Acute inferior myocardial infarction combined with papillary muscle rupture: A case report / 中南大学学报(医学版)

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.

Preliminary evaluation on the efficacy of emergency transcatheter aortic valve replacement: a multicenter study / 中华心血管病杂志

Objectives: To explore the efficacy and safety of emergency transcatheter aortic valve replacement (TAVR). Methods: Data of patients who underwent emergency TAVR in eight centers, namely Fuwai Hospital, Wuhan Asia Heart Hospital, Xijing Hospital, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Guangdong Provincial People's Hospital, Zhongshan Hospital Affiliated to Fudan University, the First Affiliated Hospital of Zhengzhou University, the Second Xiangya Hospital of Central South University, between May 2017 and December 2020 were retrospectively analyzed. The use of mechanical circulatory support system (MCS) and the results of laboratory tests (N-terminal B-type natriuretic peptide (NT-proBNP)) and echocardiography (mean aortic valve cross valve pressure difference and left ventricular ejection fraction) before and after operation were collected. The primary endpoint was all-cause death, and the secondary endpoints were stroke, major bleeding, major vascular complications, myocardial infarction, permanent pacemaker implantation, and acute renal injury. Device success was caculated, which refered to absence of procedural mortality and correct positioning of a single prosthetic heart valve into the proper anatomical location and intended performance of the prosthetic heart valve (mean aortic valve gradient<20 mmHg(1 mmHg=0.133 kPa) or peak velocity<3 m/s, with no moderate or severe prosthetic valve regurgitation). Kaplan-Meier survival curve was used to estimate the survival rate of patients during follow-up. Results: This study included 48 patients. The age was (72.5±8.1) years, and 34 patients were males (70.8%). Device success rate was 91.7% (44/48). The mean aortic valve transvalvular pressure was significantly decreased after operation ((12.3±6.4)mmHg vs. (60.2±23.8)mmHg, P<0.000 1). Left ventricular ejection fraction was significantly increased ((41.5±11.7)% vs. (31.0±11.3)%, P<0.000 1). NT-proBNP significantly decreased (3 492.0 (1 638.8, 7 165.5) ng/L vs. 12 418.5 (6 693.8, 35 000.0) ng/L, P<0.000 1). In-hospital all-cause mortality was 8.3% (4/48). During hospitalization, the rate of stroke was 2.1% (1/48), major bleeding was 6.3% (3/48), major vascular complications was 10.4% (5/48), myocardial infarction was 4.2% (2/48), permanent pacemaker implantation was 6.3% (3/48), and the rate of acute renal injury was 12.5% (6/48). MCS was used in 20 patients (41.7%). The median follow-up time was 196 days. During the follow-up, one patient died (due to systemic metastasis of pancreatic cancer), two cases suffered new myocardial infarction and one case received permanent pacemaker implantation. The survival rate of 30 days, 1 year and 2 years after the operation were 91.7% (44/48), 89.6% (43/48), 89.6% (43/48), respectively. Conclusion: Emergency TAVR may be a safe and effective treatment for patients with severe decompensated aortic valve stenosis.

Associations between postprocedural D-dimer, hs-CRP, LDL-C levels and prognosis of acute myocardial infarction patients treated by percutaneous coronary intervention / 中华心血管病杂志

Objective: To investigate the association between postprocedural D-dimer, high sensitivity C-reactive protein(hs-CRP) and low-density lipoprotein-cholesterol(LDL-C) and outcomes of acute myocardial infarction (AMI) patients treated by percutaneous coronary intervention(PCI), in order to clarify the impacts of thrombotic, inflammatory and cholesterol risks on long-term prognosis. Methods: Patients with AMI who underwent emergency PCI from January 2010 to June 2017 in Fuwai Hospital with complete baseline data were enrolled. Patients were stratified into four groups according to quartiles of D-dimer, hs-CRP and LCL-C. Cox regression was used to analyze the relationship between these biomarkers and prognosis. Restricted cubic spline (RCS) was used to characterize the continuous association between risk of all-cause death and biomarkers. The primary outcome was all-cause death. Results: A total of 3 614 patients were included in the analysis. The age was (59.2±12.0) years old, and 2 845 (78.7%) were male and 3 161 (87.5%) patients were diagnosed as ST-segment elevation myocardial infarction. The follow-up time was 652 (414, 1 880) days. Survival analysis showed that postprocedural D-dimer and hs-CRP were significantly associated with all-cause mortality (all P<0.05). Cox regression with multiple adjustments showed that patients with D-dimer≥580 μg/L presented higher risk of all-cause death (HR=2.03, 95%CI 1.22-3.38, P=0.006), compared to patients with D-dimer<220 μg/L. RCS analysis showed that risk of all-cause death was stably high when D-dimer reached 500 μg/L. Multivariable Cox regression also showed that patients with hs-CRP<2.74 mg/L (HR=1.86, 95%CI 1.10-3.15, P=0.020)or hs-CRP≥11.99 mg/L (HR=2.14, 95%CI 1.35-3.40, P=0.001) presented higher mortality compared to patients whose hs-CRP was 2.74-7.18 mg/L. RCS analysis indicated a J-shaped relation between hs-CRP and mortality, as greater risk of death was observed when hs-CRP was lower than 2 mg/L or higher than 10 mg/L. LDL-C was not associated with outcomes (all P>0.05). Conclusions: Postprocedural D-dimer is significantly associated with long-term prognosis of AMI patients treated by PCI. Patients with extremely high or low levels of hs-CRP presents worse outcomes. Intensive and tailored antithrombotic or anti-inflammatory therapies should be considered for patients with increased thrombotic risk and those with extremely high or low inflammatory risk.

Appropriate surgical repair of ventricular free wall rupture after infarction: a case report

Abstract Ventricular free wall rupture is a fatal mechanical complication of acute myocardial infarction. In some cases it can be represented as subacute clinic and may not cause death in a few minutes. Acute pseudo-aneurysms are extremely unstable and bound to fatal rupture. Herein we report a male patient who suffered dyspnea and mild chest pain, 4 weeks after acute ST-segment elevation myocardial infarction.

Clinical-epidemiological aspects of patients submitted to Percutaneous Coronary Intervention in a university hospital / Aspectos clínico-epidemiológicos de pacientes sometidos a la Intervención Coronaria Percutánea en un hospital universitario / Aspectos clínico-epidemiológicos de pacientes submetidos à Intervenção Coronária Percutânea em hospital universitário

ABSTRACT Objective: To outline the clinical-epidemiological profile of patients submitted to Percutaneous Coronary Intervention in a Reference Hospital in Urgent Cardiology Clinic of the state of Rio Grande do Norte. Method: This is a descriptive, exploratory, prospective study with a quantitative approach developed in a Brazilian University Hospital with patients submitted to Percutaneous Coronary Intervention. Data collection occurred between April and October 2017. Results: The sample consisted of 222 patients, of whom 58.10% underwent Elective Percutaneous Coronary Intervention and 41.89% were primary, 65.3% males, with a mean age of 62.7. In comorbidities "Hypertension", "Acute Myocardial Infarction", "Current Smoking" and "Physical Inactivity" were highlighted. Conclusion: In the elective patients, there was a high prevalence of risk factors and in patients with urgent cases, high time of total ischemia. It is necessary to create strategies to structure the care line, to improve the effectiveness of treatment and to minimize adverse outcomes.

RESUMEN Objetivo: Trazar el perfil clínico-epidemiológico de los pacientes sometidos a la Intervención Coronaria Percutánea en un Hospital de referencia en urgencia cardiológica del estado de Rio Grande do Norte. Método: Se trata de un estudio descriptivo, exploratorio, prospectivo con abordaje cuantitativo, desarrollado en un Hospital Universitario brasileño con pacientes sometidos a la Intervención Coronaria Percutánea. La recolección de datos ocurrió entre abril y octubre de 2017. Resultados: La muestra compuesta por 222 pacientes. De esos, 58,10% fueron sometidos a la Intervención Coronaria Percutánea electiva y el 41,89% a la primaria, el 65,3% del sexo masculino; la media de edad fue de 62,7. En las comorbilidades, se destacaron Hipertensión Arterial Sistémica, Infarto Agudo de Miocardio previo, tabaquismo actual y sedentarismo. Conclusión: En los pacientes electivos, hubo alta prevalencia de factores de riesgo y en los pacientes de urgencia, elevado tiempo de isquemia total. Se hace necesario la creación de estrategias para estructurar la línea de cuidado, mejorar la eficacia del tratamiento y minimizar los resultados adversos.

RESUMO Objetivo: Traçar o perfil clínico-epidemiológico dos pacientes submetidos à Intervenção Coronária Percutânea em um Hospital de referência em urgência cardiológica do estado do Rio Grande do Norte. Método: Trata-se de um estudo descritivo, exploratório, prospectivo, com abordagem quantitativa, desenvolvido em um Hospital Universitário brasileiro com pacientes submetidos à Intervenção Coronária Percutânea. A coleta de dados ocorreu entre abril e outubro de 2017. Resultados: Amostra composta por 222 pacientes, destes, 58,10% foram submetidos à Intervenção Coronária Percutânea eletiva e 41,89% à primária, 65,3% do sexo masculino, com média de idade de 62,7. Nas comorbidades, destacaram-se "Hipertensão Arterial Sistêmica", "Infarto Agudo do Miocárdio Prévio", "Tabagismo Atual" e "Sedentarismo". Conclusão: Nos pacientes eletivos, houve alta prevalência de fatores de risco e nos pacientes da urgência, elevado tempo de isquemia total. Faz-se necessário a criação de estratégias para estruturar a linha de cuidado, melhorar a eficácia do tratamento e minimizar os desfechos adversos.

Behavior of ultrasensitive c-reactive protein in myocardial revascularization with and without cardiopulmonary bypass

Abstract Objective: To analyze the inflammation resulting from myocardial revascularization techniques with and without cardiopulmonary bypass, based on ultrasensitive C-reactive protein (US-CRP) behavior. Methods: A prospective non-randomized clinical study with 136 patients was performed. Sixty-nine patients were enrolled for Group 1 (on-pump coronary artery bypass - ONCAB) and 67 patients were assigned to Group 2 (off-pump coronary artery bypass - OPCAB). All study participants had blood samples collected for analysis of glucose, triglycerides, creatinine, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and creatinephosphokinase (CPK) in the preoperative period. The samples of creatinephosphokinase MB (CKMB), troponin I (TnI) and US-CRP were collected in the preoperative period and at 6, 12, 24, 36, 48 and 72 hours after surgery. We also analyzed the preoperative biological variables of each patient (age, smoking, diabetes mellitus, left coronary trunk lesion, body mass index, previous myocardial infarction, myocardial fibrosis). All angiographically documented patients with >70% proximal multiarterial stenosis and ischemia, documented by stress test or classification of stable angina (class II or III), according to the Canadian Cardiovascular Society, were included. Reoperations, combined surgeries, recent acute myocardial infarction, recent inflammatory disease, deep venous thrombosis or recent pulmonary thromboembolism, acute kidney injury or chronic kidney injury were not included. Results: Correlation values between the US-CRP curve and the ONCAB group, the treatment effect and the analyzed biological variables did not present expressive results. Laboratory variables were evaluated and did not correlate with the applied treatment (P>0.05). Conclusion: The changes in the US-CRP at each moment evaluated from the postoperative period did not show any significance in relation to the surgical technique applied.

Pharmacoinvasive strategy versus primary angioplasty in patients with acute ST-segment elevation myocardial infarction / Estrategia farmacoinvasiva versus angioplastia primaria en pacientes con infarto agudo al miocardio con elevación del segmento ST

Abstract: Background: Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). The delays associated with PPCI reduce the benefits of this therapy. To minimize these delays, the pharmacoinvasive strategy (PS) was developed, consisting of applying thrombolytic therapy followed by coronary angioplasty 2 to 24 hours after. Objective: To compare the safety and efficiency of PPCI vs PS in STEMI. Methods: We included patients with STEMI who had emergency PCI. The primary endpoint was combined major adverse cardiac events (MACE), death, reinfarction, stroke, target vessel revascularization (TVR) during hospitalization. The secondary endpoints were the individual components of MACE, and major bleeding (Bleeding Academic Research Consortium: BARC ≥ 3). Results: A total of 400 patients, 263 (65.8%) for PPCI group, 114 (28.5%) for PS group and 23 (5.75%) for diagnostic group. The PS group, 79 (69.3%) were then categorized as systematic angioplasty having had a successful thrombolysis, and 35 (30.7%) were rescue angioplasty because they had a failed thrombolysis. There were no differences in MACE: 13 (9.5%) patients in PS and 27 (10.3%) patients in the PPCI (p = 0.806), there were no differences in the individual components of MACE. The rate of major bleeding was the same, 5 (3.6%) and 4 (1.5%) respectively (p = 0.173). The multivariate analysis did not show a relationship between MACE and the reperfusion strategy. Conclusions: The pharmacoinvasive strategy when compared to PPCI has a similar rate of primary and secondary endpoints. There is no increase in major bleeding therefore, it is an important strategy that offers a reperfusion therapy for patients with STEMI in a non-PCI capable hospital.(AU)

Resumen: Antecedentes: La intervención coronaria percutánea primaria (ICPP) es el tratamiento de elección en infarto agudo al miocardio con elevación del ST (IAMCEST). El retraso relacionado con ICPP disminuye el beneficio. Buscando una reperfusión oportuna se implementa la estrategia farmacoinvasiva (EFI), que consiste en realizar trombólisis seguido de ICP entre 2 a 24 horas después. Objetivo: Comparar la seguridad y eficacia en pacientes sometidos a ICPP contra EFI en IAMCEST. Métodos: Se incluyeron pacientes con IAMCEST sometidos a ICP emergente. El punto final primario son eventos cardiacos adversos mayores (ECAM), muerte, reinfarto, evento vascular cerebral y revascularización del vaso tratado, durante la hospitalización. Los puntos finales secundarios son la presencia de los componentes individuales del ECAM, y el sangrado mayor (BARC ≥ 3). Resultados: Se estudiaron 400 pacientes, 263 (65.8%) de ICPP, 114 (28.5%) a EFI y 23 (5.75%) angiografía diagnóstica. Del grupo EFI, 79 (69.3%) fueron angioplastia sistemática por trombólisis exitosa y 35 (30.7%) por angioplastia de rescate por trombólisis fallida. No se observó diferencia en la frecuencia de ECAM: EFI 13 (9.5%) contra ICPP 27 (10.3%) respectivamente (p = 0.806), tampoco hubo diferencia en los componentes individuales. No se observó diferencia en sangrado mayor, 5 (3.6%) vs 4 (1.5%), (p = 0.173). El análisis multivariado no relacionó la estrategia de reperfusión con los ECAM. Conclusiones: La EFI comparada con ICPP demuestra una tasa similar de ECAM, así como de sus componentes individuales. No se asocia con aumento de hemorragia mayor, concluyendo que ofrece el beneficio de una reperfusión oportuna sin aumento del riesgo en los hospitales que no tienen la capacidad para realizar ICPP.(AU)

Comparison of clinical outcomes regarding the use of titanium-nitride-oxide-coated stents (Titan) versus zotarolimus-eluting stents (Endeavor) in patients with ST-segment elevation myocardial infarction (STEMI): An experience from a Cardiac Center-Third care level / Comparación de los resultados clínicos con respecto al uso de stents recubiertos de óxido de titanio (Titan) versus stents liberadores de zotarolimus (Endeavor) en pacientes con infarto de miocardio por elevación del segmento ST (STEMI): Una experiencia de un centro cardiaco de Tercer nivel de atención

Abstract: Introduction: Internationally, the Titan bioactive stent efficacy and safety have been evaluated against second-generation drug-eluting stents (DES) in patients with acute coronary syndrome. In our field, however, there is not enough information about its short-term or one-year follow-up outcomes when compared with a second-generation drug-eluting stent in ST-segment elevation myocardial infarction (STEMI). Objective: To evaluate and compare immediate, in-hospital and one-year use clinical outcomes of the Titan stent versus Endeavor stent in patients with ST-segment elevation myocardial infarction. Material and methods: A descriptive, comparative, longitudinal, retrospective, observational study was performed in patients with ST-segment elevation myocardial infarction type acute coronary syndrome who were subjected to primary, pharmacoinvasive and rescue angioplasties, using a Titan stent against Endeavor stent. Primary points: major adverse cardiac events (MACEs), death, myocardial infarction, need for target lesion revascularization (TLR), target vessel revascularization (TVR), cerebrovascular event (CVE) and stent thrombosis. Secondary points: Dual antiplatelet therapy (DAPT) usage time. Results: 256 patients with ST-segment elevation myocardial infarction were examined from January 2011 to December 2014. They were treated with a Titan bioactive stent (135 patients) or Endeavor stent (121 patients). There were no significant differences related to major adverse cardiac events, death, myocardial infarction, stent thrombosis or cerebrovascular event, either in-hospital or one-year follow-up. More patients were observed in the Killip-Kimball 3-4 classification in Endeavor stent group versus patients in Titan stent group (62.2% versus 42.2%, respectively, p = 0.010). A greater pre-PTCA (Percutaneous Transluminal Coronary Angioplasty) TIMI (Thrombolysis in Myocardial Infarction) 0-1 flow rate was also observed (90.9% in Endeavor stent group versus 79.3% in Titan stent group, p = 0.010). However, the Titan stent was considerably more used in elderly patients (62.36 ± 12.95 years old versus 57.59 ± 10.42 years old in Endeavor stent group, p = 0.001); in more complex type C lesions (62.4% in Titan stent group versus 40.5% in Endeavor stent group, p = 0.010); and small vessels (28.9% in Titan stent group versus 18.2% in Endeavor stent group, p = 0.045). Target lesion revascularization and target vessel revascularization rates were similar: 0% versus 2.5%, p = 0.066 and 0% versus 0.8%, p = 0.290, in Titan stent and Endeavor stent groups, respectively. There were no significant differences on the major adverse cardiac events-free survival analysis (Log-rank Mantel-Cox 0.764 test). There were significant differences on dual antiplatelet therapy usage time (6.46 ± 4.11 months in Titan stent group versus 10.98 ± 2.51 months in Endeavor stent group, p ≤ 0.0001). Conclusions: There was no superiority registered in use of a second-generation drug-eluting stent such as the Endeavor stent versus Titan bioactive stent (titanium-nitride-oxide-coated stent) in patients with ST-segment elevation myocardial infarction regarding immediate, in-hospital and one-year follow-up clinical outcomes. The Titan stent seems to be a good choice for this kind of ST-segment elevation acute coronary syndrome in both efficacy and safety against new drug-eluting stents, and it could be used in elderly patients and/or patients with high bleeding risk requiring less time of dual antiplatelet therapy.(AU)

Resumen: Introducción: A nivel internacional, la eficacia y la seguridad de los stents bioactivos Titan se han evaluado en comparación con los stents liberadores de fármacos (su sigla en inglés es DES) de segunda generación en pacientes con síndrome coronario agudo. Sin embargo, en nuestro campo, no hay suficiente información acerca de sus resultados de seguimiento a corto plazo o de un año cuando se compara con una endoprótesis liberadora de fármacos de segunda generación en el infarto de miocardio por elevación del segmento ST (STEMI). Objetivo: Evaluar y comparar los resultados clínicos inmediatos, en el hospital y a un año de uso del stent Titan frente a stent Endeavor en pacientes con infarto de miocardio por elevación del segmento ST. Material y métodos: Se realizó un estudio observacional descriptivo, comparativo, longitudinal, retrospectivo y observacional en pacientes con el síndrome coronario agudo de infarto de miocardio por elevación del segmento ST que fueron sometidos a angioplastias primarias, farmacoinvasivas y de rescate, utilizando un stent Titan contra el stent Endeavor. Puntos primarios: eventos cardiacos adversos mayores (MACE), muerte, infarto de miocardio, necesidad de revascularización de la lesión objetivo (TLR). Revascularización del vaso objetivo (TVR), evento cerebrovascular (CVE) y trombosis del stent. Puntos secundarios: Tiempo de uso de la terapia antiplaquetaria dual (DAPT). Resultados: De enero de 2011 a diciembre de 2014 se examinaron 256 pacientes con infarto de miocardio por elevación del segmento ST. Fueron tratados con un stent bioactivo de Titan (135 pacientes) o un stent de Endeavor (121 pacientes). No hubo diferencias significativas relacionadas con los eventos cardiacos adversos mayores, muerte, infarto de miocardio, trombosis de stent o evento cerebrovascular, ni en el hospital ni en el seguimiento de un año. Se observaron más pacientes en la clasificación Killip-Kimball 3-4 en el grupo de stent Endeavor versus pacientes en el grupo de stent Titan (62.2% versus 42.2%, respectivamente, p = 0.010). También se observó una mayor tasa de flujo 0-1 antes de la PTCA (angioplastia coronaria transluminal percutánea) TIMI (trombólisis en el infarto de miocardio) (90.9% en el grupo de stent Endeavor frente a 79.3% en el grupo de stent Titan, p = 0.010). Sin embargo, la endoprótesis Titan se utilizó considerablemente más en pacientes de edad avanzada (62.36 ± 12.95 años frente a 57.59 ± 10.42 años en el grupo de endoprótesis Endeavor, p = 0.001); en las lesiones tipo C más complejas (62.4% en el grupo de stent Titan versus 40.5% en el grupo de stent Endeavor, p = 0.010); y en pequeños vasos (28.9% en el grupo de stent Titan versus 18.2% en el grupo de stent Endeavor, p = 0.045). La revascularización de las lesiones objetivo y las tasas de revascularización de los vasos objetivo fueron similares: 0% versus 2.5%, p = 0.066 y 0% versus 0.8%, p = 0.290, en los grupos de stent Titan y stent Endeavor, respectivamente. No hubo diferencias significativas en el análisis de supervivencia sin eventos cardiacos adversos mayores (ensayo de Mantel-Cox 0.764 del rango de logos). Hubo diferencias significativas en el tiempo de uso del tratamiento antiplaquetario dual (6.46 ± 4.11 meses en el grupo con stent Titan versus 10.98 ± 2.51 meses en el grupo con stent Endeavor, p ≤ 0.0001). Conclusiones: No se registró una superioridad en el uso de un stent liberador de fármacos de segunda generación como el stent Endeavor versus el stent bioactivo Titan (stent recubierto de titanio-nitrurado) en pacientes con infarto de miocardio por elevación del segmento ST con respecto a los resultados clínicos de seguimiento inmediato, hospitalario y de un año. El stent Titan parece ser una buena opción para este tipo de síndrome coronario agudo por elevación del segmento ST, tanto en eficacia como en seguridad frente a nuevos stents liberadores de fármacos, y podría utilizarse en pacientes ancianos y/o pacientes con alto riesgo de hemorragia que requieran menos tiempo de tratamiento antiplaquetario dual.(AU)

Reperfusión mecánica simple en el infarto agudo de miocardio: Determinantes, implicaciones en el pronóstico y relación con la histología del trombo / Simple mechanical reperfusion in acute myocardial infarction: determinants, prognostic implications and relation with thrombus histology

La reperfusión mecánica simple (RMS) es la lograda en la angioplastia primaria al atravesar la oclusión en la arteria responsable de infarto con la guía intracoronaria. Para evaluar los determinantes de la RMS, su implicación en el pronóstico y su relación con la histopatología del trombo rescatado, fueron analizados los casos de 601 pacientes con infarto agudo de miocardio con elevación del segmento ST y oclusión total de la arteria responsable de infarto (flujo TIMI 0). Se consideraron dos grupos según la presencia de RMS, definida por la visualización de contraste distal a la lesión luego de atravesarla con la guía intracoronaria. Se realizó el análisis histopatológico de los trombos en un subgrupo de 160 pacientes tratados con tromboaspiración. En 303 (50.4%) pacientes se obtuvo RMS. La RMS se asoció a menor ventana al tratamiento (248 vs. 286 minutos, p = 0.001), menor deterioro de la función sistólica ventricular izquierda inicial y shock al ingreso (9.2 vs.16.4%, p = 0.008), mayor tasa de éxito (94.7 vs. 78.5%, p < 0.0001) y de rescate de trombos (70/81 vs. 27/79 pacientes, p < 0.0001). La arteria responsable de infarto más frecuente fue la coronaria derecha. La RMS se asoció con menor tamaño del trombo, menor concentración de leucocitos y eritrocitos y mayor contenido de células inflamatorias, cristales de colesterol y colágeno provenientes de la placa. La RMS es un predictor independiente de éxito y su relación con la anatomía del trombo podría redefinir la indicación de la tromboaspiración.

Simple mechanical reperfusion (SMR) is defined as reperfusion achieved after wire insertion at the occluded infarct-related artery in primary angioplasty. The determinants and prognostic implications of SMR and its relationship with the histopathology of the rescued thrombus were evaluated in 601 patients with acute myocardial infarction showing ST elevation and pre-procedural total occlusion of the infarct-related artery (TIMI flow 0). Two groups were considered according to the presence of SMR, defined as the visualization of contrast material after crossing the occlusion with the guide wire. SMR was achieved in 303 patients (50.4%) and was found to be associated with less time to treatment (248 vs. 286 minutes; p = 0.001), less deteriorated initial left ventricular function and shock at admission (9.2 vs. 16.4%; p = 0.008), higher successful rate (94.7% vs. 78.5%; p < 0,0001) and of higher rate of thrombus rescue: 70/81 vs. 27/79 patients (p < 0.0001). The right coronary artery was the most frequent infarct-related artery. Histopathology of the retrieved thrombi was available for 160 patients treated with thrombus aspiration. SMR was associated with smaller thrombus, lower contents of leukocytes and erythrocytes, and higher thrombus content of inflammatory cells, cholesterol and collagen crystals from the atheromatous plaque. SMR is an independent predictor of procedure success and its relationship with the anatomy of the thrombus could redefine the indication of thrombus aspiration.

Techniques, timing & prognosis of post infarct ventricular septal repair: a re-look at old dogmas

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Reperfusion therapy of myocardial infarction in Mexico: A challenge for modern cardiology / La reperfusión en el infarto del miocardio en México: un reto para la cardiología moderna

Abstract: Mexico has been positioned as the country with the highest mortality attributed to myocardial infarction among the members of the Organization for Economic Cooperation and Development. This rate responds to multiple factors, including a low rate of reperfusion therapy and the absence of a coordinated system of care. Primary angioplasty is the reperfusion method recommended by the guidelines, but requires multiple conditions that are not reached at all times. Early pharmacological reperfusion of the culprit coronary artery and early coronary angiography (pharmacoinvasive strategy) can be the solution to the logistical problem that primary angioplasty rises. Several studies have demonstrated pharmacoinvasive strategy as effective and safe as primary angioplasty ST-elevation myocardial infarction, which is postulated as the choice to follow in communities where access to PPCI is limited. The Mexico City Government together with the National Institute of Cardiology have developed a pharmaco-invasive reperfusion treatment program to ensure effective and timely reperfusion in STEMI. The model comprises a network of care at all three levels of health, including a system for early pharmacological reperfusion in primary care centers, a digital telemedicine system, an inter-hospital transport network to ensure primary angioplasty or early percutaneous coronary intervention after fibrinolysis and a training program with certification of the health care personal. This program intends to reduce morbidity and mortality associated with myocardial infarction.

Resumen: México se ha posicionado como el país con mayor mortalidad atribuible al infarto del miocardio entre los países de la Organización de Cooperación y Desarrollo Económico. Esta tasa responde a múltiples factores, incluyendo una baja tasa de reperfusión y la ausencia de un sistema único y coordinado para la atención del infarto. Aun cuando la angioplastia es el método de reperfusión recomendado, requiere un sistema coordinado con personal entrenado y recursos materiales, condiciones que no siempre pueden ser alcanzadas. La reperfusión farmacológica temprana, seguida de angiografía coronaria temprana (estrategia farmacoinvasiva) es la solución al problema logístico que representa la angioplastia primaria. Múltiples estudios han demostrado que la estrategia farmacoinvasiva es tan segura y efectiva como la angioplastia primaria en el infarto agudo del miocardio con elevación del segmento ST, y se plantea como la estrategia de elección en comunidades donde el acceso a angioplastia está limitado por factores económicos, geográficos o socioculturales. El gobierno de la Ciudad de México en conjunto con el Instituto Nacional de Cardiología ha desarrollado un programa de estrategia farmacoinvasiva para asegurar la reperfusión temprana en el infarto del miocardio. El modelo comprende una red de atención en los 3 niveles, incluyendo un sistema de reperfusión farmacológica en centros de primer contacto, transferencia de electrocardiogramas mediante telemedicina entre el primer nivel y el Instituto Nacional de Cardiología, una red de transporte interhospitalario y un programa de entrenamiento y educación continua. El objetivo de este programa es reducir la morbilidad y la mortalidad asociadas al infarto del miocardio.

Emergency Percutaneous Coronary Intervention Through the Left Radial Artery is Associated with Less Vascular Complications than Emergency Percutaneous Coronary Intervention Through the Femoral Artery

OBJECTIVE: To compare the advantages and disadvantages of emergency percutaneous coronary intervention through the left radial artery with those of emergency percutaneous coronary intervention through the femoral artery. METHODS: A total of 206 patients with acute myocardial infarction who required emergency percutaneous coronary intervention and were admitted to our hospital between January 2011 and August 2013 were divided into the following two groups: a group that underwent percutaneous coronary intervention through the left radial artery and a group that underwent percutaneous coronary intervention through the femoral artery. The times required for angiographic catheter and guiding catheter placement, the success rate of the procedure and the incidence of vascular complications in the two groups were observed. RESULTS: There was no significant difference in catheter placement time or the ultimate success rate of the procedure between the two groups. However, the left radial artery group showed a significantly lower incidence of vascular complications than the femoral artery group (p<0.05). CONCLUSION: Emergency percutaneous coronary intervention through the left radial artery is associated with less vascular complications than emergency percutaneous coronary intervention through the femoral artery and is thus potentially advantageous for patients.

In-Lab Upfront Use of Tirofiban May Reduce the Occurrence of No-Reflow During Primary Percutaneous Coronary Intervention. A Pilot Randomized Study / Uso de Tirofibana em Laboratório pode Reduzir Ocorrência de não Reperfusão Durante Intervenção Coronariana Percutânea Primária. Um Estudo Piloto Randomizado

Abstract Background: Despite successful opening of culprit coronary artery, myocardial reperfusion does not always follows primary percutaneous coronary intervention (PPCI). Glycoprotein IIb/IIIa inhibitors are used in the treatment of no-reflow (NR), but their role to prevent it is unproven. Objective: To evaluate the effect of in-lab administration of tirofiban on the incidence of NR in ST-elevation myocardial infarction (STEMI) treated with PPCI. Methods: STEMI patients treated with PPCI were randomized (24 tirofiban and 34 placebo) in this double-blinded study to assess the impact of intravenous tirofiban on the incidence of NR after PPCI according to angiographic and electrocardiographic methods. End-points of the study were: TIMI-epicardial flow grade; myocardial blush grade (MBG); resolution of ST-elevation < 70% (RST < 70%) at 90min and 24h after PPCI. Results: Baseline anthropometric, clinical and angiographic characteristics were balanced between the groups. The occurrence of TIMI flow < 3 was not significantly different between the tirofiban (25%) and placebo (35.3%) groups. MBG ≤ 2 did not occur in the tirofiban group, and was seen in 11.7% of patients in the placebo group (p=0.13). RST < 70% occurred in 41.6% x 55.8% (p=0.42) at 90min and in 29% x 55.9% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Severe NR (RST ≤ 30%) was detected in 0% x 26.5% (p=0.01) at 90 min, and in 4.2% x 23.5% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Conclusion: This pilot study showed a trend toward reduction of NR associated with in-lab upfront use of tirofiban in STEMI patients treated with PPCI and paves the way for a full-scale study testing this hypothesis.

Resumo Fundamento: Mesmo com abertura da artéria coronária culpada bem sucedida, a reperfusão miocárdica nem sempre sucede a intervenção coronariana percutânea primária (ICPP). Inibidores da glicoproteína IIb/IIIa são usados no tratamento do fenômeno de não reperfusão (NR), mas seu papel para preveni-lo não está comprovado. Objetivo: Avaliar o efeito da administração, em laboratório, de tirofibana sobre a incidência de NR em infarto agudo do miocárdio com supra do segmento ST (IAMCSST) tratado com ICPP. Métodos: Pacientes com IAMCSST tratados com ICPP foram randomizados (24 tirofibana e 34 placebo) neste estudo duplo-cego para avaliar o impacto de tirofibana intravenosa sobre a incidência de NR após ICPP de acordo com métodos angiográficos e eletrocardiográfico. Os desfechos do estudo foram: fluxo epicárdico TIMI (grau), grau de fluxo miocárdico (MBG), resolução da elevação do segmento ST < 70% (RST < 70%) aos 90 minutos e 24 horas após ICPP. Resultados: Características antropométricas, clínicas e angiográficas basais eram equilibradas entre os grupos. A ocorrência de fluxo TIMI < 3 não foi significativamente diferente entre os grupos tirofibana (25%) e placebo (35,3%). MBG ≤ 2 não ocorreu no grupo tirofibana, e foi detectado em 11,7% dos pacientes do grupo placebo (p=0,13). RST < 70% ocorreu em 41,6% x 55,8% (p=0.42) aos 90 minutos, e em 29% x 55,9% (p=0,06) em 24 horas nos grupos tirofibana e placebo, respectivamente. NR grave (RST ≤ 30%) ocorreu em 0% x 26,5% (p=0,01) aos 90 minutos, e em 4,2% x 23,5% (p=0,06) em 24 horas nos grupos tirofibana e placebo, respectivamente. Conclusão: Este estudo piloto mostrou uma tendência de redução de NR associada ao uso, em laboratório, de tirofibana em pacientes com IAMCSST tratados com ICPP, e abre caminho para um estudo em escala real que teste essa hipótese.

Fatores de Risco Cardiovasculares em Lesões Coronarianas Críticas: Mito ou Realidade? / Cardiovascular Risk Factors in Critical Coronary Lesions: Myth or Reality?

Fundamento: A doença cardiovascular (DCV) é responsável pelos maiores índices de morbimortalidade em todo o mundo, sendo o infarto agudo do miocárdio (IAM) e acidente isquêmico cerebral, suas principais manifestações. Os fatores de risco que contribuem para o desenvolvimento da doença são amplamente conhecidos, porém resta a dúvida se maior quantidade de fatores de risco explica doenças mais graves ou o impacto isolado de um fator de risco poderia também ser determinante nos pacientes. Objetivo: O estudo correlaciona os fatores de risco para doença arterial coronariana (DAC) em indivíduos submetidos à angioplastia e/ou revascularização miocárdica (RM) devido a lesões coronarianas críticas, esclarecendo o papel dos fatores de risco clássicos para DCV, e também analisa se a condição gênero, estado marital e nível de escolaridade estariam relacionados com maior presença desses fatores de risco. Métodos: Foram aplicados questionários de fatores de risco para DCV em pacientes do departamento de Hemodinâmica e Cirurgia Cardíaca do Hospital Beneficência Portuguesa de São Paulo, na cidade de São Paulo, Brasil, seguida de análise estatística dos dados. Resultados: em nossa amostra de pacientes a maioria apresentou dois fatores de risco para DCV, sendo hipertensão arterial, dislipidemia e diabetes mellitus os mais prevalentes nesta população. Conclusão: Confirmou-se o papel dos fatores clássicos de risco na DCV como não sendo mito e sim realidade, principalmente quando pacientes com menor número de fatores apresentaram situações obstrutivas semelhantes aos dos pacientes com maior número fatores de risco presente

Background: Cardiovascular disease (CVD) is responsible for the greatest morbidity and mortality rates in the world, and acute myocardial infarction (AMI) and cerebral ischemic attack are its main manifestations. Risk factors that contribute to the development of the disease are widely known, but there remains the question of whether a higher number of risk factors explains more serious illnesses, or if the isolated impact of a risk factor could also be determinant in patients. Objective: The study correlates the risk factors for coronary artery disease (CAD) and patients undergoing angioplasty and / or coronary artery bypass graft (CABG) due to critical injuries, clarifying the role of classic risk factors for cardiovascular disease (CVD) and analyzing if factors such as gender, marital status and education level are related to a greater presence of these risk factors. Methods: We used questionnaires of risk factors for CVD with patients at the Hemodynamics Department and Cardiac Surgery Charity Hospital Portuguese São Paulo, in São Paulo, Brazil, followed by statistical analysis. Results: In our sample most patients showed two risk factors for CVD, and hypertension, dyslipidemia and diabetes mellitus were the most prevalent ones in this population. Conclusion: The study confirmed that the role of classic risk factors in cardiovascular disease is not a myth but a reality, especially when patients with fewer risk factors presented obstructive situations similarly to patients with more risk factors

Risco Cirúrgico e Funcionalidade em Pacientes Submetidos à Cirurgia Cardíaca / Surgical Risk and Functionality in Patients Undergoing Heart Surgery

Fundamento: A cirurgia cardíaca pode levar a um declínio da função pulmonar e periférica. O EuroSCORE avalia o risco da cirurgia cardíaca, e a mensuração da independência funcional verifica a capacidade para desempenhar atividades funcionais. Objetivo: Identificar a correlação entre uma escala de risco cardíaco e a funcionalidade de pacientes submetidos à cirurgia cardíaca. Métodos: Trata-se de um estudo transversal prospectivo, realizado com pacientes submetidos à avaliação da funcionalidade no período pré-operatório, por meio da mensuração da independência funcional e de avaliação pelo EuroSCORE, afim de estabelecer o nível de risco para a cirurgia cardíaca. Após o procedimento cirúrgico, no primeiro dia após alta da unidade de terapia intensiva, a mensuração da independência funcional foi reavaliada e comparada com o valor inicial. Resultados: Incluímos 52 pacientes (55,8% homens) com média de idade de 56,9 ± 14,2 anos. A média da mensuração da independência funcional pré-operatória foi de 125,4 e a pós-operatória 106,78. Foi aplicado o teste t, que mostrou redução significativa entre os períodos analisados, com o valor de p = 0,000. Ao correlacionar os valores da mensuração da independência funcional pós-operatória com o risco cardíaco, observou-se relação importante, sendo p = 0,006 e r = -0.37. Conclusão: Uma avaliação pré-operatória demonstrando um maior risco cardíaco tem impacto negativo sobre a funcionalidade de pacientes submetidos à cirurgia cardíaca

Background: Cardiac surgery can lead to a decline in lung and peripheral function. EuroSCORE is a scale that assesses cardiac surgery risk and the measurement of functional independence evaluates the ability to perform functional activities. Objective: To identify the correlation between a cardiac risk scale and functionality in patients undergoing CS. Methods: This is a prospective cross-sectional study, carried out with patients submitted to functional evaluation in the preoperative period, through the measurement of functional independence and evaluation by the EuroSCORE, to establish the level of risk for cardiac surgery. After the surgical procedure, on the first day after discharge from the intensive care unit, the functional independence measurement (FIM) was reevaluated and compared to the initial value. Results: We included 52 patients (55.8% men) with a mean age of 56.9 ± 14.2 years. The mean preoperative and postoperative FIM values were 125.4 and 106.78. The t test was performed, which showed a significant reduction between the analyzed periods, with a value of p = 0.000. By correlating the postoperative FIM values with the cardiac risk, it was observed that there was an important association, with p = 0.006 and r = -0.37. Conclusion: We concluded that a preoperative assessment showing an increased cardiac risk has a negative impact on the functionality of patients undergoing cardiac surgery

Orientação para a atividade sexual após infarto agudo do miocárdio: estamos negligenciando? / Counseling on sexual activity after acute myocardial infarction: are we overlooking it?

A ocorrência de infarto agudo do miocárdio (IAM) causa mudanças consideráveis na vida do paciente, que se defronta com desafios físicos e psicológicos. Destaca-se a importante redução da atividade sexual, fator influenciador da qualidade de vida. É, portanto, importante que os profissionais da saúde estejam capacitados a orientar os pacientes na retomada da atividade sexual após o IAM e como realizar tal atividade de forma segura. Este trabalho tem por objetivo enfatizar a necessidade, ainda negligenciada, de os profissionais de saúde realizarem tal orientação de forma adequada, contribuindo assim para a qualidade de vida do paciente.

Acute myocardial infarction (AMI) causes significant changes in the life of patients, who face physical and psychological challenges.These include reduction in sexual activity, a factor that influences the quality of life. It is therefore important that health professionals be able to advise patients on the resumption of sexual activity after AMI and how to do that safely. This study is designed to emphasize the neglected need for healthcare professionals to perform such guidance properly, thus contributing to the quality of life of the patient.

Trombólisis prehospitalaria: en perspectiva nacional. Estrategia farmacoinvasiva para la reperfusión temprana del IAMCEST en México / Prehospital thrombolysis: A national perspective. Pharmaco-invasive strategy for early reperfusion of STEMI in Mexico

Resumen: Objetivo: Revisar la evidencia existente sobre el papel de la trombólisis prehospitalaria en los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) como parte de una estrategia de vanguardia para reducir el tiempo de reperfusión miocárdica y, con ello, mejorar la supervivencia y la función. Métodos: Se utilizó la técnica de exploración-reducción-evaluación-análisis y síntesis de estudios relacionados, con una visión general de las recomendaciones actuales, de los datos de ensayos clínicos controlados y de los registros nacionales e internacionales sobre las diferentes estrategias de reperfusión para el IAMCEST. En total, se examinaron 186 referencias sobre trombólisis prehospitalaria, 130 referencias en tiempos puerta-tratamiento, 139 referencias en la gestión de IAMCEST y los registros nacionales e internacionales, así como 135 referencias en intervención coronaria percutánea primaria y de rescate en IAMCEST. Finalmente se retuvieron las 48 referencias que se consideraron más relevantes e informativas. Conclusión: El factor "tiempo" es esencial en el éxito de la reperfusión temprana en el IAMCEST sobre todo si se toma en cuenta la trombólisis prehospitalaria. La intervención coronaria percutánea primaria está sujeta a su factibilidad antes de 120 min del inicio de los síntomas. En nuestro medio, al igual que en el ámbito internacional, la trombólisis continúa siendo una estrategia con gran alcance en las expectativas de vida y función de los pacientes. Los sistemas de telecomunicación deben incorporarse en tiempo real a las necesidades prioritarias de enfermedades catastróficas como el IAMCEST, donde la vida es dependiente del tiempo.

Abstract: Objective: To review the existing evidence on the role of prehospital thrombolysis in patients with ST-segment elevation acute myocardial infarction (STEMI) as part of a strategy of cutting edge to reduce the time of coronary reperfusion and as a consequence improves both the survival and function. Methods: We used the technique of exploration-reduction-evaluation-analysis and synthesis of related studies, with an overview of current recommendations, data from controlled clinical trials and from the national and international registries about the different strategies for STEMI reperfusion. In total, we examined 186 references on prehospital thrombolysis, 130 references in times door-treatment, 139 references in STEMI management and national and international registries as well as 135 references on rescue and primary percutaneous coronary intervention for STEMI. Finally the 48 references that were more relevant and informative were retained. Conclusion: The "time" factor is crucial in the success of early reperfusion in STEMI especially if thrombolysis is applied correctly during the prehospital time. The primary percutaneous coronary intervention is contingent upon its feasibility before 120 min from the onset of symptoms. In our midst to internationally, thrombolysis continues to be a strategy with great impact on their expectations of life and function of patients. Telecommunication systems should be incorporate in real time to the priority needs of catastrophic diseases such as STEMI where life is depending on time.