and has a high potential for improvement despite all technical innovations. Mechanical circulatory support (MCS) systems can be meaningful depending on the clinical situation, although a clear study situation for this is so far lacking. Multivessel coronary disease and a high SYNTAX score combined with impaired ventricular function is a possible predictor combination for the use of MCS that justifies the higher risk of complications.
Assuntos
Doença da Artéria Coronariana , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Intervenção Coronária Percutânea , Humanos , Balão Intra-Aórtico/efeitos adversos , Doença da Artéria Coronariana/complicações , Choque Cardiogênico/terapiaRESUMO
For the treatment of structural heart disease, current options in the catheterization laboratory include MitraClip® implantation for treating severe mitral regurgitation, transcatheter aortic valve implantation (TAVI), closure of a patent foramen ovale (PFO) and occlusion of the left atrial appendage (LAA). These treatment options are based on a precise diagnosis provided by modern cardiac imaging, which is indispensable for treatment recommendations. Its importance for supporting the invasive procedures in the catheterization laboratory is less well known. Due to enhanced soft tissue characterization, it complements fluoroscopy and invasive angiography and thus enormously improves the safety of the procedures. In addition, it allows individualized follow-up care. The current article gives an overview of the clinically most frequently used procedures.
Assuntos
Técnicas de Imagem Cardíaca/métodos , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/cirurgia , Aumento da Imagem/métodos , Imagem Multimodal/métodos , Cirurgia Assistida por Computador/métodos , Medicina Baseada em Evidências , Humanos , Seleção de Pacientes , Cuidados Pré-Operatórios/métodos , Resultado do TratamentoRESUMO
Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases [Eur Heart Journal (2014) 35, 28732926,doi:10.1093/eurheartj/ehu281]. In Table 3, the radiation for MRI is "0" and not "-". The corrected table is shown below.
RESUMO
In September 2014 the European Society of Cardiology issued guidelines for the diagnosis and treatment of aortic diseases in adults. Contrast-enhanced computed tomography (CT) represents the imaging modality of first choice as it is rapidly and almost ubiquitously available and can evaluate the entire aorta in a single-step examination. In patients with a high clinical suspicion of an acute aortic syndrome based on (family) history and symptoms, CT should be performed without further delay to confirm or refute the diagnosis. Diseases involving the ascending aorta remain a domain of open surgery, be it on an emergency basis in an acute type A dissection or electively in asymptomatic aneurysms with an aortic diameter >5.5 cm. The presence of risk factors (e. g. bicuspid aortic valve, Marfan syndrome and aortic dissection/rupture in the family history) may prompt earlier surgical repair at a lower threshold diameter. The treatment of descending aortic disease is primarily conservative including modification of cardiovascular risk factors. If indicated, endovascular aortic stent graft repair appears to be superior to open surgery for descending thoracic aortic disease or equivalent in the treatment of infrarenal abdominal aortic aneurysms. The management of aortic diseases related to genetic connective tissue diseases (e. g. Marfan syndrome, Loeys-Dietz syndrome and Ehlers-Danlos syndrome) is complex and requires special multidisciplinary expertise.
Assuntos
Doenças da Aorta/diagnóstico , Doenças da Aorta/cirurgia , Cardiologia/normas , Procedimentos Cirúrgicos Cardiovasculares/normas , Diagnóstico por Imagem/normas , Técnicas de Diagnóstico Cardiovascular/normas , Seleção de Pacientes , Europa (Continente) , HumanosAssuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Procedimentos Endovasculares , Aorta Torácica/anatomia & histologia , Doenças da Aorta/complicações , Doenças da Aorta/diagnóstico , Doenças da Aorta/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Humanos , Complicações Pós-Operatórias/prevenção & controleRESUMO
Surgical aortic valve replacement is the conventional treatment for symptomatic aortic valve stenosis; however, the technique of transfemoral transcatheter aortic valve implantation has recently been developed for older patients at high risk for surgery. We assessed whether this procedure could be safely performed under sedation in 100 patients. Their predicted surgical mortality was 21.6% and mean (SD) age 80 (6.6) years. Sedation was provided by remifentanil infusion (0-0.2 µg.kg(-1).min(-1)) and midazolam (1-3 mg), as required. All patients were closely haemodynamically monitored throughout by an anaesthetist and inotropic drugs administered as indicated by invasive monitoring. Sedation alone was required in 83 patients; in 17 patients sedation had to be converted to general anaesthesia, mainly because of interventional complications (n = 12). All conversions to general anaesthesia occurred after successful valve implantation. Mean (SD) anaesthesia time was 31 (12) min and procedural time 107 (77) min; 30-day and 1-year all-cause mortality were 6% and 13%, respectively. In the majority of patients, transcatheter valve implantation can safely be facilitated by sedation, provided monitoring and drug administration are carried out by an experienced cardiac anaesthetist.
Assuntos
Anestesia Geral , Valva Aórtica/cirurgia , Sedação Consciente , Implante de Prótese de Valva Cardíaca , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Ecocardiografia Transesofagiana , Estudos de Viabilidade , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , MasculinoRESUMO
Malperfusion of the thoracoabdominal aorta and its side branches is a common complication of aortic dissection, often proving fatal. Vital organ malperfusion accompanying acute aortic dissection is a major cause of mortality and morbidity and requires timely reperfusion of the ischemic organs as well as adequate management of the aortic dissection. Ischemic damage to vital organs supplied by the thoracoabdominal aorta greatly increases the overall risk of aortic dissection. As initial symptoms may be subtle, malperfusion tends to be recognized late, and therefore accounts for a considerable percentage of fatalities.Effective reperfusion is not readily achieved by central aortic surgery alone in a certain number of patients. Various strategies have been used, including entry closure by central aortic surgery or stent grafting, surgical or catheter fenestration, bypass grafting and percutaneous stenting.Endovascular bare-metal stent placement is an attractive and promising treatment option since it is readily available, is less invasive and presents fewer risks to the patient.
Assuntos
Aneurisma da Aorta Torácica/diagnóstico , Dissecção Aórtica/diagnóstico , Isquemia/diagnóstico , Abdome Agudo/etiologia , Abdome Agudo/mortalidade , Abdome Agudo/cirurgia , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/cirurgia , Idoso , Dissecção Aórtica/mortalidade , Dissecção Aórtica/cirurgia , Angioplastia , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/cirurgia , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/mortalidade , Arteriopatias Oclusivas/cirurgia , Implante de Prótese Vascular , Causas de Morte , Artéria Celíaca , Ecocardiografia Transesofagiana , Extremidades/irrigação sanguínea , Feminino , Humanos , Isquemia/cirurgia , Rim/irrigação sanguínea , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/cirurgia , Fatores de Risco , Stents , Tomografia Computadorizada por Raios X , Vísceras/irrigação sanguíneaRESUMO
Acute aortic syndrome (AAS) comprises a variety of pathologically distinct life-threatening conditions such as aortic dissection, intramural hematoma (IMH) of the aorta, penetrating aortic ulcer (PAU), traumatic transection as well as symptomatic aortic aneurysm. Patients presenting with AAS require immediate diagnosis in order to rapidly initiate adequate therapeutic measures. Echocardiography is a rapidly available imaging technique which detects AAS with high sensitivity and specificity. Compared to computed tomography (CT) and magnetic resonance imaging (MRI), echocardiography allows emergency examination of unstable patients at bedside or even directly in the operating room. Transthoracic echocardiography (TTE) may be used initially in the emergency setting to gain information about left ventricular function as well as the presence of aortic regurgitation and pericardial effusion, but has only limited diagnostic accuracy for diagnosing AAS. Transoesophageal echocardiography (TOE) is used to directly visualise the aortic pathology in both the ascending and descending aorta. This article reviews the role of echocardiography in the emergency assessment of patients presenting with acute aortic syndrome.
Assuntos
Síndromes do Arco Aórtico/diagnóstico por imagem , Doença Aguda , Ecocardiografia Transesofagiana , Humanos , SíndromeRESUMO
Acute aortic dissection is a life threatening disease, which is occasionally limited to an ascending aorta only (DeBakey type II). In majority of patients it involves the aortic arch and entire rest of the aorta (DeBakey type I). The standardized cannulation and operation strategy can not be used in cases, when aortic arch branches are involved in dissection (complex aortic arch dissection) or in cases with malperfusion or severely compromised hemodynamics (tamponade or heart failure due to severe aortic valve insufficiency). The aim of this present review is to present the "Essen" treatment concept of complicated acute aortic arch dissection from diagnostics to operation strategy.
Assuntos
Aorta Torácica , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Humanos , Hipotermia Induzida , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
Intramural hematoma (IMH) of the aorta and penetrating aortic ulcer (PAU) are important variant forms of classic double-barrel aortic dissection in patients presenting with acute aortic syndrome. Recent insights provided by modern high-resolution imaging are currently challenging previous pathophysiologic concepts underlying IMH and PAU, suggesting a close relationship of both entities. Thoracic endovascular aortic repair (TEVAR) offers a less invasive approach to the treatment of affected patients with very encouraging early to midterm results. This review discusses current indication for TEVAR in IMH and PAU patients in the view of an improved understanding of these diseases.
Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Hematoma/cirurgia , Úlcera/cirurgia , Doença Aguda , Dissecção Aórtica/diagnóstico , Aorta Torácica/patologia , Aneurisma da Aorta Torácica/diagnóstico , Doenças da Aorta/diagnóstico , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Ecocardiografia Transesofagiana , Hematoma/diagnóstico , Humanos , Tomografia por Emissão de Pósitrons , Stents , Síndrome , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Úlcera/diagnósticoRESUMO
We report the first case of a male patient with iodine-induced hyperthyroidism and unstable angina pectoris in whom a diagnostic cardiac catheterization with gadolinium as contrast agent was chosen. The patient was hospitalized with an iodine-induced hyperthyroidism after angioplasty using an iodinated contrast agent. He presented with a continuous arrhythmia and unstable angina pectoris. A repeated cardiac catheterization using iodinated contrast agent was contraindicated. This case report shows that gadolinium is a useful alternative contrast agent for cardiac intervention in patients with iodine-induced hyperthyroidism.
Assuntos
Cateterismo Cardíaco/métodos , Gadolínio , Hipertireoidismo/induzido quimicamente , Iodo/efeitos adversos , Meios de Contraste , Angiografia Coronária/efeitos adversos , Angiografia Coronária/métodos , Humanos , Pessoa de Meia-IdadeRESUMO
PURPOSE: To compare the signal-to-noise and contrast-to-noise ratio as well as the image quality of 3D inversion recovery steady-state free precession (IR-SSFP) and 3D inversion recovery fast low angle shot (IR-FLASH) sequences for contrast-enhanced breath-hold MRCA. MATERIALS AND METHODS: 24 healthy volunteers (10 female, 14 male, mean age 29.8 +/- 6.1 years) were involved in this study. All examinations were performed on a 1.5 T MR scanner (Magnetom Sonata, Siemens, Germany) after injection of 0.05 mmol/kg body weight MS-325 (EPIX Pharmaceuticals, Cambridge, MA and Schering AG, Berlin, Germany). MRCA was performed using IR-SSFP (TR 3.8 ms, TE 1.6 ms, FA 65 degrees , 35 phase encoded steps, bandwidth 540 Hz/pixel, slice thickness 1.5 mm, in-plane resolution 1.2 x 0.9 - 1.4 x 1.0 mm) and IR-FLASH (TR 3.8 ms, TE 1.6 ms, FA 25 degrees , bandwidth 490 Hz/pixel, slice thickness 1.5 mm, in-plane resolution 1.2 x 0.9 - 1.4 x 1.0 mm) sequences. For all scans the inversion time was set to null the signal intensity of the myocardium. Signal-to-noise ratio (SNR) as well as contrast-to-noise ratio (CNR) measurements (blood versus myocardium) were performed. The image quality was assessed based on a 5-point scale ranging from 1 (excellent) to 5 (non-diagnostic) by two radiologists in consensus. RESULTS: The mean signal-to-noise ratio of blood (27.7 +/- 4.7 vs. 22.6 +/- 4.9, P < 0.0001) and the contrast-to-noise ratio (21.0 +/- 4.3 vs. 15.8 +/- 4.3, P < 0.0001) showed significantly higher values for IR-SSFP sequences. The mean image quality scores were significantly higher for SSFP (3.6 +/- 0.7) than FLASH (2.8 +/- 0.9) sequences (P < 0.05). CONCLUSION: IR-SSFP sequences show a considerable overall improvement in image quality compared to IR-FLASH sequences for MRCA after injection of a gadolinium-based blood pool contrast agent.
Assuntos
Meios de Contraste , Vasos Coronários/anatomia & histologia , Angiografia por Ressonância Magnética/métodos , Compostos Organometálicos , Adulto , Feminino , Gadolínio , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Modelos TeóricosRESUMO
BACKGROUND: Residual reduction of relative coronary flow velocity reserve (rCVR) after successful coronary intervention has been related to microvascular impairment. However, the incidence of cardiac enzyme elevation as a surrogate marker of an underlying embolic myocardial injury in these cases has not been studied. METHODS AND RESULTS: A series of 55 consecutive patients with successful coronary stenting, periprocedural intracoronary Doppler analysis, and determination of creatine kinase (CK; upper limit of normal [ULN] for women 70 IU/L, for men 80 IU/L) and cardiac troponin T (cTnT; bedside test, threshold 0.1 ng/mL) before and 6, 12, and 24 hours after intervention were studied. Postprocedural rCVR was the only intracoronary Doppler parameter that independently correlated with cTnT (r=-0.498, P<0.001) and CK outcome (r=-0.406, P=0.002). Receiver operating characteristic analysis identified a postprocedural rCVR of 0.78 as the best discriminating value, with a sensitivity of 83.3% and 69.2% and a specificity of 79.1% and 76.2% for detection of cTnT and CK elevation, respectively. Stratified according to this cutoff value, the incidence of cTnT elevation was 52.6% in patients with (n=19) and 5.6% in patients without (n=36) a postprocedural rCVR <0.78 (P<0.001), associated with a CK elevation >1 times the ULN in 36.8% and 5.6% (P=0.005) of patients, respectively. CONCLUSIONS: Cardiac marker elevation can frequently be found after coronary procedures that are associated with a persistent reduction of rCVR, indicating procedural embolization of atherothrombotic debris with microvascular impairment and myocardial injury as a potential underlying mechanism.
Assuntos
Circulação Coronária , Doença das Coronárias/metabolismo , Miocárdio/metabolismo , Idoso , Biomarcadores/análise , Angiografia Coronária , Doença das Coronárias/fisiopatologia , Doença das Coronárias/terapia , Creatina Quinase/metabolismo , Ecocardiografia Doppler , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Estudos Prospectivos , Stents , Troponina T/metabolismoRESUMO
Strict blood pressure control is pivotal in the management of patients with aortic dissection (AD), but is frequently difficult to achieve. We determined antihypertensive medical therapy and levels of blood pressure (BP) control in 40 patients with chronic AD. Patient charts were reviewed for clinical variables, serial BP measurements, and antihypertensive drug therapy. Patients were divided into two groups: patients in group 1 had effective BP control (<135/80 mmHg), patients in group 2 had resistant hypertension (BP>/=135/80 mmHg despite prescription of at least three antihypertensive drugs). Overall, systolic BP (SBP) was 130+/-20 mmHg, and diastolic BP (DBP) was 72+/-13 mmHg. Patients received a median of 4 (1-6) antihypertensive drugs. beta-blockers were used in 38/40 (95%) patients. Effective BP control was achieved in 24/40 (60%) patients (group 1), while 16/40 (40%) patients had resistant hypertension (group 2) despite receiving significantly more antihypertensive drugs (5 [4-6] vs 4 [1-5], P=0.001). Mean SBP was 116+/-9 (101-132) mmHg in group 1 and 151+/-13 (137-181) mmHg in group 2 (P<0.001); there was no difference in DBP. Group 2 patients had a significantly higher body mass index and were younger than patients in group 1. In conclusion, in the majority of patients with chronic AD, effective BP control can be achieved, but usually requires the combination of multiple antihypertensive drugs. However, in a significant proportion of patients (40%), who appear to be younger and more obese, medical therapy fails to achieve effective BP control despite use of a multiple drug regimen.
Assuntos
Anti-Hipertensivos/uso terapêutico , Aneurisma Aórtico/complicações , Dissecção Aórtica/complicações , Pressão Sanguínea/fisiologia , Hipertensão/tratamento farmacológico , Antagonistas Adrenérgicos alfa/uso terapêutico , Adulto , Idoso , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/fisiopatologia , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/fisiopatologia , Aortografia , Pressão Sanguínea/efeitos dos fármacos , Bloqueadores dos Canais de Cálcio/uso terapêutico , Doença Crônica , Diuréticos/uso terapêutico , Quimioterapia Combinada , Ecocardiografia Transesofagiana , Feminino , Humanos , Hipertensão/etiologia , Hipertensão/fisiopatologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Simpatolíticos/uso terapêutico , Tomografia Computadorizada por Raios X , Falha de TratamentoRESUMO
AIM: Purpose of our study was to compare the image quality of 3D-navigator steady state free precession (SSFP) and gradient echo (GE) sequences for magnetic resonance coronary angiography (MRCA) in volunteers and patients. METHODS: Following informed consent 8 volunteers and 12 patients were included into this study. In all subjects a 3D navigator MRCA of the right and the left coronary artery was performed with a SSFP (TR 3.9 ms, TE 1.7 ms, FA 65 degrees, bandwidth 540 Hz) and a GE (TR 5.8 ms, TE 2.2 ms, FA 25 degrees, bandwidth 200 Hz) sequence using a 1.5 T-MR-System (Magnetom Sonata, Siemens Erlangen). The slice thickness was 1.5 mm and the in-plane resolution was 0.9 x 0.7 mm (2) for all measurements. RESULTS: The blood pool showed a significantly (p < 0.01) higher signal intensity on SSFP images (147 +/- 36) compared to GE images (103 +/- 36). Although noise increased with SSFP (9.3 +/- 1.4 versus 5.3 +/- 0.9), the contrast-to-noise ratio between myocardium and the coronaries was significantly (p < 0.01) higher on SSFP images (7.8 +/- 3.7 versus 3.4 +/- 3.3). The CNR between the coronaries and the epicardial fat showed no significant differences (12 +/- 5 versus 13 +/- 4). CONCLUSION: The 3D-navigator SSFP sequence is a promising new technique for MRCA which improves the contrast between the coronaries and the myocardium and shortens the data acquisition compared to gradient-echo imaging.
Assuntos
Angiografia Coronária/instrumentação , Doença das Coronárias/diagnóstico , Aumento da Imagem/instrumentação , Processamento de Imagem Assistida por Computador/instrumentação , Imageamento Tridimensional/instrumentação , Angiografia por Ressonância Magnética/instrumentação , Adulto , Idoso , Vasos Coronários/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Valores de Referência , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Biochemical markers have been an integrative part of non-invasive diagnostic strategies in cardiology for nearly 50 years, experiencing a renascence by the recently acknowledged prognostic potential of cardiac troponins in acute coronary syndromes. DIAGNOSIS: According to the guidelines of the National Academy of Clinical Biochemistry and the International Federation of Clinical Chemistry cardiac troponin T and cardiac troponin I should be considered as the new "gold markers" of ischemic myocardial injury. One characteristic feature of these new markers is the improved diagnostic potential, reflected by the choice of two cut-off values to distinguish minor myocardial injury from acute myocardial infarction. In addition, cardiac troponins allow risk stratification in the clinical setting of acute coronary syndromes: approximately threefold higher mortality rate for patients with rest angina or ST segment elevation and cardiac troponin elevation on admission. Other indications for cardiac marker analysis are monitoring of therapeutic success in case of invasive and non-invasive reperfusion strategies and non-invasive diagnosis of non-ischemic myocardial injury (myocarditis, cardiac contusion and chemotherapy). CONCLUSION: Biochemical cardiac markers are a useful tool in the diagnosis of both ischemic and non-ischemic myocardial injury. Among these, cardiac troponins seem to become the gold markers for the new millennium.
Assuntos
Biomarcadores/sangue , Cardiomiopatias/sangue , Cardiomiopatias/diagnóstico , Isquemia Miocárdica/sangue , Isquemia Miocárdica/diagnóstico , Proteínas de Neoplasias , Proteínas Supressoras de Tumor , Angina Instável/sangue , Angina Instável/diagnóstico , Cardiomiopatias/enzimologia , Proteínas de Transporte/sangue , Doença das Coronárias/sangue , Doença das Coronárias/diagnóstico , Creatina Quinase/sangue , Diagnóstico Diferencial , Proteína 7 de Ligação a Ácidos Graxos , Proteínas de Ligação a Ácido Graxo , Alemanha , Traumatismos Cardíacos/sangue , Traumatismos Cardíacos/diagnóstico , Humanos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Isquemia Miocárdica/enzimologia , Miocardite/sangue , Miocardite/diagnóstico , Mioglobina/sangue , Cadeias Pesadas de Miosina/sangue , Cadeias Leves de Miosina/sangue , Fosforilases/sangue , Guias de Prática Clínica como Assunto , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Índice de Gravidade de Doença , Troponina I/sangue , Troponina T/sangue , Disfunção Ventricular/sangue , Disfunção Ventricular/diagnósticoRESUMO
BACKGROUND: Cardiovascular diseases are very common in patients with end-stage renal disease and are the underlying cause of approximately half the deaths in dialysis patients. In those patients vascular calcifications are typically seen in the tunica media and therefore represent histopathological changes different to those in atherosclerosis. For the evaluation of cardiovascular risk in chronic dialysis patients, a method is needed to reliably identify patients who have to undergo invasive diagnostics. Coronary artery calcium assessed by electron beam computed tomography (EBT) has been suggested to measure the extent of coronary atherosclerosis in patients with normal renal function. It might also be of value in the stratification of cardiovascular risk in patients with renal failure. CASE REPORT: We report the case of a 21-year-old female with end-stage renal disease as a result of idiopathic infantile hypercalcemia with nephrocalcinosis and extensive vascular calcification. Due to a total atrioventricular block, a 2-chamber pacemaker had been implanted in 1998. Because of a very high calcium score in EBT, depressed left ventricular function in echocardiography, and limited physical strength she was sent to coronary angiography. Severe 2-vessel coronary artery disease was found and successfully treated by balloon angioplasty. She was then listed for renal transplantation. Angiographic 6-month follow-up showed an excellent long-term result. CONCLUSION: This case demonstrates that coronary artery disease can also be present in young dialysis patients. Discrimination of atherosclerotic vascular calcification and tunica media sclerosis typical in dialysis patients without hemodynamic effects is difficult. EBT allows for the direct detection of coronary calcium. Its extent correlates with coronary atherosclerosis and the probability of acute coronary syndromes in patients with normal renal function. This evidence has not been proved for dialysis patients, yet. However, EBT may be of value in the stratification of cardiovascular risk for patients awaiting renal transplantation.
Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Hipercalcemia/complicações , Transplante de Rim/métodos , Nefrocalcinose/complicações , Tomografia Computadorizada por Raios X , Adulto , Doença da Artéria Coronariana/etiologia , Feminino , Humanos , Hipercalcemia/induzido quimicamente , Falência Renal Crônica/etiologia , Nefrocalcinose/induzido quimicamente , Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
HISTORY AND CLINICAL SYMPTOMS: A 58-year-old man was admitted to our hospital with acute chest pain and subfebrile temperatures. Two years ago, endovascular aortic stent-graft placement had been performed for acute type B aortic dissection complicated by malperfusion syndrome. DIAGNOSTIC ASSESSMENT: CT angiography showed a discrete soft-tissue attenuation mass between the aorta and esophagus. The patient developed progressive swallow disorder and esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerations at the level of the implanted aortic stent-graft. Intravenous treatment with broad spectrum antibiotics was started. The FDG-PET/CT scan showed increased FDG uptake and air entrapment in the affected region establishing the diagnosis of aortoesophageal fistula formation. THERAPY AND OUTCOME: Given the generally poor condition of the patient and the high risk of any aggressive surgical intervention, a new limited surgical approach was chosen consisting of open transthoracic esophageal resection, blind closure of the stomach and cervical esophagostomy. A percutaneous endoscopic gastrostomy tube was placed. After three months, esophageal continuity was restored by retrosternal colon interposition. The presented therapeutic management resulted in a full recovery of the patient. CONCLUSION: Aortoesophageal fistula is a rare complication of thoracic aortic stent-graft placement. Patient may present with unspecific symptoms such as fever and rised inflammatory markers, but may also present with massive upper gastrointestinal bleeding. The herein presented limited therapy with esophageal resection represents a promising to the otherwise difficult therapy of aortoesophageal fistula.
Assuntos
Angioplastia , Aneurisma da Aorta Torácica/cirurgia , Doenças da Aorta/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Aortografia , Implante de Prótese Vascular , Fístula Esofágica/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Stents , Tomografia Computadorizada por Raios X , Fístula Vascular/diagnóstico por imagem , Anastomose Cirúrgica , Doenças da Aorta/cirurgia , Colo/transplante , Endoscopia do Sistema Digestório , Fístula Esofágica/cirurgia , Esôfago/cirurgia , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Mediastinite/diagnóstico por imagem , Mediastinite/cirurgia , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Complicações Pós-Operatórias/cirurgia , Reoperação , Fístula Vascular/cirurgiaRESUMO
BACKGROUND: In coronary angiography, the use of contrast agents containing iodine still defines the gold standard. In patients with contraindications for iodine exposition, gadolinium has been considered to be a safe alternative to standard iodinated contrast medium for coronary angiography. The aim of the present study was to assess the safety and technical quality of gadolinium-based coronary angiography. METHODS: Nineteen consecutive patients with contraindication to iodinated contrast medium underwent gadolinium-based coronary angiography. Contraindications included previous anaphylactic shock or severe allergic reaction to iodinated contrast medium (n = 13) or thyrotoxicosis (n = 6). Gadolinium was diluted 1:1 with sodium chloride before application. Patients were clinically observed for potential side effects, and renal function was assessed by determination of creatinine values and calculation of creatinine clearance in pre- and postprocedural blood samples. Image quality was evaluated by two independent observers, and classified into three different categories (grade 1, high diagnostic quality; grade 2, moderate diagnostic quality; and grade 3, poor quality). RESULTS: During angiography, a mean of 32.6 +/- 10.9 mL (range 10-45 mL) gadolinium was used. No patient developed a significant impairment of renal function within 24 hours after the examination (mean creatinine value preprocedural: 1.12 +/- 0.15 mg/dL, postprocedural: 6 hours 1.15 +/- 0.18 mg/dL, 24 hours 1.13 +/- 0.16 mg/dL) (baseline vs. 6 hours P = 0.23, baseline vs. 24 hours P = 0.66, 6 hours vs. 24 hours P = 0.12) (mean creatinine clearance preprocedural: 73.8 +/- 18 mg/dL, postprocedural: 6 hours 71.7 +/- 16.8 mg/dL, 24 hours 73.2 +/- 17.8 mg/dL) (baseline vs. 6 hours P = 0.2, baseline vs. 24 hours P = 0.71, 6 hours vs. 24 hours P = 0.21). Four patients (21%) suffered severe complications due to gadolinium application, such as malignant cardiac arrhythmias (n = 3) and hemodynamic decompensation (n = 1). Image quality was generally reduced in comparison to iodine contrast coronary angiography, but was adequate for diagnostic purposes (13 patients [68.4%] had reasonably good picture contrast [grade 2.1 +/- 0.3]; in 6 patients [31.6%], image quality was satisfactory [grade 2.6 +/- 0.13]). Opacification of distal vessels as compared to proximal segments was remarkably reduced. CONCLUSIONS: Gadolinium-based coronary angiography is a potential alternative technique in patients with allergy to iodinated contrast medium or thyrotoxicosis with reduced, but acceptable, image quality for diagnostic purposes. Nevertheless, possible life-threatening side effects and complications have to be considered.