RESUMO
BACKGROUND: The assessment of myocardial viability is crucial before percutaneous coronary intervention (PCI) is carried out to ensure that the patient will gain benefit. Trans-coronary pacing (TCP) has previously been used to pace myocardium but may also provide information on myocardial viability. METHODS: Patients with a single, significant coronary stenosis requiring PCI were recruited. They underwent a cardiac MRI to assess myocardial viability. Prior to PCI, a coronary guidewire was used to measure pacing threshold, impedance, and R-wave amplitude in different myocardial segments to determine any association between the electrical parameters and myocardial viability. RESULTS: Eight patients were recruited and six patients underwent intervention. Pacing sensitivity did not demonstrate statistically significant differences between normal and scarred myocardium. Impedance demonstrated a mean of 304.8 ± 74.0 Ω in normal myocardium (NM), 244.1 ± 66.6 Ω in <50% myocardial scar (MS), and 222.3 ± 33.8 Ω in ≥50% MS. Pacing threshold demonstrated a mean of 1.960 ± 1.226 V in NM, 5.009 ± 2.773 V in <50% MS, and 3.950 ± 0.883 V in ≥50% MS. For both impedance and threshold, there was a significant difference among the groups (P = 0.12 and P = 0.002, respectively), and post hoc Tukey's pairwise comparison demonstrated significant differences between NM and scarred myocardium. No significant differences were found between <50% MS and ≥50% MS. CONCLUSIONS: Impedance and pacing threshold, measured during TCP, can be used to differentiate between normal myocardium and scarred myocardium. Further research is needed to determine whether TCP can discriminate between viable and nonviable myocardium.
Assuntos
Estimulação Cardíaca Artificial , Doença da Artéria Coronariana/diagnóstico , Estenose Coronária/diagnóstico , Técnicas Eletrofisiológicas Cardíacas , Miocárdio/patologia , Adulto , Idoso , Doença da Artéria Coronariana/patologia , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/cirurgia , Estenose Coronária/patologia , Estenose Coronária/cirurgia , Impedância Elétrica , Estudos de Viabilidade , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Projetos Piloto , Valor Preditivo dos Testes , Estudos Prospectivos , Sobrevivência de TecidosRESUMO
INTRODUCTION: The mainstay treatment for reducing the symptoms of angina and long-term risk of heart attacks in patients with heart disease is stent implantation in the diseased coronary artery. While this procedure has revolutionised treatment, the incidence of secondary events remains a concern. These repeat events are thought to be due, in part, to continued enhanced platelet reactivity, endothelial dysfunction and ultimately restenosis of the stented artery. In this study, we will investigate whether a once a day inorganic nitrate administration might favourably modulate platelet reactivity and endothelial function leading to a decrease in restenosis. METHODS AND DESIGN: NITRATE-OCT is a double-blind, randomised, single-centre, placebo-controlled phase II trial that will enrol 246 patients with stable angina due to have elective percutaneous coronary intervention procedure with stent implantation. Patients will be randomised to receive 6â months of a once a day dose of either nitrate-rich beetroot juice or nitrate-deplete beetroot juice (placebo) starting up to 1â week before their procedure. The primary outcome is reduction of in-stent late loss assessed by quantitative coronary angiography and optical coherence tomography at 6â months. The study is powered to detect a 0.22±0.55â mm reduction in late loss in the treatment group compared with the placebo group. Secondary end points include change from baseline assessment of endothelial function measured using flow-mediated dilation at 6â months, target vessel revascularisation (TVR), restenosis rate (diameter>50%) and in-segment late loss at 6â months, markers of inflammation and platelet reactivity and major adverse cardiac events (ie, myocardial infarction, death, cerebrovascular accident, TVR) at 12 and 24â months. ETHICS AND DISSEMINATION: The study was approved by the Local Ethics Committee (15/LO/0555). Trial results will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION NUMBERS: NCT02529189 and ISRCTN17373946, Pre-results.
Assuntos
Angina Estável/cirurgia , Plaquetas/efeitos dos fármacos , Estenose Coronária/prevenção & controle , Vasos Coronários/efeitos dos fármacos , Nitratos/uso terapêutico , Ativação Plaquetária/efeitos dos fármacos , Stents , Adolescente , Adulto , Angina Estável/terapia , Beta vulgaris/química , Implante de Prótese Vascular , Estenose Coronária/etiologia , Estenose Coronária/cirurgia , Vasos Coronários/cirurgia , Método Duplo-Cego , Endotélio Vascular/efeitos dos fármacos , Humanos , Inflamação/etiologia , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/prevenção & controle , Isquemia Miocárdica/tratamento farmacológico , Isquemia Miocárdica/cirurgia , Nitratos/farmacologia , Cuidados Pré-Operatórios , Stents/efeitos adversosRESUMO
BACKGROUND: The renoprotective effect of N-acetylcystein in patients undergoing coronary artery bypass graft surgery is controversial. METHODS: We assessed the renoprotective effect of the highest dose of N-acetylcystein sanctioned for clinical use in a prospective, double-blind, placebo-controlled study including 70 chronic kidney disease patients, stage 3 or 4, who underwent coronary artery bypass graft surgery, on cardiopulmonary bypass (CPB) and off CPB, and were randomly allocated to receive either N-acetylcystein 150 mg/kg followed by 50 mg/kg for 6 hours in 0.9% saline or only 0.9% saline. Acute kidney injury was defined by the Acute Kidney Injury Network classification. RESULTS: The incidence of kidney injury was reduced in the N-acetylcystein group (57.1% versus 28.6%, p=0.016). Nonuse of N-acetylcystein (relative risk 3.58, 95% confidence interval: 1.04 to 12.33, p=0.04) and cardiopulmonary bypass (relative risk 4.55, 95% confidence interval: 1.28 to 16.15, p=0.02) were independent predictors of kidney injury. In patients treated with CPB, N-acetylcystein reduced the incidence of kidney injury from 63% to 46%. Oxidative stress was increased in control subjects (p=0.01) and abolished in patients receiving N-acetylcystein. CONCLUSIONS: Maximum intravenous doses of N-acetylcystein reduce the incidence of acute kidney injury in patients with kidney disease undergoing coronary artery bypass graft surgery, abolish oxidative stress, and mitigate the negative effect of CPB on renal function.
Assuntos
Acetilcisteína/administração & dosagem , Injúria Renal Aguda/prevenção & controle , Ponte de Artéria Coronária/métodos , Estenose Coronária/cirurgia , Falência Renal Crônica/diagnóstico , Pulsoterapia/métodos , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Intervalos de Confiança , Ponte de Artéria Coronária/efeitos adversos , Estenose Coronária/complicações , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Prognóstico , Estudos Prospectivos , Radiografia , Valores de Referência , Medição de Risco , Estatísticas não Paramétricas , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Acute coronary syndrome has a high mortality rate that dramatically increases in the presence of left main coronary artery (LMCA) disease. Over the past decades, coronary artery bypass graft (CABG) surgery has been commonly accepted as the standard of care for patients with LMCA stenosis and is still considered the first-line treatment in current practice guidelines. Percutaneous coronary intervention (PCI) of protected and unprotected LMCA has gained popularity and is increasingly utilized with comparable outcomes to CABG in randomized controlled trials. In-stent restenosis and the need for revascularization provide the main obstacle to LMCA revascularization. The advent of better PCI equipment, stents, ablative devices, intravascular ultrasound, hemodynamic support devices and antithrombotic agents have ignited a renewed interest in the practice of LMCA PCI, especially for high surgical risk patients who are neither candidates nor agreeable to CABG surgery. Herein, we review the studies comparing unprotected LMCA stenting with CABG surgery in regard to 3 main endpoints: mortality, major adverse events and the incidence of repeat revascularization.
Assuntos
Síndrome Coronariana Aguda/terapia , Ponte de Artéria Coronária/métodos , Stents , Síndrome Coronariana Aguda/cirurgia , Reestenose Coronária/patologia , Estenose Coronária/fisiopatologia , Estenose Coronária/cirurgia , Estenose Coronária/terapia , Desenho de Equipamento , Humanos , Intervenção Coronária Percutânea/métodos , Guias de Prática Clínica como Assunto , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Over the centuries, opium has been the most frequent substance abused in the Middle East. There are many controversial aspects about the effects of opioids on the atherosclerosis process, which is still unclear. METHODS: All patients who were candidates for coronary artery bypass graft in Tehran Heart Center were registered and evaluated for risk factors such as diabetes mellitus, hypertension, smoking status and duration, opium abuse, involved coronary arteries and left main branch lesion > 50%, carotid stenosis > or = 70%. RESULTS: A total of 1,339 patients were enrolled in the study, of whom 400 (29.9%) were female and the other 939 (70.1%) male. Female patients were omitted from analysis due to the low numbers of female opium addicts. Our study revealed that in the addicted population, the risk of diabetes and hypertension was lower than in the non-addicted group (p < 0.05 for each variable) and fasting blood sugar tended to be less in addicted ones, but the number of involved coronary arteries, left main stenosis > 50% and extent of carotid stenosis was not significantly different between the two groups. CONCLUSIONS: Our investigations demonstrate that opium is not cardioprotective, as has been claimed by some previous studies, and does not even decelerate atherosclerosis of carotid arteries in opium-addicted patients, but more evidence is still needed to completely prove the case.
Assuntos
Estenose das Carótidas/epidemiologia , Ponte de Artéria Coronária , Estenose Coronária/cirurgia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Ópio/efeitos adversos , Idoso , Estenose das Carótidas/diagnóstico por imagem , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/epidemiologia , Humanos , Irã (Geográfico)/epidemiologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Ultrassonografia DopplerRESUMO
A 75-year-old man was referred to our hospital with a diagnosis of lower rectal cancer. Unstable angina attack occurred after admission and cardiac angiography revealed stenosis of three coronary arteries which were treated by percutaneous transluminal coronary angioplasty unsuccessfully. Coronary artery bypass graft was performed after colostomy. It is possible for operative stress, extracorporeal circulation and blood transfusion to diminish immunocompetence and increase the risk of recurrence. Therefore, CPT-11/5-FU/l-LV combination therapy (CPT-11 80 mg/m(2), 5-FU 500 mg/m(2), l-LV 250 mg/m(2) day 1, 8, 15 every 5 weeks) was carried out as neoadjuvant chemotherapy. The tumor decreased in size, and the level of tumor marker was normalized after two courses of the combination therapy. The patient is alive without recurrence three years after abdominoperineal resection.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Ponte de Artéria Coronária , Neoplasias Retais/tratamento farmacológico , Idoso , Camptotecina/análogos & derivados , Camptotecina/uso terapêutico , Quimioterapia Adjuvante , Estenose Coronária/complicações , Estenose Coronária/cirurgia , Fluoruracila/uso terapêutico , Humanos , Leucovorina/uso terapêutico , Masculino , Neoplasias Retais/complicaçõesRESUMO
BACKGROUND: The objective of the present study was to determine the effect of processing of pericardial blood with a cell-saving device (CS) and vacuum-assisted cardiopulmonary bypass (VACPB) on reduction of postoperative inflammation. METHODS: One hundred patients who underwent on-pump coronary artery bypass grafting surgery were included in a prospective randomized study. Patients were randomly assigned into four groups of 25 patients, each in a two-by-two factorial design: group A had no CS and no VACPB, group B had VACPB alone, group C had CS alone, and group D had CS and VACPB. The complement factors C4a, C3a, and C5a, and the terminal complex sC5b-9, MBL (mannose-binding lectin), and Bb were measured in plasma preoperatively and at 30 and 240 minutes after termination of CPB. RESULTS: Mean age, CPB, and aortic cross-clamping times were similar in all groups. At 30 and 240 minutes after CPB, C3a, sC5b-9, and Bb were increased and C5a and MBL levels were decreased compared with preoperative levels in all groups. At 240 minutes, Bb levels were lower in patients with CS (p = 0.0002). CONCLUSIONS: The present study shows that contemporary CPB remains associated with a striking activation of all complement pathways and its terminal component. The use of CS decreases the activation of the complement alternative pathway.
Assuntos
Transfusão de Sangue Autóloga/instrumentação , Ponte Cardiopulmonar/métodos , Ativação do Complemento , Hipóxia-Isquemia Encefálica/prevenção & controle , Inflamação/prevenção & controle , Idoso , Análise de Variância , Velocidade do Fluxo Sanguíneo , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Estenose Coronária/mortalidade , Estenose Coronária/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pericárdio , Complicações Pós-Operatórias/prevenção & controle , Probabilidade , Estudos Prospectivos , Sensibilidade e Especificidade , Análise de Sobrevida , Resultado do TratamentoAssuntos
Angioplastia Coronária com Balão/instrumentação , Oclusão de Enxerto Vascular/terapia , Stents/efeitos adversos , Angioplastia Coronária com Balão/métodos , Cateterismo Cardíaco , Angiografia Coronária/métodos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Cyperus , Sistemas de Liberação de Medicamentos , Falha de Equipamento , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Preparações de Plantas/uso terapêutico , Recidiva , Retratamento , Medição de Risco , Índice de Gravidade de Doença , Taxus , Resultado do Tratamento , Grau de Desobstrução Vascular/fisiologiaRESUMO
Occlusion of LCX During RF Catheter Ablation. We report a case of acute occlusion of the left circumflex coronary artery during catheter ablation in the coronary sinus to complete the linear lesion between the postero-lateral mitral annulus and the left inferior pulmonary vein for the treatment of atrial fibrillation.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Estenose Coronária/etiologia , Valva Mitral/cirurgia , Doença Aguda , Fibrilação Atrial/etiologia , Implante de Prótese Vascular , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Técnicas Eletrofisiológicas Cardíacas , Doenças das Valvas Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , StentsRESUMO
BACKGROUND: The benefits of intraoperative autologous donation (IAD) in reducing the need for allogeneic blood transfusion in surgery have been debated for several years. The purpose of this study was to determine if IAD alone or in conjunction with hemoglobin raffimer (HR) confers a reduction in red cell or blood component transfusion compared with results in standard clinical practice. STUDY DESIGN: The Phase III clinical trial was a multicenter, randomized, double-blind study to determine the efficacy and safety of HR versus 10% pentastarch when used to facilitate IAD in 299 patients undergoing primary coronary artery bypass grafting. The patients received HR or pentastarch as an adjunct to IAD immediately before cardiopulmonary bypass. Results were compared with transfusion requirements for 150 matched patients in the reference group. RESULTS: The frequency of allogeneic RBC transfusion in the HR, pentastarch, and reference groups was 56%, 76%, and 95%, respectively. The number of allogeneic red cell units used was 49 in the HR group, 104 in the pentastarch group, and 480 in the reference group (p < 0.001). The total number of non-RBC units administered was 150 in the HR group, 238 in the pentastarch group, and 270 in the reference group. CONCLUSIONS: In this study, patients treated with HR in conjunction with IAD received fewer transfusions overall and a lower volume of allogeneic RBCs and non-RBC allogeneic blood products than did the two comparison groups. This confers a real benefit on the overall blood supply by decreasing use and increasing availability.
Assuntos
Transfusão de Sangue Autóloga , Ponte de Artéria Coronária/métodos , Estenose Coronária/cirurgia , Hemoglobinas/administração & dosagem , Rafinose/análogos & derivados , Rafinose/administração & dosagem , Idoso , Substitutos Sanguíneos/administração & dosagem , Substitutos Sanguíneos/efeitos adversos , Transfusão de Sangue/estatística & dados numéricos , Transfusão de Sangue Autóloga/estatística & dados numéricos , Estenose Coronária/sangue , Método Duplo-Cego , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Derivados de Hidroxietil Amido , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
OBJECTIVE: We recently demonstrated that Rho-kinase, an effector of the small GTPase Rho, is substantially involved in the pathogenesis of arteriosclerosis. In this study, we examined whether Rho-kinase is also involved in in-stent restenosis and if so, what mechanism is involved. METHODS AND RESULTS: Pigs underwent stent implantation in the left coronary artery with or without administration of fasudil (30 mg/kg per day orally), a specific Rho-kinase inhibitor, starting 2 days before the procedure for a duration of 4 weeks. On day 28, reductions in coronary diameter and neointimal formation associated with macrophage accumulation, collagen deposition, and transforming growth factor (TGF)-beta1 expression were noted at the stent site, and all were significantly suppressed by fasudil. On day 7, fasudil significantly increased the frequency of TUNEL-positive apoptotic cells, while it tended to reduce that of bromodeoxyuridine-positive proliferating cells in the neointima. Western blot analysis on day 7 demonstrated that phosphorylations of the ezrin/radixin/moesin family (a marker of Rho-kinase activity in vivo) and protein expression of monocyte chemoattractant protein-1and bcl-2 were upregulated at the stent site and were significantly suppressed by fasudil. CONCLUSIONS: These results indicate that long-term inhibition of Rho-kinase suppresses in-stent neointimal formation by multiple mechanisms, including reduced vascular inflammation, enhanced apoptosis, and decreased collagen deposition.
Assuntos
1-(5-Isoquinolinasulfonil)-2-Metilpiperazina/análogos & derivados , 1-(5-Isoquinolinasulfonil)-2-Metilpiperazina/farmacologia , Reestenose Coronária/enzimologia , Inibidores Enzimáticos/farmacologia , Proteínas Serina-Treonina Quinases/fisiologia , Stents , Túnica Íntima/patologia , Animais , Apoptose/efeitos dos fármacos , Proteínas Sanguíneas/metabolismo , Cateterismo/efeitos adversos , Quimiocina CCL2/biossíntese , Quimiocina CCL2/genética , Colágeno/metabolismo , Reestenose Coronária/patologia , Reestenose Coronária/prevenção & controle , Estenose Coronária/cirurgia , Estenose Coronária/terapia , Proteínas do Citoesqueleto/metabolismo , Avaliação Pré-Clínica de Medicamentos , Genes bcl-2 , Peptídeos e Proteínas de Sinalização Intracelular , Masculino , Proteínas de Membrana/metabolismo , Proteínas dos Microfilamentos/metabolismo , Fosfoproteínas/metabolismo , Fosforilação/efeitos dos fármacos , Processamento de Proteína Pós-Traducional/efeitos dos fármacos , Proteínas Serina-Treonina Quinases/antagonistas & inibidores , Proteínas Proto-Oncogênicas c-bcl-2/biossíntese , Método Simples-Cego , Suínos , Túnica Íntima/efeitos dos fármacos , Túnica Íntima/enzimologia , Quinases Associadas a rhoRESUMO
OBJECTIVE: To investigate an optimized glucose-insulin-potassium (GIK) solution regimen as an alternate myocardial protective strategy in off-pump coronary artery bypass graft (OP-CAB) surgery and as a supplement to conventional coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB). DESIGN: Prospective, randomized, placebo-controlled. SETTING: Single institution, cardiothoracic specialty hospital. PARTICIPANTS: Forty-four patients scheduled for elective multivessel coronary artery surgery using either conventional CPB (n = 22) or OP-CAB techniques (n = 22). INTERVENTIONS: Preischemic, ischemic, and postischemic administration of GIK solution was carried out, optimally dosed to ensure nonesterified fatty acid (NEFA) suppression, and supplemented with magnesium, a glycolytic enzymatic cofactor. MEASUREMENTS AND MAIN RESULTS: GIK solution therapy reduced plasma NEFA levels (p < 0.001) in OP-CAB surgery and CPB groups but failed to affect the incidence of non-Q wave perioperative myocardial infarction, incidence of postoperative atrial fibrillation, incidence of postoperative infection, reduction in creatinine clearance, or duration of postoperative intensive care unit or hospital length of stay. After adjusting for GIK solution therapy, OP-CAB surgery resulted in significantly less ischemic injury (troponin I >15 microg/L, 19.0% v 91.3%; p = 0.0001) and reduced postoperative infections (14.3% v 43.5%; p = 0.049). CONCLUSION: GIK solution therapy achieved NEFA suppression and an insignificant trend toward reduced biochemical parameters of ischemic injury in OP-CAB surgery and CPB groups, but no major clinical benefit (perioperative myocardial infarction, intensive care unit length of stay, or hospital length of stay) was shown after elective CABG surgery in low-risk patients. Compared with CPB, OP-CAB surgery significantly reduced ischemic injury and postoperative infections.